Emory University | Woodruff Health Sciences Center
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The Human Element of Practice

Connecting with patients and their stories for better outcomes

By Dana Goldman, Illustrations by Josée Bisaillon

Story Photo

Katherine Voorhorst 15DPT remembers the question that changed the course of treatment for her patient, a double amputee: "Will you read some of my poetry?" he asked.

That patient was Hugh "Eddie" Suggs, a former teacher who had been doing yardwork five years earlier when a log truck jumped a curb and ran over his legs. "I wasn't supposed to live," Suggs says. But after a drug-induced coma, 150 units of blood in 24 hours (a hospital record), loss of both legs, multiple surgeries, and skin grafts, he found himself not only alive but in physical therapy.

"I couldn't really move or hardly get out of bed," Suggs recalls. He was also struggling with post-traumatic stress, serious physical pain, and questions about his future. "I coped by developing personal relationships with my caregivers," he says. "My writing was a tool I used to try to do that."

Some of his physical therapists weren't interested in Suggs' life outside physical therapy, much less the inner life he expressed in his poetry. But Voorhorst had already shown interest in who the man was beyond his amputations. She'd been trained by Emory professors—including Sarah Blanton and Bruce Greenfield, among others—to see her patients as more than just a constellation of symptoms and to recognize physical therapy as more than just a scientific discipline. She regularly asked her patients about their days, their goals for therapy, their pets, and whatever she learned mattered to them—including poetry.

The next session, Suggs brought in a poem he'd written about the truck accident in which he'd lost both legs.

"I listened and we cried for a minute," Voorhorst recalls. "And then he looked at me and said, 'All right, let's do this PT.' Afterward, he told me it was the most productive therapy session he'd had—and he'd been doing this for three years."

That productive therapy session couldn't have happened without Voorhorst showing personal interest in Suggs.

And now Emory's Division of Physical Therapy is working to ensure that connecting with patients becomes the norm, not the exception. It's part of an effort to explore the many ways that humans experience life and make sense of it—and to link the humanities in general to physical therapy in particular. Students are learning about careful listening and the importance of understanding a patient's needs, values, and goals. Students are searching for the meaning that patients ascribe to their illness and life paths.

Faculty created this initiative to foster reflective practice and patient-centered care. After all, the effectiveness of physical therapy is clearly linked to the strength of the relationship between a patient and a physical therapist, says Bruce Greenfield, PT, PhD, associate professor of rehab medicine. "We have to appreciate that at, its essence, health care is a relational practice. You're dealing with human beings," he says. "When you're caring for human beings you have to learn to treat the patient not as an object to be diagnosed, but as a human being to be cared for, with feelings, needs, fears, expectations, and goals."

Associate Professor Sarah Blanton, PT, DPT, NCS, agrees. "Hearing each other's stories is a diagnostic tool, and it's also a way to create strength in the therapeutic relationship," she says. "A good therapist may help the patient with his goal, but a really excellent therapist understands the meaning behind the goals." It's one thing to help a patient with stroke relearn how to change her child's diaper; it's another, Blanton says, to understand that a patient desperately wants to regain her sense of identity as a mother.

Such understanding and clinical wisdom doesn't come overnight. But faculty members are working to cultivate that clinical wisdom by including narrative reflection experiences throughout the curriculum. Students write regular reflections on clinical experiences, including not just what happened, but what they felt, saw, heard, and might do differently in the future.

Greenfield was one of the faculty members who initiated the curriculum-wide use of reflective narratives after realizing, almost a decade ago, that students had no formal way to process their intense and sometimes profound clinical experiences. He also was the lead author of a 2015 article in the journal Physical Therapy highlighting the pedagogical tool. "One of the dimensions of expert practice is that experts are lifelong learners and use ongoing reflection," he says. "They're continually reflecting on experiences—trying to determine what happened, what went wrong or right, how they felt, what they learned, and how they would handle a similar patient in the future. We try to train our students like experts as early as possible through the narrative process of reflection."

Students write about a range of topics, including difficult cases, worries about their own competence, and efforts to overcome biases. Rob Koester 15DPT, CSCS, studied the humanities as an undergraduate and says that narrative reflection was an important tool during his clinical rotations. Says Koester, "Narrative reflection gave me a prescriptive way to digest these sometimes really tough encounters in such a way that I felt I gained some insight and was better equipped to handle similar situations in the future."

Emilly Marshall 17DPT remembers one particularly useful reflection after a difficult day. She was working with an elderly woman in a hospital when a doctor came in and told the woman that her husband was dying across the hall. "The doctor was just calm and realistic about it," Marshall remembers. But Marshall wasn't sure what to do. "Do I step out of the room? Do I stop our session?" she remembers thinking. "I'd never been faced with a patient experiencing the death of a spouse."

