Commentary, Exclusives, Patient Care

Patch Adams and EMS: Patients are People Too

Your patient is not a human specimen, he or she is a person with feelings and emotions, Anthony Correia writes. Treat them with respect. (Photo/Adam Mason)

In the movie Patch Adams, a doctor and group of residents surround an awake and alert patient lying on a bed in the hallway of a hospital. The doctor opens up a clipboard and reads to the attentive residents: This is a female with diabetes mellitus with a gangrenous lower left leg and foot. He asks the residents if they have any questions. One wants to know if the patient has a bone infection. Another wants to know about treatment. At this point, the woman looks up at this resident with a look of surprise and concern. A medical student, pretending to be one of the residents, asks the whole group in a quiet voice: “What’s her name? I was just wondering what’s the patient’s name?” The doctor looks at him with a bit of surprise, opens the clipboard and studies it again. “Marjorie,” the doctor says. Adams then holds Marjorie’s hand as she looks up at him with a smile as the rest of the class moves on.

Related

The moral of this story is Marjorie isn’t just a physical human specimen, she’s a person with feelings and emotions. In the research compiled by Trzeciak & Mazzarelli in Compassionomics,1 they devote a whole chapter to the “compassion crisis” in healthcare, which the above scene is indicative of. According to an informal survey conducted on social media of a cross section of EMS providers, educators and leaders; the lack of compassion and empathy is a significant issue in EMS today. We’ll look at what the research says about the importance of compassion and emotional intelligence in patient interactions and outcomes. Our conversation will discuss the benefits of prioritizing patients as people first.

One of the more prominent reasons doctors get sued is poor bedside manner. Trzeciak and Mazzarelli provide several examples of where lack of compassion increases potential for malpractice suits. According to a June 1, 2015, article by Aaron E. Carroll in the New York Times, called “To be Sued Less, Doctors Should Talk to Patients More,” primary care physicians get sued less due to “…time educating their patients about their care, more likely to use humor and laugh with their patients.”2

According to Wes Oglive MPA, JD,LP, NRP, an actively practicing paramedic and lawyer in Texas for the past 15 years: “The public doesn’t even know the difference between an EMT and a paramedic, let alone whether an EMT or paramedic is clinically competent. But, they do know whether that EMT or paramedic is nice”. My own observational research over the past 40 years as both a provider and a chief officer has included multiple experiences of poor bedside manner. Complaints levied against EMS providers were because of poor behavior or through treating the patient and/or their family with a lack of respect and compassion.

While EMS folks don’t often get sued for their bedside manner and the way that they interact with patients, the lack of empathy and compassion reflects itself in other ways. “Ninety-five percent of patient complaints about EMS care that I received over 27 years as a chief officer had to do with personnel interactions – medics were abrupt, abusive, not sympathetic, disrespectful to family or other caregivers,” according to Skip Kirkwood, MS, JD, NRP (Ret.), FACPE. Patients and families don’t much know or care if you picked the right medication, interpreted the ECG correctly, or did other technical skills well – they know if you were nice, kind, polite, and professional. 

“Having a smile, being attentive to the patient and the family isn’t hard and doesn’t cost anything. Having concern for their well-being isn’t hard, but will keep you out of trouble, or at least lessen the trouble, if something goes wrong. It does, however, take practice, especially if you’re not the empathetic type,” according to Brian Fitzpatrick, MICP, a supervising paramedic in New Jersey.

“Supervisors also have a role to play. Having your staff let you know when they suspect a complaint will be made allows the boss to potentially figure out right away if there really is something to complain about or if the complainant is blowing off steam and just wants to vent. It saves a lot of work and heartache if it wasn’t an actual problem, just a warning. Of course, if the supervisor does not have practical experience in being an empathetic provider or is as uncaring as the staff, he or she could just be exacerbating the situation with the person registering the complaint, as well as not being able to effectively address the emotional needs of the providers who report to him or her.”

