What is the golden standard of healthcare today? Medical professionals are operating in a more disconnected environment than their predecessors. Compliance standards and excessive documentation keep them in front of computers instead of patients, and low reimbursement rates mean packing the day with appointments and sacrificing quality of care. Dr. Larry Benz is finding ways to humanize healthcare again. In his new book, Called to Care, he shows how to ignore constraints and build quality connections by treating patients as people, not numbers.
He and his team know that patients who feel heard are more engaged in their treatment and more patient engagement equals better outcomes for everyone. His book is about reconnection, claiming your compassion, restoring your patient relationships, and reviving your calling.
Drew Applebaum: Hey listeners, my name is Drew Applebaum and I’m excited to be here today with Larry Benz, author of Called to Care. Larry, excited you’re here, welcome to the Author Hour podcast.
Larry Benz: Thank you, appreciate the opportunity.
Drew Applebaum: First, tell us a little bit about your background and then we’ll get into what inspired you to write this book?
Larry Benz: Yeah, thank you, I’m president CEO of Confluent Health. Nobody’s ever heard of Confluent Health but it is literally just the holding company that owns three inter-related businesses. Probably our most noted is our outpatient physical therapy clinics, we have various name brands in about 14 states, and they are all outpatient PT.
We have some occupational therapy, lots of sports medicine, where people go for aches pains, sprains, and strains. Then we have a company called Fit for Work, which does on-site work injury prevention management in about 900 sites throughout the US. So, think manufacturing companies, any places where people have higher injury rates than normal.
Then our third business is called Evidence in Motion, and we started this over 15 years ago. It’s an education company that initially trained physical therapists, once they became licensed–think residency, continuing education, fellowships, and certification programs, but is now partnered with universities across the country to deliver entry-level physical therapy graduates, which is a two-year post graduate program that culminates and then they become a licensed PT. I have the pleasure of leading over 3,000 plus employees who have had incredible growth over the last several years. That’s my day job.
Drew Applebaum: And your new job is author. Congratulations on finishing your book. What was the inspiration to put your words on paper?
Larry Benz: My background, I’m a physical therapist. I have some additional degrees on top of that, I went back and got an MBA, I’ve got a masters in applied positive psychology, and I’ve got a doctorate in physical therapy. One of the things I noticed as a physical therapist–my career started in the mid-80s, I was in the military and the military has a tremendous healthcare system and at that point, we were allowed to treat patients and order X-rays and medications and things like that.
I was always sort of infatuated by what I’ll call the “nonclinical indicators of clinical success.” So, how you talk to a patient, your bedside manner.
If I told a patient their X rays were normal, there was a subset that automatically got 100% better. There was a study done on a Boeing that basically, if you called a worker’s comp patient within two days of being hurt, regardless of what their injury was, and said look, we care about you, we miss you, when are you coming back to work? That had a bigger predictor of them coming back to work than what I was doing in physical therapy with them.
I was kind of caught up in this, call it placebo, call it bedside manner, does any of this really impact the clinical outcome? That stayed with me throughout my career. In addition, I did some work in Haiti, under rudimentary conditions and would find that just simple things will make patients a lot better, such as the way you smiled with them.
On top of all this, running a business, we tried to differentiate our physical therapy care along three dimensions, the first two are what we did for many years.
Those two dimensions were customer service training–how can we have the best customer service? We have a program called amazing customer service that we defined, teach, live, and reward. Then we have our evidence-based practice, our clinical excellence, and these are therapists that are board certified, they contribute to third party outcomes, surveys that are done by independent folks that show what our patient loyalty is, our patient satisfaction, what our clinical outcomes are and we did pretty well with those as a company.
Then I noticed there were really two things that were happening in the field that were particularly bothersome to me. One is we’re starting to see providers, not just PT’s, but physicians, over 50% in some studies show that they’re burned out. The other thing that started to happen was there became an overemphasis, in my view, of what is known as best evidence, meaning that I have to be able to recite three studies before I can do an intervention to tell you why it works, and all the studies to show that it works, even though there’s a plethora of things that work that we don’t have evidence for.
