Introduction

“The heart has its reasons which reason knows nothing of…We know the truth not only by the reason, but by the heart.”

—Blaise Pascal

The above quotation has resonated with me throughout my adult life. It was the heart’s reason that inspired me to become a physical therapist. I came to that decision when I was still very young, and I never wavered from it, even as I began to navigate the difficult path toward attaining a degree and credentials.

My first role as a physical therapist was treating soldiers. These were patients that placed their full faith in the practitioner’s hands so they could diligently and quickly return to the field and fulfill their mission. The immediate feedback in terms of outcome and gratitude from these loyal soldiers enduring my early career in the US Army confirmed and solidified my decision to become a PT. As I entered the private practice world in the late 1980s, these same intrinsic motivators remained high for many years—until significant systemic changes began to derail the motivation of myself and others. These changes were the impetus for this book.

There have been two major occurrences in healthcare that, in my opinion, have had undesired effects for most providers. For many of us, these occurrences have reduced our calling to purposeful work and generated unprecedented levels of attrition, burnout, and disengagement. Over the past several years, in an attempt to make healthcare more efficient, various “process improvements” (excessive documentation, regulations, and a variety of other hoops and ladders) have replaced time spent with patients. External studies have documented that as much as 25 percent of a provider’s time is not spent with a patient. Our internal studies show that for physical therapy encounters, the time spent away from patients is even greater. This time is now spent on unrelated but required administrative and insurance tasks that distract from provider–patient relationships and generally make healthcare worse for everybody.

The move toward and emphasis on evidence-based practice has also had another unintended and unfortunate consequence: providers now all too often focus excessively on techniques and proven interventions while overlooking cognitive or tacit knowledge skills—like how empathy, listening, communication, and collaboration can also affect healthcare outcomes. This unbalanced approach furthered my desire to put humanity back into healthcare and share what the research has to say about the so-called “soft” skills in medicine.

I have worked my entire career to make physical therapy a paradigm for innovative healthcare and have played various roles, including lobbying with colleagues to urge the passing of legislative changes in Kentucky, such as legislation bringing parity to physical therapy and primary care co-pays. This new legislation was a huge win for the physical therapy profession as it helped set a precedent for other states around the country where physical therapists were seeking similar change. I have also helped launch state and regional provider networks and coalitions whose mission is to improve business conditions for independent physical therapy practices nationwide.

My most recent years have been spent highlighting the cost-effectiveness and efficacy of “Physical Therapy First,” which occurs when a patient accesses a physical therapist first for care after experiencing a musculoskeletal ache, pain, strain, or sprain and in particular if they have cervical or low back pain. When followed, patients benefit from faster recovery without drugs, imaging, or surgery, and employers and insurance companies benefit from resolved claims at significantly lower costs. Working with a variety of collaborators, this approach has proven out empirically in many markets across the US.

But throughout my career, I have been attracted to and intrigued by the nonclinical indicators of clinical success. For example, I have long wondered how a supervisor simply calling a work-injured patient within seventy-two hours of injury and telling him or her how much he or she has been missed might have a greater impact on whether this person comes back to work than various interventions, medications, and the passage of time. Or how is it that a subset of injured Army officers, upon learning that their x-ray results are normal, can have immediate and almost supernatural recoveries? Why did every one of my Haitian patients, following the 2010 earthquake, seemingly leave after treatment with a wide-eyed, so-called Duchenne smile despite my ability to offer only rudimentary interventions in substandard medical conditions? To the contrary, why do certain words and phrases inadvertently influence adverse effects or what is known as nocebo? We know that such nonclinical factors or what some call bedside manner are premier influencers of clinical outcome. The best current evidence refers to a more holistic “therapeutic alliance” and has garnered significant research interest.

My infatuation with this topic eventually led me to study the science of positive psychology via the University of Pennsylvania’s Master of Applied Positive Psychology Program (MAPP) where I soon discovered there was plenty of “reason” for these occurrences in the form of research. In 1998, Dr. Martin Seligman, incoming president of the American Psychological Association (APA), had challenged the field of psychology to broaden its focus to study and implement interventions that went beyond human problems and pathology to include the study of human strengths and well-being—basically, what’s going right.2 He thus initiated positive psychology, which is “a science of positive subjective experience, positive individual traits, and positive institutions.”3 Positive psychology takes a “strengths-based” approach to studying the specific ways people can build on their talents, skills, and values to generate greater happiness, success, and fulfillment. It is ripe with implications across a broad spectrum of professions, among them education, organizational scholarship, and healthcare.

Positive psychology literature has grown rapidly in significance since Seligman’s challenge in 1998, generating over 18,000 scientific papers (2,300 were published in 2011 alone) and representing over 4 percent of PsycINFO, which is the largest source of psychological literature.4 Still, there is little to no integration of its diverse topics within the healthcare profession, and the literature is even sparser in the field of physical therapy.

Most recently, I have been focused on integrating positive psychology into the clinical practice of physical therapy and healthcare in general. I began by going back to school and getting a master’s degree in Applied Positive Psychology from the University of Pennsylvania. This program, under the direction of Dr. James Pawelski, was the first of its kind worldwide and was created by none other than Dr. Martin Seligman.5

In this era of enormous societal change, the pressure is now on healthcare executives to identify, adapt, and configure relevant healthcare technologies to yield greater efficiencies, reduce costs, manage greater transparencies, and cope with an environment now beset by rules, regulations, and insurance requirements. In 2014, the Physicians Foundation conducted a survey which received responses from 20,088 medical doctors and was reportedly the largest and most comprehensive survey of physicians as of that date.6

The survey contained some remarkable results:

• Over 51 percent of respondents were pessimistic about the future of healthcare
• 38.7 percent of respondents reported that medicine and healthcare were changing in such a way that they planned on accelerating their retirement plans
• 50.2 percent indicated they would not recommend the profession to their children
• 28.7 percent of respondents said they would choose a different career if they had to do it all over again
• Physicians noted that they were spending less time on patient care because paperwork was consuming 20 percent of their time
• Over 55 percent described their professional morale and feelings about the state of the medical profession as negative7

As a result of so many changes, compassionate care is all too often being replaced by institutional care characterized by electronic medical records (EMRs), coding, and algorithms. This is an unintended consequence of the focus on evidence-based practice, EMRs, and compliance, and it has resulted in provider burnout and patient dehumanization as demonstrated in the survey results. Provider burnout impairs patient outcomes,8 and dehumanization denies distinctively human concern for another human being9—particularly through the practice of depersonalization. First identified by the renowned psychoanalyst Isabel Menzies Lyth in 1960, depersonalization is...