There is significant data related to the benefits of treating our patients’ in a holistic manner. The holistic concept is treating a patient’s physical, mental and social well-being in an integrated and comprehensive manner. The mind and body connection are intertwined and not mutually exclusive. According to Adams, who wrote the research-based book, Gesundheit: “You treat a disease, you win, you lose. You treat a person, I guarantee you, you’ll win, no matter what the outcome. Our job is to increase health. That means improving the quality of life, not just delaying death.”3 Trzeciak & Mazzarelli cite a University of Colorado study that found positive clinical outcomes based on a higher level of psychological and emotional support from healthcare providers.

EMS has strayed way off the path from being people-centered caregivers as they were when we were just “ambulance drivers prior to EMTs and paramedics in prehospital medical services. That’s when ambulances “gave people rides to hospitals” with very little emergency care. The primary tool attendants had back then to reduce the suffering and pain was being supportive, empathetic and compassionate.

Back then being compassionate was one of the most common therapies they had available to them. As EMS evolved and took a more “professional” stance to be better clinicians, with increased technical skills, we’ve de-emphasized the personal, human connection. We prioritize evidenced-based medical treatment over interpersonal skills. We don’t give the same prominence to the patient’s emotional and mental wellbeing. This is supported by an informal survey conducted in 2011 on the EMTLIFE website which asked the following question: Which of the following people do you believe make the best EMS professionals?

The number one answer with 61% of the votes was: an “EMT who remains completely detached and objective and does not allow emotion to affect treatment.” While this survey had a sample size, it provides validation to the informal survey noted previously.

EMS and ambulance services have drastically changed since the late 1960s with the advent of mobile intensive care units and increased coursework in lifesaving knowledge and skills for providers. In both EMT and paramedic classes, the emphasis was and still is on life-saving therapies, while compassion and human interaction have little curriculum related to beside care, compassion and emotional intelligence.

Today, many EMS providers could be better prepared to deal with the emotional trauma patients and their kin are suffering. In my experience and observations, I’ve noticed that a significant number of providers have become very disillusioned when the EMS run is not a “life-saving event. It’s not uncommon for providers to become annoyed with the 75-year-old “Mrs. Smith” who calls 911 at 3 a.m. for a tummy ache that she had for the past two days. It’s not uncommon for our personnel to demean drunks and drug addicts. They don’t see them as humans, they think these patients created their own problems and don’t require or deserve our highly advanced lifesaving services and skills.

These characterizations are represented in the movie Bringing Out The Dead, or the TV series Rescue Me. In these shows, you can clearly see these representations of “us” in EMS. Researchers at John Hopkins found in a study of an ICU that 74% of the interactions of healthcare workers with patients and their families lacked compassion. This is one of the examples of the compassion crisis that Trzeciak and Mazzarelli described in their research. Do we have a compassion crisis in EMS?

“Not for nothing, there’s an old saying that patients don’t always remember what you said or did, but they remember the way you made them feel. Patients should feel safe and relieved in your care; part of that is being heard. A patient that feels as though you are listening and validating what they are saying will not only feel safer, but may be more likely to disclose information that could be medically relevant to their situation comments,” says Tracy Iglesias, BSN, RN, MICN, ACM,CCRN, CFRN. Iglesias has worked in the hospital and the streets of New Jersey. Her comments are supported by a follow-up study of bus crash survivors in Sweden in 2007. The researchers found what victims remembered most was the lack of compassion by the healthcare providers that treated them at several different hospitals five years later.

Dr. Adams comments: “Doctors should never buy into the lie of professional distance. Medicine is an extremely intense profession. Medical personnel daily see such profound human suffering that ‘distance’ may be another term for repression. But without intimacy how can healers offset the pain and suffering they are so helpless to cure?”

When people call EMS, they believe they’re having one of the worst days of their lives. Let’s leave them with the most positive experience. What we as EMS providers should be keenly aware of is that our patients and their family are calling EMS because “they” are having an emergency. While it may be a routine call for us, it may be the worst day of their life, leaving them feeling anxious and scared.

Amy Siefker, an EMT instructor with degree in healthcare, comments on the realities of treating patients clinically, yet adds compassion to the equation. “Granted,” she says, “sometimes we need to move and explain at the same time to provide some sort of comfort as we tend to the patients, but it is doable in most cases. This can’t be taught in class I think it has to be emphasized when you are out there. And seasoned providers should be easily emulated by their volunteers and students- finding the balance of compassion and emergency care.” As previously noted, they won’t remember the clinical treatment, but they’ll remember how we made them feel. Connection, compassion and promoting patient dignity should be the foundation to all patient interactions. It’s not just our job to treat our patients, it’s our job to advocate for their well-being.