The combination of those two, coupled with insurance, declining reimbursements, and regulations, caused a reaction where you had to start seeing a lot more patients to make the same amount of revenue. It became a factory approach, a how much coffee can I make approach. All these things laid heavily on me and I said, you know, there’s got to be a better way. How can we take kind, compassionate, empathetic care and make that highly differentiating so that providers will reclaim their passion and their calling for the work that they do, which is always a meaningful job?
It will also make the clinical outcomes better for the patients. Then lastly, how does that differentiate me from a value proposition in the marketplace as a company that does care. That led me to really start to study the evidence behind these soft skills or empathy and all of these kinds of kind compassionate care traits. What you find is there is significant applied positive psychology research that can be transported into healthcare, but nobody’s really ever done it.
We emphasize it, but what is the evidence? The book really is a culmination of that journey and it specifically takes all of those interventions, techniques, and these communication patterns and it says, this is how you make your patients better. On top of that, you’ll have less burnout, you’ll have a renewal in your career and as a company, and if you adopt these principles, you’ll be highly differentiating in the marketplace that you work in.
The Called to Care Approach
Drew Applebaum: Yeah, let’s dig into those. In the Called to Care approach, you want to accomplish three primary objectives. What are those objectives?
Larry Benz: The Called to Care approach, the first and foremost is that you want to enhance a better clinical outcome of care for your patient. You have the direct intervention, the hands-on skills if you will, these are the soft skills like high-quality connections and empathy–it’s self-efficacy and goal setting and peak-end effect and all of these interventions that we discussed in the book. By implementing them, you’ll enhance and improve the clinical outcomes, the goals that they set. That’s the primary objective.
The second objective is that as a provider, if I have better empathy, counterintuitively, I’ll have better quality work relationship. I’ll have enhanced self-esteem and I’ll have enhanced self-efficacy and I’ll have renewal, meaning less chance of burnout, and more zest for my career. The second principle is the element of renewal and reestablishing that, I chose this job because there’s meaningful work. That’s why it’s Called to Care because you were called to do that job.
The third avenue is, by implementing this, your clinic, your company, your physician’s office, your hospital, you can be more differentiating in the marketplace. This is never more important than it is today, when we have the COVID period and where lots of care is turned into telehealth, which is a much-needed modality of delivery, but studies show you lose empathy. You lose the ability with patients to see them in the eyes, see their facial expressions and their posture. All this is very timely right now and those are the three primary objectives.
Drew Applebaum: Yeah, people love numbers. How did you test the efficacy of the Called to Care approach?
Larry Benz: Yeah, it’s a great question. We did it a number of ways, the biggest thing we did is part of the study–my original study was when I was working on a thesis at the University of Pennsylvania, The Marty Sullivan program called MAPP, Masters in Applied Positive Psychology, which is essentially a blended or a hybrid program. You go on-site four days a month and then you do a thesis around your area of interest, and my area of interest is healthcare.
We trained 1,300 physical therapists and since then, we have replicated this in many different professions with the Called to Care principles. So, we tested the empathy and the patient’s response with self-administered reports prior to training. And then how did they react once the therapist went through all of this training and what did their outcomes look like? This is oversimplifying it, but when you teach therapists to be empathetic, they have better connections, they have positive interactions with their patients, and it results in enhancement of the patient’s experience and better clinical outcomes.
Drew Applebaum: You talk about high-quality connections and connection building, can you tell us what that feels like? What does a high-quality connection really look like between a practitioner and patient?
Larry Benz: Yeah, the biggest thing we stress with high-quality connections is the mutuality of the relationship. How am I really connecting with a patient so that they know that I care? Well, that occurs through a number of what are traditionally called soft skills–being empathetic, engaging in empathetic listening, which is taking the perspective of the patient, recognizing what they’re saying is their truth, and their perspective.
