“Taking uncertainty into account can enhance a physicians therapeutic effectiveness because it demonstrates his honesty, his willingness to be more engaged with his patients, his commitment to the reality of th esituation rather than resorting to evasion, half-truths, and lies. It makes it easier to change course if the first strategy fails.” – Jerome Groopman
As the old saying goes “actions speak louder than words,” and it is not any different in the clinical setting. Or is it? What influences patient satisfaction? If provide world class care, but your colleague at the front desk is rude to the patient, will the clinic receive 5 stars on Google? If you have mastered your manipulation techniques, design the ideal exercise prescription program, and provide ample pain neuroscience education, will short, abrupt conversation cause the patient to seek care elsewhere? Conversely, what if you are a great conversationalist and you exude warmth, will your raw manual, exercise, and assessment skills matter?
If patient satisfaction was a sole representation of our actions, new graduates would be in trouble. But we know words are powerful. In the last post, I covered patient expectations, and we establish those expectations and goals through language. The words we use to educate can influence the effectiveness of imparting knowledge and influencing behavior. When we use our words is equally important to the words we choose.
Not only does the frequency of our communication impact learning and performance, they impact a patients perceived importance of the information. For example, routinely asking someone how they are feeling, always changing the exercises at the first sign of discomfort, and primarily conducting exercises on the table screams to the patient they are fragile. We must be aware of all nuances of communication.
In this post, I will focus on how our actions and body language can greatly impact a patient’s satisfaction and outcomes.
What are non-verbal behaviors?
First, we need to outline a couple key definitions. A positive non-verbal behavior (NVB) is body language or actions that convey a positive emotion, attitude or relationship. A negative NVB is the opposite and conveys a negative emotion, attitude or relationship. Examples of micro-level NVBs include smiling, leaning forward, hand movement, eye contact, tone of voice, body gesture, etc., while macro-level NVBs are a collection of micro-level behaviors that conveys a psychological meaning such as dominance, confidence or warmth.
In an article by Daniali and Flaten, the authors outlined many NVBs and assessed their impact on patient satisfaction and outcomes. What did they find? That actions truly do speak loudly.
When actions speak louder than words
A clinician’s negative NVBs contributed to decreased cognitive and physical functioning of patients. Two of the largest culprits were keeping a larger distance and not looking at patients.1 Both decreased the satisfaction with care and overall outcomes. Basically, shuttling a patient to the ‘exercise area’ and occasionally turning your head to yell “good form” or “squeeze those shoulder blades more” and only interacting when the patient or aide asks, “what’s the next exercise?” is not going to cut it. While this can be difficult to navigate in a busy clinic environment, it is key for us to identify strategies to avoid displaying the perception we are ignoring our patients.
Conversely, patients who were exposed to enthusiastic clinicians were in a better emotional state. Overall, enthusiasm by clinicians reduced negative emotions. This does not mean you need to be the life of the party and the loud, obnoxious therapist, but you do need to at least appear to enjoy your job. This is not a case of introversion versus extroversion. In fact, introverts tend to be superior in establishing one on one relationships, listening, and engaging in meaningful conversations. Own your personality and communication type and use it to engage with your patients.
Dress for success
In addition to the clinician’s emotional state, higher professional status and higher confidence leads to lower pain reports, more accurate pain ratings, and better physical and emotional state. This begs the question, “how should we dress in the clinic?” While many of us have doctorates, lab coats and a stethoscope wrapped around our necks will convey the wrong message and confuse the patient. We are not medical doctors and a lab coat is unnecessary. But what about dress shirt and tie? Perhaps you work in a clinic that mimic a CrossFit gym and often replicate the high intensity exercises your patient perform. In this setting, gym clothes may be appropriate, but they should be branded, proper fitting, and not wrinkled. Other settings may benefit from the shirt and tie, especially if you frequently engage with referral sources in the community. How you look matters.
Lastly, confidence and competence status of clinicians generated higher placebo effects. We have touched on this in the past and I will cover placebo and nocebo in greater depth in the next post. In the meantime, it is important to acknowledge that placebo is not an evil effect we should avoid. It is unethical to withhold risk factors, inflating expected outcomes, or educate patients on a mechanism we know to be false in order to maximize placebo – such as telling the patient their tissue will rapidly mend together during the application of ultrasound. But conveying confidence and trust in a technique is appropriate and beneficial. You want the patient to trust you and the treatment you are providing.
In summary, displaying confidence, enthusiasm, competence and dressing professionally will boost your outcomes and satisfaction. Keeping your patients at a distance and looking the other way often will dampen your outcomes.
How do we define success?