Let’s look at the multiple benefits of a holistic approach to managing and treating patients. Over the last 30 years, there has been an increased emphasis on “integrative medicine.” This is about using traditional and non-traditional processes to treat the “whole” patient. A good portion of treatment is dealing with the mental and emotional well-being of the patient. These are processes and practices the Chinese have been using with success for over 3,000 years.

A meta-analysis by Lamers et al. advises of the benefits of emotional well-being toward physical healing, “Higher levels of emotional well-being are beneficial for recovery and survival in physically ill patients.”4 It’s critically important to connect with the patient on an emotional level as noted in the following research article.

A good bedside manner does count after all, Stanford research shows.5 A strong emotional fit between how a patient ideally seeks to feel and their doctor makes it more likely that the patient follows the doctor’s health advice, according to a study by Stanford psychology Associate Professor Jeanne Tsai and Tamara Sims, a postdoctoral fellow at Stanford.

Key to this emotional connection between provider and patient is good communication skills, good listening skills and being compassionate. As the research indicates, good emotional care is as important as good clinical care for most patients. In Compassionomics, Trzeciak & Mazzarelli researched over a thousand research projects and provides compelling evidence that compassion doesn’t only help improve a patient’s mental well-being, but in many cases improves their physical condition.

As found in the research, the key to a holistic mind/body relationship approach to caring for a patient is connecting with the patient, their family and/or caregivers on a personal level. However, having empathy, compassion and understanding are not usually at the top of the character attributes we assess when hiring new EMS personnel. Very little effort is put into measuring emotional intelligence, a key to positive interpersonal  interactions. Most EMS personnel are hired for their certifications, not their compassion. As we’ll find out in this discussion, hiring a person without the right emotional intelligence qualities sets them up for failure.

Our providers work in extremely stressful environments and deal with human suffering on a daily basis. Providers can be disillusioned about what our job really is. Many are provided very little preparation for these encounters. Few are provided the education and mentoring to deal with the mental anguish that their patients and families suffer, along with seeing horrific sights. These experiences can lead to personnel becoming “burned out.” Negative attitudes and belligerent behavior are two of the predominant characteristics of modern EMS providers due to these encounters. Research from the Mayo Clinic demonstrates that “burned out” physicians have a two-times higher odds of making major medical errors. Could this also be the issue in EMS? Burnout not only impacts how they treat their patients, but their coworkers too.

Adams addresses this issue in Chapter 1 of his book. “The blight of burnout is so pervasive in the healthcare system that everyone expects it to happen.” What does that say about healthcare, when burnout is expected to happen, as opposed to something we can easily prevent? Hiring and preparing our people for these challenges is not only key to their performance as EMS providers, but the overall mental wellbeing as well.

Many times, EMS is the first interaction with a person entering the healthcare system and often the longest one-on-one, uninterrupted interaction they will have with a healthcare provider. Although this could be a “typical call” for us, to the patient and the family, it is not. Our first 15 minutes of connecting with the patient could be a much more positive experience if we lived and worked by Adams’ values.

One of Adams’ quotes relates to patient interactions. “They want to have a fabulous listener, they want sweet tenderness and no sense that you are in a hurry,” he wrote. We, as mobile medical professionals, have a responsibility to our patients and their families with balancing our clinical activities along with making the emotional connection with them. In Compassionomics (Chapter 8 “The Power of 40 seconds”) research from Northwestern University finds that it takes a patient about 32 seconds of uninterrupted time to provide a description of their medical issues. In a John Hopkins University study, researchers found it took physicians 40 seconds to deliver a compassionate response to cancer patients to reduce anxiety. In a little over a minute of patient contact time, EMS could develop a compassionate report with their patients. In a little over a minute EMS, could reduce anxiety  and start the healing process.

EMS/mobile medicine is a team sport, whether it’s with just a partner or a group of other emergency responders. We interact with patients and their families in a collective process, similar to the cancer center teams of medical professionals do. All on the EMS run have a role to play in an interconnected manner. The team communicates, collaborates and counts on each other toward providing the best patient experience possible. It’s key that we create a culture in our organizations of holistic care.