There is the emotional sharing behind this, meaning that I as a therapist may not have the exact experience that they’re telling me about but a similar experience that I can draw on and then share that emotion. Then the combination of these effective and cognitive types of empathy, really motivates me towards pro-social concern or action.
Now, oftentimes, we call that compassion, which is not just recognizing what’s going on, but actually doing something. I think underlying all of that is not having too much judgment about the patient. You know, it is really difficult to turn off judgment and make it non-judgmental.
So, it’s really the quality of the listening, and allowing the patient to speak their truth. What’s happened in healthcare is because of the time constraints, a lot less listening is going on. You typically rush in and this is the diagnosis. When we test medical practitioners for empathy, it’s interesting that physicians actually have quite a bit of empathy while they’re in medical school, but it drops off when they graduate.
With physical therapists, what we find out is that they have empathy but it’s really the pro-social concern, and they want to rush right into the action. I see you are a patient, you tell me your back pain, and I rush to start doing the interventions and the exercise and the manual therapy for your back pain. Rather than listening to your expressed needs and your unexpressed needs. In a nutshell, that’s what really facilitates a higher quality connection with a patient.
Empathy in Action
Drew Applebaum: You mentioned empathy in action and do you have any cases that you remember of empathy and action really changing the course of a patient?
Larry Benz: Many, without a doubt. One of the cases I talk about in the book is a patient that came in as a diabetic with some multi-system disease. It really manifests itself in a number of ways with neuropathy, with pain, and one of the techniques we talked a lot about is called emotional handling, which is really being able to ask about feelings and acknowledging and then legitimatizing the patient’s emotions. Because oftentimes, we ask really objective questions–who, what, when, and where, how did you get hurt, how much does it hurt–we don’t’ ask the subjective questions.
With this particular patient, the therapist, after going through empathetic listening and emotional handling and a little bit of mindfulness, and acting with great humility, was able to draw on their emotion of their own grandmother, who is a serious diabetic. He then relayed the story of her to the patient and they both developed this incredible connection. Diabetic patients, they have a compliance rate of maybe 50%. We track this stuff very closely and this particular case, the patient came in for 100% of our treatments, got much better care, much better outcomes, and was taught all kinds of self-management coping skills, and behavioral skills and is just flourishing despite having what is a very difficult diagnosis.
Drew Applebaum: Wow, that’s incredible. You also mentioned a technique to increase empathy using films or music and you call it the Don Quixote effect. Can you tell us about that?
Larry Benz: Yeah, the Don Quixote effect is really interesting. You assume we might be aging ourselves here, but I assume everybody’s either familiar with Don Quixote or has read the book, which is a very interesting book by an author who wrote it when he was in jail. Talk about empathy.
In any event, it’s a big romantic tale about knights and princesses. Don Quixote’s got this squire by the name of Sancho Panza and he goes out to try to accomplish all of these deeds of great daring and gallantry. He has these incredible delusions.
Well, the reality is, the extreme nature of that idealism, they call a quixotic dream. When you’re watching the film or reading the book, you really become enamored with Sancho Panza, who of course ends up exemplifying all of the chivalry through loyalty, courteousness, and protection. We call this the Don Quixote effect that you actually start to identify and really recognize the squire, and then that enhances your empathy to go out and be in a realistic situation with a patient. It’s quite fascinating actually.
Drew Applebaum: Yeah, it was really interesting to read about. Talk about the health implications of general positive emotions and just positivity for patients.
Larry Benz: This is a really good question, there’s been a tremendous amount of research by Barbara Fredrickson who has been the most famed author of a concept called broaden and build. You often see that in layman’s literature called the positivity effect or the ratio. While there’s been some debate about what the ratio should be, it’s generally been shown that in really positive relationships, they are magnified when the positivity ratio, which means, the number of positives to negatives exceeds three to one.