That night, Marshall cried when she thought about her patient—and then sat down to write her reflective narrative. "In the moment you're trying to think and act and adapt to whatever your patient is giving you. But reflecting makes you see it from the outside," she says.

"Not only am I able to judge myself," Marshall says, "but also at the same time ask, 'What could I have done differently?' or 'What does this mean?'" In other words, Marshall was doing exactly the sort of reflection that her professors had hoped for—the kind that leads to clinical competency and, in the long term, wisdom.

Emory physical therapy professors know that incorporating the humanities also means raising awareness of the human experience in all its forms. That's what spurred Blanton, Greenfield, and division director Zoher Kapasi to work with humanities scholars within the rehabilitation sciences to create a new, open-access, online publication—The Journal of the Humanities in Rehabilitation (JournalofHumanitiesinRehabilitation.org).

And while the scholarly, peer-reviewed journal includes research, it also values the knowledge, experience, and stories of patients, caregivers, and others outside the field of rehab—including artists who focus on the human form in movement.

One recent issue featured an article about representations of trauma in the art of Frida Kahlo, who struggled with illness and pain throughout her life. It also showcased interviews with Pulitzer Prize-winning writers Natasha Trethewey and Margaret Edson.

In other words, The Journal of the Humanities in Rehabilitation is an interdisciplinary, academic journal that would consider Suggs' poetry an important part of the canon in the field of physical therapy. After all, says Blanton, "It's critical to listen to each other and hear the stories of our journeys. That's an important piece of having narrative reflections and space for patient and family reflections. This is a critical way to hear their voices."

Those voices have included Dick Taylor, a contributor to the journal who survived a stroke in 2013. Lines from his poem "Ode to a Stroke, or a Life Altered" detail the experience of losing control of his body:

How astonishing our bodies,
Intricate machines to behold,
Easily functioning,
Without being told!
Until…..that nightmarish instant,
Unforeseen, unexpected, unwarranted, unfair,
When an explosion of cranial havoc,
Renders me motionless and unaware.
I look at my lifeless arm,
I tell my hand to grip, to clasp,
And wonder why it won't respond
Nothing works, "my God!" I gasp!

"I was inspired by the stroke," Taylor says now. He hopes that physical therapists and others will, in turn, be inspired to remember their patients' humanity. "I hope professional people who work with stroke patients can get a better perspective on what stroke patients are going through," he says.

Voorhorst, who was one of the students who worked on the journal, echoes Taylor's sentiment. "I hope it prompts a different, really deep reflection from clinical professionals. I hope it gives us a moment to take a step back and re-evaluate the sorts of clinicians we want to be, the types of caregivers we want to be."

The Division of Physical Therapy is also collaborating with Emory's anthropology department on an upcoming course: Disability, Resilience, and the Mortal Self. "The idea is to begin to understand concepts of human normalcy and resiliency within the context of disability," says Greenfield. The course was developed by professors and students as a cross-discipline, multi-campus offering focusing on the philosophical and conceptual understandings of disability. Emory's Coalition of Liberal Arts chose it from among many new course applications for funding.

Meanwhile, Voorhorst and Suggs have both moved on since meeting during Voorhorst's clinical rotation. Voorhorst graduated in May and will soon be working with an inpatient neurologic team. Suggs is in the cusp of publishing two books: one a fictional story and one of personal poetry. But they stay in touch. Lines from his poem "It's All Good" show that he's continuing his physical and emotional recovery:

You shift your weight around in the wheelchair.
Some stuff just takes longer.
Can't see the wheels of the loaded log trailer running
over you anymore not unless you really try.
So quit trying to remember a moment that can't be changed.
Plenty of other stuff in there took pieces of you for
souvenirs anyhow.
Just pet that old dog
and sip your coffee.
Sun sure feels good this morning.
It's all good.

Suggs's ability to write more upbeat poetry is, in part, related to his ability to connect with caregivers like Voorhorst. "I don't know if I would have recovered if I hadn't worked with people who really treated me as a person," says Suggs. "People like Katherine [Voorhorst] are what pulled me along and kept me going."

editorial board

The Journal of the Humanities in Rehabilitation editorial board and contributors. From left (seated): Emory division director Zoher Kapasi, Katherine Voorhorst 15DPT, patient contributor Dick Taylor, and Emory Associate Professor Bruce Greenfield. From left (standing): Emory English doctoral student Stephanie Larson, Emily Marshall 17DPT, University of Minnesota Professor Jim Carey, Emory Associate Professor Sarah Blanton, Dean and Professor of Physical Therapy at Creighton University Gail Jensen, Nancy Kirsch, director of the DPT program at Rutgers University, and Aimee Reiss, 03DPT, managing editor and researcher.

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