Our mobile medicine/EMS agencies need to live and breathe their organization’s core values, mission and vision in order to be a high performing organization. Key attributes to providing high quality clinical care is an organization demonstrating compassion, respect and understanding to all of our patients, their families and other loved ones. A patient’s emotional, social and physical status are all interconnected. All who treat them should have some awareness of all three components of a person’s well-being. EMS/mobile medicine professionals could take a cue from the frequently practiced cancer treatment process that takes a team approach of integrated providers treating patients and their families in a holistic manner.

Creating a culture of holistic patient care doesn’t come from just snapping your fingers and willing it to be so. Besides doing the hard work of building the culture in your organization, it’s involved in recruiting, hiring and developing your people.

In recruitment, you should consider the message you put out as to the type of person you’re looking for. Besides clinical competencies, do you advertise for caring, compassionate and patient providers? Does your recruitment highlight that dealing with people is a skill you use almost 100% of the time?

When interviewing potential new employees, do you build emotional intelligence related questions into your assessment? Do you give equal weight to interpersonal skills as you do for clinical skills and certifications?

When onboarding new personnel, does your initial orientation discuss the importance of getting along with others, with being kind and respectful to their patients? Do you include emotional intelligence and bedside manner skills on the new employee feedback loop? Do you have a formal mentoring program along with your field training? Is the culture of your organization people-centered or performance centered? Are your mentors assigned based on ability to inspire a well-rounded provider or someone who gets the job due to seniority or a certification?

Helping to cultivate a well-rounded person includes developing their level of emotional intelligence – and the ability to be compassionate – is an important component to the professional development of a new employee. I was involved with training new employees and students in one of the EMS agencies I was part of. As part of the field training and mentoring process for new EMTs, medics and students, we emphasized the importance of emotional intelligence in concert with clinical performance. In addition to the interactive discussion on this topic, they were urged to watch Patch Adams to see examples of this being used.

We would then have a discussion of what they learned from the movie and how they could utilize it in their treatment of future patients. It was then reinforced on every patient contact as well as discussed in the after action review report. My observational research during this process demonstrated an increased awareness by EMTs, medics and students of the benefit of increased compassion, as well as incorporating increased attention toward emotional wellbeing as part of the over treatment modality for patients. With new research and data demonstrating the importance of the interpersonal aspects of our job and training in emotional intelligence, related to the ability to know how to treat people with the respect and dignity they deserve. This will increase the patients’ and their families’ quality of life as well as their satisfaction with EMS. In addition, it can positively impact provider job satisfaction and well-being.

Adams’ work is centered around “it takes a village concept” of treating patients. It includes a conglomeration of healthcare and allied workers who are part of the village. It should be that way as well in mobile medicine/EMS. Adams also includes the patient and their family in their care. What a concept – let the patient participate in their own care. A meta-analysis of 127 research projects funded by the National Institute Of Health and Robert Wood Foundation found that patient centered communications from healthcare providers was associated with a 62% higher odds of patient adherence to treatment.1 Based on the science, being compassionate, and have an organization with a culture of compassion is not just a nice thing to; it’s mission critical.

In today’s environment of mobile medicine/community paramedicine/integrated healthcare is all the more reason to break down the borders and collaborate across the spectrum of healthcare and social services to provide community- and people-centric holistic healthcare. We have to stop treating patients like specimens. Time to stop providing one size fits all EMS and transform to comprehensive and collaborative Mobile Medicine that is patient and community centric.

Sara Heath writes in the July 9, 2019, issue of Patient Engagement HIT: “Teamwork between these entities increases the quality of healthcare, reduces repetitive tests, and addresses incongruities in care, which can ultimately lead to better health outcomes….Team-based care may also be a potential tool for reducing physician burnout, an industry-wide epidemic that impacts 83 percent of hospitals.”6 While this is based in the in hospital healthcare setting, there doesn’t appear to be any reason it can’t be transferred to mobile medicine/EMS. Especially since it’s already being done in healthcare, we can add it to the continuum of care. We can expand the village. We can learn from each other.