In marriages, they’re finding it can be as high as five to seven to one to have flourishing marriages. Broaden build basically says, the heliotropic effect or the impact of positivity is that patients will be drawn in and it releases lots of downstream effects in terms of healing, in terms of mood and emotions. This concept of a mind, body connection is no longer just a concept, we are intertwined with our mind the whole time, so you can impact the healing process through if you will, the psychological aspect of interacting with each other and setting up a very positive environment.
We use a third party survey called the CARE survey, which is the compassion and relational empathy questionnaire. It is a 10-question validated instrument that came out of Scotland many years ago. It’s terrific. That is how we measure the impact of empathy on a patient. One of the key questions is, how positive was your therapist, physician, or caregiver during the course of the interaction?
We know that healthcare can often be a negative environment. There’s anxiety, there’s pain, the reality is pivoting to a positive environment through a ratio of greater than three to one and closer to five to one has a dramatic impact on the patient care.
Drew Applebaum: It’s really interesting you mentioned the ratio and there is some serious news that happens during this care and it can’t all be positive.
Larry Benz: No, absolutely not. I mean anything taken into excess is irrational. So, what you want to do is balance that with the realism and the goals of the patient that you have right in front of you at any particular time. I think sometimes our default mode wants to be overly positive and unrealistic, but you have to have the patient paint the picture of what their outcome looks like and you set a level of expectation with them to make sure everybody and everything is in place for a positive outcome.
Drew Applebaum: You go in depth with the book that you think the good news is good news but there are endless opportunities to respond to patient’s good news in different ways. Can you talk about those responses?
Larry Benz: Yes, I think you are referring to the active constructive process. You know there really are what amounts to several ways you could react when a patient tells you good news. If you think about yourself and sharing the good news with somebody, you’re taking a risk, right? You are being a little bit vulnerable in that sense and what we find is that there are four approaches to it. If you tell me some good news, you come in and say, “Larry, I was able to walk down the street just like you asked me to do and I didn’t think I could do it, but you know what? I did it.”
And I respond to you, “Great, okay let’s go on and get started on your physical therapy.” Well, I just basically threw a bomb at you. Another thing is if I ignored you completely or I say, “Oh well, don’t expect to do that every day. You know you might enhance your injury if you do too much of it.”
But what if I responded, “Oh great! That is really good to hear. Tell me about how you felt when you were able to achieve that,” that active constructive response that you have just now given to a patient is the only one of those four categories of types of responses that have a benefit that endures the relationship, that develops the mutuality that you want that allows that patient to relive that moment and how they felt and make that connection. So, it is extremely important that providers don’t routinely drop bombs on patients by inadvertently or unknowingly, unwittingly if you will, saying the wrong thing.
Three Types of Goals
Drew Applebaum: You mentioned there are different types of goals that need to be set to make positive change. You had a goal of writing a book and you completed that, congratulations. Can you talk to us about the three types of goals that providers need to understand?
Larry Benz: Yeah, so it is interesting, you know there have been tons of study on goal setting. We like to divide our goals into categories, in patient care, because all too often what we are trying to do with the patient is set goals such as, “I need to walk X amount or I want to run in a marathon,” and you have all of these different types of goals that you could set. So, what we’ve found through the research is that there are really three different types of goals to set with a patient.
The first one is called a performance goal and that is the one you expect. You know you want to leave PT or you want to leave the hospital or the physician’s care and you want to be able to perform something and you want to make sure that it is challenging but you also need to make sure that it is very, very specific. That is your performance goal and the most logical one. That is the one in healthcare that we focus on primarily and unfortunately, to the mutual exclusion of the other goals.
One of which is a learning goal and part of learning goals is really allowing the patient to demonstrate the activity that you have instructed them on. Very, very seldom do we give patients instructions. The research really shows that oftentimes the patient is cut off after about 20 or 30 seconds. The majority of patients when asked, “Did you receive instructions on this medication and how to use it?” They say no.