Measuring success can be a tricky endeavor. It is quite relative as there are many domains of success and interpretations of outcomes; it is not always a binary outcome. A patient may view success as meeting their goal of running a 5K pain free in under 25 minutes. Anything less is failure. Another patient may view success as simply finishing the race, even if walking breaks were required. Everyone does live by the Ricky Bobby mantra of “If you ain’t first, you’re last.” What other parties? How does everyone else in healthcare measure success?
If you ask a researcher, success may be exceeding the minimally clinically important difference (MCID) or achieving a greater level of change relative to a control (with acceptable p-values and confidence intervals of course). If you ask Medicare, success is once a patient is “functional” (because that isn’t muddy at all…). If you ask a therapist, it may be 0/10 pain, full range of motion, 0% on the Oswestry Disability Index, or a beautiful single leg pistol squat with absolutely no compensation, pain, or difficulty. But what if the patient doesn’t care about any of those things. How do we juggle the markers of “success” for all relevant stakeholders?
This post won’t be able to answer that question as there is not a simple one size fits all answer. What I will try to untangle is the factors that influence how satisfied a patient is with physical therapy. Why does this matter? Patient satisfaction has a substantial impact on both current and future performance. How a patient perceives their care can dictate the success of interventions, their compliance with care, how they speaks about their providers in public, and potentially future reimbursement. So, it is kind of a big deal.
The domains of patient satisfaction
Alright, let’s get to the evidence. Patient satisfaction measures can target many different domains. Take the surveys Focus on Therapeutic Outcomes (FOTO) administers for example. Their satisfaction questions cover treatment, information about condition provided, input on goal settings, access to facility, availability of convenient appointments, and overall satisfaction. This provides us a substantial amount of information and allows us to tease out potential issues and highlight areas of strength.
Quick note, patient satisfaction scores are only valuable if we act on the data. Treating data as a “fun fact” is essentially useless and does not allow us to grow as clinicians. Of course, the data must be accurate. Ulterior motives and biases can impact the answers patients provide and when the clinician provide the surveys. For example, if a clinician asks a patient how satisfied they are with face to face, they are more likely to receive a positive report. Most people do not like confrontation. This is different for outcome measures.
Outcome measures are designed to highlight functional areas of difficulty. These are best completed with the clinician present. Incorporating Patient Reported Outcome Measures (PROM), such as the Functional Status measures used by FOTO, assessment into clinical practice throughout an episode of care has the potential to promote shared decision making between patients, their families, and providers. 2 PROM assessment heightens the provider’s awareness of patients’ health concerns and facilitates communication regarding available medical evidence for optimal treatment options.3 Geroge et al found patients who were satisfied with symptoms reported higher physical function, lower pain intensity, and less symptom bothersomeness (great word chosen by the authors) at 6 months. The 2 strongest absolute and unique predictors of patient satisfaction with symptoms at 6 months were whether treatment expectations were met and change in symptom bothersomeness.4 Patient satisfaction are most associated with items that reflected a high-quality interaction with the therapist – such as time, adequate explanations and instructions to patients. Environmental factors such as clinic location, parking, time spent waiting for the therapist, and type of equipment used are not strongly correlated with overall satisfaction with care.5
How do we get accurate satisfaction data?
We work on our craft daily. We take courses, read research, engage in clinical conversations, and reflect on past treatments to improve out care. All of these strategies certainly improve the care we provide patients, but they don’t guarantee satisfaction and outcome scores will improve. There is an art to administering measures. I’m going to provide a couple strategies I have learned over the past few years as the National Director of Quality and Research for PT Solutions.
Quick caveat, this is not meant to artificially inflate your scores. Furthermore, the goal of obtaining outcomes and satisfaction scores is not simply to inflate the ego and display your awesomeness to everyone. The purpose is to objectively assess your quality of care and make the necessary adjustments. You may apply guideline adherent care and have mastered your exercise prescription and manual therapy techniques, but if the patients are unhappy and prematurely ending the plan of care then the quality is not high.
Obtain timely scores. Patient evaluation worsens as the gap between encounter and completing the measure increases. Our memories become less clear as time passes.6 I would argue the most important indicator of whether your outcome data is accurate is the ‘days between status and discharge’. This number represents how many days you treated a patient after obtaining their final outcome measure. The larger the number, the more days you treated and helped a patient without obtaining credit for the improvement. Additionally, patients (and clinicians) have poor long-term memory for our subjective experiences. The longer a patient goes without a survey, the more they are guessing at how they previously felt.
This is where you have to weigh in-person vs. email surveys. In person provides more immediate ratings and a larger volume of data. Emails rely on open and click-rates. However, a patient may feel less pressured to convey disappointment over email.
