Feature Overcoming Patient Misbeliefs Patients may hold strong beliefs about their health or health care that are not supported by evidence or facts. How can you best educate individuals without alienating them—and still promote optimal outcomes? By Michele Wojciechowski | December 2015 While working as a physical therapist (PT) in Virginia years ago, Chuck Gulas, PT, PhD, had a patient who held an unusual belief about why she had developed arthritis in her legs. "When she was young, this woman had taken her jeans off the clothesline before they were fully dry and put them on," Gulas recounts. "Her grandmother told her she'd get arthritis as a result. So, when my patient grew up and was diagnosed with arthritis in her legs, she blamed the 'bad choice' she'd made earlier in her life." Patient misbeliefs, and their potentially negative consequences if not corrected, are an issue across health care. Pediatricians, for example, have tried with uneven success in recent years to convince their patients' parents that vaccinations are much more likely to be beneficial than harmful. To cite just 1 startling statistic, only 81.4% of kindergarteners in Seattle, Washington, have received the polio vaccine. That figure is lower than the 2013 immunization rates for 1-year-olds in such developing countries as Rwanda, Zimbabwe, Mongolia, and Sudan, according to World Health Organization data.3 While some health-related misbeliefs stem from ignorance, cultural differences, or linguistic barriers, others are linked to urban legends or myths inspired by family members, friends, or other personal influences. When faced with such misbeliefs, whatever their source, how should PTs respond? Listening is the first step, says Gulas, who now is dean of the Walker College of Health Professions at Missouri's Maryville University. Lend an Ear Although Gulas's patient said she was willing to follow his treatment recommendations, Gulas recalls, she did not initially believe he could help her. Her sole motivation to adhere to his plan of care was that her physician had sent her to him. Rather than tell the woman her grandmother has been misinformed, Gulas engaged her in conversation and got her to open up. "As a physical therapist, you have to be a great listener," he says. "You need to ask questions and show patients they have a key role in their own treatment." In this case, he says, he asked such questions as "What happened to you?", "Why has this happened?", and "What do you think will make your condition better?" Gulas delved further into the grandmother's beliefs, too. This led into a discussion about the patient's life and health views. "I wanted to keep the conversation going and let her know that I was listening," he says. "I felt sure that other health care practitioners had cut her off as soon as she shared her incorrect belief. " Herb Karpatkin, PT, DSc, NCS, MSCS, echoes Gulas's views on the power of listening and the necessity of ensuring that patients feel heard. Karpatkin, an assistant professor at Hunter College of The City University of New York and owner of Herb Karpatkin Physical Therapy, primarily treats patients with multiple sclerosis (MS). Most people who have the disease are unaware that physical therapy can be extremely helpful to them, he notes. Many, in fact, believe it will make their condition worse. "I'd never tell those patients they're wrong," Karpatkin says. "Were I to do that, they might go away and never come back. Instead, I start by simply asking them what they believe, and why." This not only shows his interest in their personal story, but it gives him information he can use in formulating what he feels will be his most effective response. The way Nicole Taniguchi, PT, GCS, puts it is, "I encourage a feeling of openness and try not to judge." She is acting manager of therapy services (physical therapy, occupational therapy, and speech-language pathology) at the Alaska Native Tribal Health Consortium, which is based in Anchorage. "I always ask patients who are noncompliant what their rationale or reasoning is for having veered away from their home exercise program—and if they are resistant generally to accepting medical advice, why that is." "I listen for the source of the misinformation," says Lisa VanHoose, PT, PhD. "Is it a family member, a friend, or an item the patient read on the Internet or elsewhere?" VanHoose chairs the physical therapy department at Hampton University in Virginia and is the owner of VH Consulting LLC. "That 'source' information is useful in determining how to approach the misbelief." VanHoose works primarily with cancer survivors. That population and their family members — like patients with MS and their loved ones — often believe that exercise and physical activity will do more harm than good, and are unaware of the wealth of research showing the exact opposite to be true. "Such misbeliefs," VanHoose notes, "often adversely affect adherence to home exercise programs and/or instructions to increase physical activity throughout the day." It's at this point that PTs must step in and enlighten their patients, say the clinicians contacted for this article. Teach, Don't Preach Knowing he would need to educate his patient with arthritis in a way that would, well, have legs, Gulas calibrated incremental response to her misbelief. He purposely did not broach the subject during her first treatment session — although, had she erroneously believed something that already was negatively affecting her health, he would have. In this instance, his strategy was to wait and establish trust. The most important thing for PTs to do before sharing corrective information with a patient is to determine how best the patient will receive it, VanHoose says. "Some patients respond