A learning goal is one that you have set with the patient that allows them to demonstrate, right in front of you, that they know how to do what you’ve asked them to do.
Then the third one, we like to call an intrinsic goal and this one has to be set by the patient. So, the performance goal, I have a collaborative process. You know your knee hurts, here is what’s realistic, here is what we are going to set together. A learning goal, I am teaching you about something you have to demonstrate.
But an intrinsic goal is exclusively based on the personal interest of the patient and because of that, intrinsic goals really inspire our passion and our commitment and what we call flow, which is a challenge that is in front of us but I get caught up in it and time literally flies. What we like to say, is set the intrinsic goal that’s you. That is the goal you deserve for yourself. What would take for you to achieve this goal, how would it make you feel by doing this intrinsic goal?
We also use what is known as a contrasting effect, whereas, you know tell me what the end of the story looks like and let’s work backward. Let me explain that a little bit because it is an important differentiating concept. Often times, we’ll take a patient, and let’s say they can’t walk 100 yards. Our goals might be, “Okay, we need to get your range of motion to the proper way, and then we are going to ten yards, and then we are going to go 30 yards, and then we are going to go 100 yards.”
It is incrementally from time going forward. We like the contrasting effect, which tells us a vision, or what does your best future ideal self look like? Describe it to me. “I am running with my kids in the park,” or, “I just completed a 5K walk.” Okay, now let’s work backward and see what we have to do to get you there. And that contrasting effect has been shown in research to really, really enhance a person’s ability to achieve that goal.
They have taken two groups, one that they have contrasting, what the end looks like. The other group is, here is where we’re at, at the beginning and every time the contrasting group outperforms the initial goal-setting group.
Drew Applebaum: Wow. Yeah, that’s impressive. You know, I think what everyone finds interesting is the placebo effect and you go to a little bit about placebo responses. Can you talk a little bit about the science behind them?
Larry Benz: Yes, so this is a very, very large body of research. Placebo is one of the more fascinating topics that people want to learn about. I think the example I gave you is if somebody calls you, you have a higher percentage of going back, but they have done placebo research on drugs with different colors of drugs. Basically, there is an inactive substance in them but something about it physiologically–they used to think it was all mental.
Now they know that that’s not true. It causes a very positive response and that is the placebo. What I like to tell folks about just the word placebo is well, you use it every day. When you are encouraging somebody to act in a certain way, you are in essence enhancing a placebo. One of the examples I like to give when I teach is I tell them right at the beginning, “Yeah, I have to do something here. I am going to give you this lecture today and at the end of this lecture, I am going to give you a quiz. The top of five of you who get the highest scores on this quiz, which we’re going to do over the internet and through your smart phone, you are going to get a prize from me.”
Well, the reality is, then I get to the end of the lecture and I tell them, “Oh I am just lying about the quiz.” The reality is those folks who at that premise of I am going to have a quiz causes a placebo effect where they retain more information.
In fact, you can even tell them in advance. I am telling you that this is a placebo and I am not really going to do this but I want you to act like the information that I am about to teach you today you are going to be tested on, and you will get a reward for having the highest grade. Even that works. But in essence, just to put it out there. Placebo really means I shall please in Latin and basically what you are trying to do is the patient’s symptoms improve when he or she is receiving an inactive substance in the clinical trials.
It has been mostly done on medication, but it is used in a lot of other facets, where “nocebo” which means I shall harm. A nocebo is when a patient experiences an adverse or harmful effect when they receive an inactive substance. So, for example, I read to you the possible adverse effects of this drug. Well, statistically we know there is a certain percentage who will experience those only because I read to them what the adverse effects are.
Some countries have a regulation that a patient is allowed to sign off saying that they don’t want to hear what the adverse effects are because of this phenomenon known as a nocebo. So, what I really outline in the chapter of that book is a significantly easy way to use placebo. Because really, we ought to be enhancing the placebo effect and mitigating or negating the nocebo effect.
