Megan is scheduled for aquatic therapy three times a week. Every time she shows, she sees a different clinician. During each session, her therapist-of-the-day perches on the deck, resplendent in corporate polo and khakis ("How hot he must be!" opines Megan), clipboard in hand, adding such clinical pearls to her session as "10 more."
If another therapist happens to be poolside, an informal social pow-wow often commences, with both therapists vetting personal woes and work-based grievances between glances pool-ward to ensure their wards are continuing some semblance of movement.
The only physical touch ever occurs when it appears that danger is in the mix. A wet deck might warrant a hand-hold or an absent-minded arm wrapped around the gait belt (after all, those incident reports are such buggers to fill out).
Sometimes, during the very last moments of her 30-minute session, a mildly peeved Megan asks the therapist what his name is, just to drive home the point that no one had bothered to share.
Megan was a remarkably generous soul. She was known in the neighborhood as the church lady who brought freezer meals for all the college students who were too far from home. And yet, it never occurred to Megan to bake her therapist a batch of brownies. In casual conversation, she never made use of the affectionately possessive "my therapist." In actuality, she never talked about her sessions at all. Why would she? There was nothing remarkable to talk about.
At the end of two months of two-to-three aquatic sessions per week, Megan scored six points higher on her Berg scale, her Timed Up and Go had improved by four seconds, and her 6-minute walk distance had improved by 50 feet. And if you asked Megan what she thought about her therapy regimen, she would have told you the truth: It was a bust.
Patients who make functional improvements with therapy, but who are unhappy with the care they receive, don't find therapy to be of benefit. And it's not just a subjective feeling of malaise. This discontent boils over into the realm of physical improvement. The former colors the latter.
In other words, in order for therapy to be maximally effective, therapists need to care whether their patients are satisfied with their treatment. And, to be blunt, this can be translated in almost every situation to whether patients are satisfied with their therapist.
Patient Satisfaction vs. Outcome
Several studies have examined the precarious relationship between patient satisfaction and functional improvement. Beattie et al put it this way:1
"Maximizing patient satisfaction is a sound philosophy from both a clinical perspective and a business perspective. Satisfied patients are more likely to adhere to treatment and continue to seek healthcare at a given facility. Our findings indicate that adequate time spent in patient care and the professionalism of the therapist and clinic staff are more important for patient satisfaction than the location of the facility, the quality of equipment, and the availability of parking.
"We believe that, in the current healthcare environment, the emphasis on cost-cutting, high patient volume, and the use of 'care extenders' can reduce the time for the patient-therapist interactions that appeared to contribute to satisfaction."
The results of their study showed that patient satisfaction with care was most strongly correlated with the quality of patient-therapist interactions. This includes the therapist spending adequate time with the patient, demonstrating strong listening and communication skills, and offering a clear explanation of treatment.
Note that the commonly cited "important factors" such as clinic location, fancy equipment and close parking are less important in determining patient satisfaction.
Steve George published a paper examining the difference between satisfaction with treatment effect versus satisfaction with treatment delivery for the low-back pain patient.2 His findings suggest that patient satisfaction is a multidimensional construct and that a patient being "satisfied" with care may have little to do with whether the patient is actually better.
Hush, Cameron and Mackey explored this theme in great depth.3 Their systematic review explored the collective findings of multiple studies about the subjective experience of the patient. Not surprisingly, all studies examined by the researchers identified therapist attributes as the critical dimension of patient satisfaction - attributes such as professionalism, competence, friendliness, caring, ability to communicate effectively (e.g. offering a clear explanation of treatment), spending adequate time with the patient, and demonstrating strong listening skills.
Note that these are all therapist attributes, not treatment attributes. You might call this "the relationship." Any therapist worth her salt could tell you how essential rapport is to the success of intervention.
Call it the "Christmas-cookie" phenomenon. The more likely the patient is to bring in a batch of cookies on the holiday, the more vested the patient is in the relationship, thus elevating the likelihood of a positive outcome. Some therapists may choose to sneer at such archaic ideas as rapport, but it's hard to argue with the published evidence.
The researchers found that patient satisfaction was infrequently and inconsistently associated with the treatment the patients received. Strangely, actual changes in physical status had little to do with how patients rated the success of their intervention. In general, patients who felt comfortable with their therapist, who liked their therapist, who believed they were being treated as an adult, and who felt like they were being shown how to actively participate in treatment were more likely to feel satisfied with their outcome.
When patients were asked what other factors made for a maximally satisfying treatment, their answers were not earth shattering. In general, they were:
• More satisfied when the treatment duration was adequate (read: longer);
• More satisfied when treated by the same practitioner every session;
• More satisfied working with PTs compared with physicians (especially when teaching elements were involved);
• More satisfied with treatment provided in private clinics compared with not-for-profit, hospital-based facilities.
And while treatment attributes might matter to some extent (for instance, patients were as satisfied with exercise as they were with manual therapy, massage, or electrotherapies), the intervention itself was not king. Time and time again, patients turned their eyes to the importance of the relationship with their therapist.
The Closing Pitch
Those of us lucky enough to spend our days in the water are in an enviable position. The pool is a wonderful place to produce patient improvement while ensuring patient satisfaction. Not only are we allowed to touch our patients, we are expected to do so.
We get to combine a specific (hopefully therapeutic) intervention with touch. We get to look into our patient's eyes, listen to their woes, and spend one-on-one time together explaining the science behind their treatments and our hopes for their future.
And, at the end of the day, we get to eat cookies. This is a world I want to live in.
References are available online at www.advanceweb.com/pt.
Andrea Salzman is creator of the Aquatic Resources Network (www.aquaticnet.com), an online clearinghouse of aquatic therapy and fitness information. More than 8,000 aquatic-specific articles and downloads are available free, and those seeking advanced competency in aquatic therapy can pursue a tiered curriculum of training through Aquatic Therapy University (www.swimatu.com). Contact: firstname.lastname@example.org.