best to a credible source, such as published evidence, that refutes the misinformation," she notes, "while others need to hear how the intervention or technique proposed by the PT benefited other patients in similar situations." The latter scenario played out in the case of Gulas's patient. A physical therapy aide who was working with Gulas heard about the patient's belief in her grandmother's statement. As it happened, the aide's grandmother, too, had believed that wearing damp jeans would cause arthritis. At Gulas's urging, the aide told the patient, "My grandmother believed that, but we now know that it isn't true." That first-person encounter, combined with the realization she was starting to perform better, convinced the patient of physical therapy's efficacy and her own need to buy in more seriously to her treatment. Different patients learn in different ways, VanHoose notes. While it's appropriate to bring evidence into the conversation, for example, it's important that PTs be sensitive to patients' literacy in general and health literacy in particular. "Everyone digests information differently," she points out, "so evidence may need to be presented in an auditory, visual, or kinesthetic manner to ensure patient comprehension. Take-home information can reinforce that message and facilitate further discussion during the next visit." Taniguchi employs a variety of educational methods to communicate information. "What a patient hears and thinks sometimes is different from what I actually said," she says. "When I can demonstrate my words by using models and pictures, the messages tend to come across more effectively." VanHoose has seen instances in which health care professionals became confrontational with patients in the process of educating them. That's always counterproductive, she says. Rather, PTs should pay close attention to what their patients are saying and note their nonverbal language. Doing so will determine the patient's level of readiness for receiving information that contradicts his or her beliefs. Karpatkin shares an instance in which taking a measured approach reaped dividends. His patient—a young, well-educated woman with MS—was reluctant to exercise more because, she said, it made her feel worse. He tried to convince her she'd feel better in the long run, but he wasn't having much success. When he engaged her in conversation about what form of exercise, specifically, she was referencing, he immediately realized what the problem was and why her misbelief was being reinforced. The woman had gone for a bike ride a few days before, Karpatkin learned, and, by the time she had finished, she felt that her symptoms were much worse than they had been before the ride. The PT explained to her that what she was experiencing was "pseudo-exacerbation"—false exacerbation—of her MS. The demands of cycling had increased her core body temperature, which heightened her symptoms. The condition is temporary, Karpatkin explained, with no adverse long-term effects. The patient confirmed that she felt better soon after the ride was completed. Still, she had lingering doubts that exercise was advisable. Karpatkin and another MS specialist at his practice then sat down with the patient and explained the physiology of what happens to her body before, during, and after exercise. Both men were instructors, so they shared PowerPoint presentations and literature in order to educate her. They were cautious not to bombard her with evidence. Of equal importance, they were careful not to discount what she reported having experienced. "We illustrated and explained why not exercising would make things worse for her, because she would get weaker and weaker," Karpatkin says. Once she understood why she needed to keep exercising, her hesitation disappeared. After that, she adhered faithfully to the recommended exercise program. "I consider what I'm doing to be partnering with my patients," he says. "My role is not just to render therapy, but to make the patient as knowledgeable about the process as he or she possibly can be. The more educated my patients are, the better they're going to do with their physical therapy." When Karpatkin has patients who share misbeliefs, he often asks them where they are getting their information. If it's something they're read, he takes the time to review the material with them and calmly and dispassionately explain what is fact, fiction, and half-truth—and why. He reassures them by pointing out that he has treated scores of patients with their condition, and that, by working together, his patients and he have achieved great results. Karpatkin often shares anecdotes about other patients he's treated—what the problems were, which approaches he used, and what improvements resulted. PTs also can tap online technology to educate patients. Gulas recommends using YouTube videos to explain information. If you understand patients' beliefs, he notes, it's easier to choose the videos to which patients are likeliest to respond. For example, if you know that the patient respects health care providers, choose a video in which a health care practitioner is giving the demonstration or delivering the explanation. If, on the other hand, the patient is likely to respond better to testimony from someone who "looks like" him or her—roughly the same age and ethnicity—seek out a video that "stars" such an individual. Gulas tells new PTs that they may need to repeat information a few times. "Patient education is not a 1-time discussion," he says. "The next time the patient comes in, you may have to go back over everything you said in the previous session. We must be ready to educate again and again, and we can't show any sign of impatience. If we betray any frustration, we're not going to be