Complete the specific actions from the outcome tool on the day a survey is administered. If a questionnaire asks how difficult it is to walk a quarter mile, then have the patient walk a quarter mile on the treadmill the day they complete the questionnaire. Again, this limits the guesswork and provides a more updated assessment.
Prep the patient but do not hover or bias them. This strategy falls under ‘obtaining accurate scores’ not ‘maximizing your score, even if it is artificial’. If you hover over a patient during the survey, your body language or the way you ask a question (or your mere presence) may cause scores to be artificially high. Patient are reluctant to disclose negative attitudes toward a health care provider because of a sense of dependency on patient-provider communication. This doesn’t benefit anyone. Instead, fully explain the survey and be available for questions.
From theory to practice
Ok, your NVBs are world class, you are providing evidence-based care, and you are a master at collecting the data appropriately, what can go wrong? In many cases, it will be smooth sailing to world class outcomes and satisfaction, but there are a few remaining barriers to be cognizant of.
The malalignment of therapist and patient goals can be detrimental to satisfaction. It is imperative you are both on the same page with the goals and the methods for obtaining them. This is where motivational interviewing comes into play as this alignment may take weeks to obtain. Another barrier is understanding what the patient values. They lack the knowledge to assess accurately the technical competence of health care personnel and therefore may only judge satisfaction on outcomes. Others, however, may care far more about the ‘experience’ and weigh NVBs and the interaction with employees much higher. It is important to recognize these differences and assess all. A final thought on this topic is the impact the scores can have on our treatment choices. It can be tempting to provide whatever treatment a patient wants, regardless of the efficacy, to simply satisfy them. This can be a major driver of continued use of treatment with poor efficacy and limits both our progression as a profession and the long-term outcomes of a patient.
Patient satisfaction and outcome measures are by no means the pinnacle of assessment tools. However, they do carry immense value and can help guide improvement for the benefit of our patients and ourselves.
- Daniali H, Flaten MA. A Qualitative Systematic Review of Effects of Provider Characteristics and Nonverbal Behavior on Pain, and Placebo and Nocebo Effects. Front Psychiatry 2019;10:242. doi: 10.3389/fpsyt.2019.00242 [published Online First: 2019/05/01]
- Werneke MW, Deutscher D, Fritz J, et al. Associations between interim patient-reported outcome measures and functional status at discharge from rehabilitation for non-specific lumbar impairments. Qual Life Res 2020;29(2):439-51. doi: 10.1007/s11136-019-02314-6 [published Online First: 2019/10/02]
- Dobrozsi S, Panepinto J. Patient-reported outcomes in clinical practice. Hematology Am Soc Hematol Educ Program 2015;2015:501-6. doi: 10.1182/asheducation-2015.1.501 [published Online First: 2015/12/08]
- George SZ, Hirsh AT. Distinguishing patient satisfaction with treatment delivery from treatment effect: a preliminary investigation of patient satisfaction with symptoms after physical therapy treatment of low back pain. Arch Phys Med Rehabil 2005;86(7):1338-44. doi: 10.1016/j.apmr.2004.11.037 [published Online First: 2005/07/09]
- Beattie PF, Pinto MB, Nelson MK, et al. Patient satisfaction with outpatient physical therapy: instrument validation. Phys Ther 2002;82(6):557-65. [published Online First: 2002/05/31]
- Brem AK, Ran K, Pascual-Leone A. Learning and memory. Handb Clin Neurol 2013;116:693-737. doi: 10.1016/B978-0-444-53497-2.00055-3 [published Online First: 2013/10/12]
ABOUT THE AUTHOR
Zach Walston, PT, DPT, OCS serves as the National Director of Quality and Research at PT Solutions. Zach grew up in Northern Virginia and earned his Bachelor of Science in Human Nutrition, Foods, and Exercise at Virginia Polytechnic Institute and State University. He then received his Doctorate of Physical Therapy from Emory University before graduating from the PT Solutions’ Orthopaedic Residency Program in 2015. Zach now serves as the Residency Program Coordinator and the director of the practice’s Clinical Mentorship Program providing training for over 100 physical therapists a year.
Zach has numerous research publications in peer-reviewed rehabilitation and medical journals. He has developed and taught weekend continuing education courses in the areas of plan of care development, exercise prescription, pain science, and nutrition. He has presented full education sessions at APTA NEXT conference and ACRM, PTAG, and FOTO annual conferences multiple platforms sessions and posters at CSM.
Zach is an active member of the Orthopedic and Research sections of the American Physical Therapy Association and the Physical Therapy Association of Georgia. He currently served on the APTA Science and Practice Affairs Committee and the PTAG Barney Poole Leadership Academy.
Zach currently lives in Marietta, GA with his wife, son, and two dogs. Connect with Zach on Twitter, LinkedIn, and his website.