Another aspect of Adams’ whole community approach to healthcare is being involved in the community. From Adams’ Gesundheit Institute webpage: “The Gesundheit Institute, a non-profit healthcare organization, is a project in holistic medical care based on the belief that one cannot separate the health of the individual from the health of the family, the community, the society, and the world. Our mission is to reframe and reclaim the concept of ‘hospital.’”

From his team’s work around the world, as well as at the Institute, they work diligently at reframing healthcare. While it hasn’t taken off as Adams envisioned, they are working one person, one community at a time at making a difference. The Institute located in West Virginia has a garden, a performing arts room and an art workshop. He invites patients and healthcare providers to come work at the Institute for two weeks at a time.

While it may not be practical to put an art studio or a garden at EMS stations, it provides impetus for thought on how we might better become community and people centric. We should increase our efforts to better understand the culture of our communities, while providing them a process to grow. A way to promote better health, isn’t that our ultimate goal as healthcare providers? To improve outcomes? Adams and the Gesundheit concepts encourage imagination, innovation and exploration.

The following research article, Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health, provides the following perspective: “Research reveals that the opportunities for healthy choices in homes, neighborhoods, schools, and workplaces can have decisive impacts on health. This article reviews scientific evidence from promising interventions focused on the social determinants of health, and describes ways in which they can improve population health and reduce health disparities.”7

It’s up to us all to reimagine EMS into Mobile Medicine for our communities. To understand our community; and to understand the medical, emotional and social challenges the people in our communities are dealing with. We have to look at it at the macro level of our whole community, as well as the micro level of each individual patient. A comprehensive approach of developing a strategic vision that takes a holistic approach to creating an environment of health will benefit your patients and the communities they live in. Bring in all your stakeholders to this process: government, community and spiritual leaders, as well as healthcare, mental health and social services partners.

Break down barriers, silos and borders. Come together with a common vision to improve health. Do it to improve physical health, to improve mental health, to improve spiritual health. Engaging these partners and stakeholders in the community environment will allow you to better determine programs and services that will improve overall community health. Improving community health has the potential to assist in addressing related social problems for patients and communities alike.

Adams’ provides a sage perspective community interaction related to health in Chapter 5. “For more than a million years, human primates have lived in tribes. I’m sure we came together for mutual interdependence in child rearing, security and food gathering.” It would appear we might be able to learn something from our ancestors and bring community to healthcare. However as Adams’ notes further in the chapter: “Community will not sustain itself casually. It requires patience and flexibility, virtues that remove hurdles.” To create this collective of independent, but interrelated community organizations requires commitment to work through issues, to have a shared vision/values that keeps the focus on the mission of better individual and community health.

The same example of how mobile medicine/EMS can start this journey towards creating patient centered, community-based healthcare come from Barbara Prickett Ramutkowski, RN, BSN.

“Invite local ER nurses to contribute suggestions about the EMS – Emergency Room interface,” according to Ramutkowski, who has taught in healthcare for over 20 years, as well as authored a medical textbook. “Perhaps do the same with assisted living and other eldercare agencies. Collaborate with local health departments county, township, whatever you call it, on how to reach patient populations that are neglected or underserved i.e. the homeless and drug addicts.”

It’s time for a paradigm shift to go from individual organizations and agencies interacting in individual spoke and hub relationships to webbed network of interactive relationships where everyone connects with each other in a collective and holistic manner. This process will create an environment where cumulative engagement of all these resources will all contribute to healthier communities.

At a speaking engagement in 2013 to a gathering of medical professionals, Adams suggested “people embark on a vision quest to dream about and discover the kind of care they want to deliver, and to receive.” Engaging all facets of a community with this perspective will allow a collective vision of what healthcare should look like for a community. A participative collaboration from all stakeholders will provide you with a foundation to build a true community based healthcare system – where the emphasis is on health over sickness – and where all parties bring unique contributions to the process that integrates into the whole program.

We, in mobile medicine/EMS have to start in our own agencies to improve organizational culture. In order to improve interactions with patients and their families, these agencies need to take care of their people first. Their most important resource is their human resources. These agencies will be better able to serve their communities when their people’s mental and spiritual wellbeing is being cared for. Key to this is building a high-performing team that looks out for each other and values team over individualism. It will not only help improve quality of patient care and service; it will reduce mental stress related issues. This perspective is supported in the following research.