as effective in educating the patient or achieving desired outcomes." Still, VanHoose says, PTs must realize that even after they've done everything they can to educate patients, their decisions may not always be based on facts. "Those choices are patients' to make," she notes. "My recommendation," she adds, "is to document the education provided to the patient, the patient's response, the patient's decision, and the potential impact of that decision on the therapeutic plan of care." Honor Belief Systems Trickier to navigate in some ways can be strongly held cultural or religious beliefs that may affect patients' approach to their health or health care. As with beliefs that stem from factually erroneous information, PTs should respond respectfully and constructively. Nicole Taniguchi recalls a patient who had sustained a tibia/fibula fracture but felt that the external fixator used to keep her fractured bones stabilized and in alignment had been removed prematurely. She reported pain and told Taniguchi that, without the device, she felt as if her foot was unstable. This made her fearful to walk. Taniguchi showed her the most recent X-rays and assured her that the orthopedic surgeon would not have removed the fixator were it still needed. The patient was not mollified. Taniguchi approached traditional healers in that area of Alaska, knowing that her patient was influenced by the healers' beliefs. How could they help her better accept the fixator's removal? One healer noted a traditional belief that the human body holds memories of its ancestors and that if a foreign body—such as metal—is introduced, conflict can arise. He recommended that Taniguchi tell his patient that some pain is to be expected as a result, but that removal of the device was a good thing, and that the patient's ancestors would help her heal. Taniguchi told her patient what the healer had said. From that point on, she reported less pain, and was able to work through it without anxiety as the pain further diminished. "When patients' beliefs are different from what I learned in PT school, I acknowledge it," says Taniguchi. "I never say anything negative. I cite facts, while being sensitive to cultural and religious beliefs that may play a role in the patient's health behaviors. Even so, sometimes it isn't until the patient sees improvement that he or she will accept that physical therapy is working." The relationship between PT and patient never should be contentious. "It's appropriate to challenge incorrect information, but always do so in a respectful manner," VanHoose says. "Never be condescending," And remember this important fact, she adds: "If you feel that a patient's misbelief is placing you in an ethical dilemma, or that you simply can't get through to that individual, you can decline to provide services, and recommend that the patient see another PT who might better meets his or her needs." "Respect must go both ways," VanHoose observes. "The patient should respect that you are the movement expert, but you, in turn, should respect that the patient is the expert when it comes to his or her body and learned life experiences." Maryland-based Michele Wojciechowski is a frequent contributor to PT in Motion."Wise" AdvicePTs can have misbeliefs, too. While PTs' misbeliefs may not have roots in a grandmother's conviction, an urban myth, or a cultural practice, they, too, can be detrimental to patients and the health care system.That's why APTA became 1 of more than 50 medical specialty groups to release a "Choosing Wisely" list as part of a multiyear effort of the same name. Led by the American Board of Internal Medicine, the initiative engages and supports health care providers in being "better stewards of finite resources." Choosing Wisely participants are charged with highlighting health practices and procedures that either aren't support by the evidence or should be employed only in limited circumstances.In September 2014, the association released "Five Things Physical Therapist and Patients Should Question"—practices and procedures that that tend to be carried out frequently but whose usefulness in some scenarios has been called into question by evidence. In other words, ways of doing things that are "tried," yes. But "true"? Maybe not."The whole purpose of the multiprofessional Choosing Wisely campaign is to encourage conversations about the types of patient treatment care that are truly necessary, based on the best available evidence and the patient's unique circumstances," says Nancy White, PT, DPT, executive director of the Arlington (Virginia) Free Clinic and formerly executive vice president for professional affairs at APTA. "Health care practitioners can use the campaign's documents to further their own conversations with patients, and as guides to use health care resources in the most appropriate and economical manner."APTA's 5 recommendations are:Don't use (superficial or deep) heat to obtain clinically important long-term outcomes in musculoskeletal conditions.Don't prescribe under-dosed strength training programs for older adults. Instead, match the frequency, intensity, and duration of exercise to the individual's abilities and goals.Don't recommend bed rest following diagnosis of acute deep vein thrombosis (DVT) after the initiation of anti-coagulation therapy, unless significant medical concerns are present.Don't use continuous passive motion machines for the postoperative management of patients following uncomplicated total knee replacement.Don't use whirlpool for wound management.The explanations of those recommendations, a downloadable copy of the list, and other information on APTA's Choosing Wisely participation and the broader campaign are available at http://Integrity.apta.org/ChoosingWisely/.