In meta-analysis research found in APAPsychNET by it was found: “the teamwork climate of a work unit is highly related to the level of engagement that the staff feel in their work. If further details the impact it has on the staff’s strong commitment to, and sense of, ownership to their job responsibilities.”8Further, the research found teamwork quality is inversely related to the level of burnout experienced by staff. These are just two examples of the benefits of good teams, as well as the hazards of poorly performing teams. Based on the research and Adams’ experiences. There is evidence that these important practices will reduce complaints, increase morale and overall job performance. As well as improving the general public’s views, outlook and opinions about EMS providers and the services they provide.

To accomplish this vision of providing more holistic and compassionate mobile medical/EMS does not come by osmosis, it comes from having the passion, desire and commitment to promote positive change on the behalf of our patients and communities we serve. It also comes from developing strategic plans, a roadmap to new territories in healthcare. Joined together with a cross section of allied health and community organizations who will be part of this paradigm shift in prehospital healthcare. Working with interested visionaries such as those who are part of the Congress of Mobile Medical Professionals (CoMMP). This process won’t be easy, but thanks to the work of dedicated medical professionals, like Adams, along with Trzeciak and Mazzarelli and many others, they’ve provided the evidence to support the rationale and purpose behind this journey to a more patient and community centric healthcare environment.

I would like to leave you with this quote from Adams. As he posits to us healthcare providers: “What do we want? What are our dreams and fantasies? How do we band together and work with our communities to make them a reality? Do not be daunted by the enormity of the problems associated with healthcare delivery or with the lethargic pace of change. If you find people of a like mind and desire and are willing to devote your life to a goal, all your dreams-about a new healthcare system, or a new society-are possible.”

The author thanks to the following with their spiritual and English composition skills: Amy Siefker, Mike Taigman, Ed Kensler, Barbara Prickett Ramutkowski, Skip Kirkwood, Tracy Iglesias, Brian Fitzpatrick, Rommie Duckworth and Wes Ogilvie.

References

  1. Trzeciak, S & Mazzarelli A. (2019). Compassionomics. Studer Group [Internet]. Pensacola, Fla. www.studergroup.com.
  2. Carroll, AE. (2015). To Be Sued Less, Doctors Should Consider Talking to Patients More. [Internet]. New York (NY). Available from: https://www.nytimes.com/2015/06/02/upshot/to-be-sued-less-doctors-should-talk-to-patients-more.html.
  3. Adams, P. & Mylander M, (1998) M. Gesundheit. Healing Art Press. Rochester (VT). Available from: www.innertraditions.com.
  4. Lamers, S. M., Bolier, L., Westerhof, G. J., Smit, F., & Bohlmeijer, E. T. (2012). The impact of emotional well-being on long-term recovery and survival in physical illness: a meta-analysis. Journal of behavioral medicine, 35(5), 538–547. https://doi.org/10.1007/s10865-011-9379-8.
  5. Parker C. Emotional fit important between a patient’s desired feelings and physician, Stanford research shows. [Internet]. Stanford (CA). 2015 April 2. [cited 2020 Sept 22. Available from: https://news.stanford.edu/2015/04/02/doctor-patient-emotion-040215/.
  6. Health, S. How to Use Team-Based Care to Improve the Patient Experience [Internet]. 2019 Jul 9 [cited 2020 Sept 23]. Available from: https://patientengagementhit.com/news/how-to-use-team-based-care-to-improve-the-patient-experience.
  7. Thornton R, Glove C, Cené C, Glik D, Henderson J, Williams D. Evaluating Strategies For Reducing Health Disparities By Addressing The Social Determinants Of Health [Internet]. Health Affairs. 2017 Aug 1 [cited 2020 Sept 23]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524193/.
  8. Rosen, M. A., DiazGranados, D., Dietz, A. S., Benishek, L. E., Thompson, D., Pronovost, P. J., & Weaver, S. J. (2018). Teamwork in healthcare: Key discoveries enabling safer, high-quality care. American Psychologist, 73(4), 433–450. Available from: https://pubmed.ncbi.nlm.nih.gov/29792459/. https://doi.org/10.1037/amp0000298.