The reality is you know a placebo is a good thing. It is a positive thing. We have to recognize what it is for within the balance of ethics and all of the things you would want to do as a professional, use it to the impact that you can, and much of that is through communication techniques.
Drew Applebaum: Wow, that is super interesting. Now you mentioned something earlier I want to bring back and I started to tie it together in Seinfeld when George Castanza leaves the room after a good joke. You want patient long term interactions to end on a high peak. So, talk to us about the peak end rule?
Larry Benz: So the peak end has a tremendous amount of research on it. If anybody has ever read the book Thinking Fast and Slow or is familiar with the Nobel Prize Winner in economics, Daniel Kahneman, who developed this idea of the peak-end effect, to just simplify it, we tend to remember events, occurrences, experiences based on how they ended and at various peaks. So, for example, in any kind of musical or play or book, you will notice that they wait for this grand finale because your experience is going to be known at the peak or at the end of it.
They have done a tremendous amount of research. My favorite research that they have done on this has been on colonoscopy patients where they literally have made the end of the experience of a colonoscopy appear pleasant in a way that patients ended up remembering it less of a negative impact, as a colonoscopy certainly was especially when this was done in the days before the better anesthetics. Therefore, you should try to enhance this end of an experience, so the patients remember the overall experience much better.
So that is how you remember things as their peak and how they end. As Shakespeare said, all is well that ends well.
Drew Applebaum: Also in the book, you mentioned a doctor who is so overrun with patients who have the same disease that he spends about three minutes with them, which is not the best experience. Talk to us about some of the steps of putting the patient back into patient care.
Larry Benz: So, our tendency often times as a practitioner is to be in a number’s game, to try to maximize our outputs in part because of the insurance reimbursement. But what we unwittingly do is negatively impact the outcome of any particular patient. What we’re really trying to emphasize in Called to Care is that you can actually achieve all that you want but you have to be intentional with empathetic listening.
You have to be intentional in setting the right kinds of goals. You have to use non-judgment and perspective-taking or emotional empathy and pro-social concern, and that is not measured in minutes. It is measured in meaning. So, to make that difference with the patient, you can incorporate it. What we have done through this process is at the end of the book, we have a set of skills called the skills checklist that highlight the various constructs, transportable positive psychology interventions that do work.
Some of them are practitioner-based like mindfulness and gratitude. Most of them are things that are actually done with patients. The listening, the empathy, the high-quality connections, the peak-end, and those kinds of things. The combination of all of those is what we believe will have the most dramatic impact in your career and more importantly, the re-establishing of your why, your raison d’être, if you will, of why you became a medical practitioner.
Drew Applebaum: And there is so much more in the book. I think I can ask you so many more questions but this will be my last question–how do you see Telehealth, which you mentioned earlier is increasing by the day, how do you see it changing the way doctors and patients interact?
Larry Benz: That’s a great question. The numbers on Telehealth are very impressive. I think in certain aspects of healthcare like primary care, the number is quite dramatically increasing. You know as COVID is going on, and practices re-establish back to a 100% in primary care, there are actually above a 100% because you still have a lot of patients that want Telehealth, but for the more hands-on practitioners such as physical therapy and others, you would really need a combination of both.
What you lose in Telehealth is you lose the ability to connect with a patient in a meaningful way and on top of that in physical therapy, for example, we put our hands-on patients. I think what you are going to see is going to be a blended hybrid or eclectic approach where you are going to do some interventions via Telehealth delivery and some on-site.
We are experimenting with this within our own company. For example, I have a patient in here and I need to access a behavioral health specialist or a pain management physician or a neurosurgeon. I can Telehealth that physician right into my care when the patient is on-site. We call that a virtual clinic, and fortunately because of Zoom meetings and team meetings and everything else, people have gotten over a lot of fear of technology and have been thrust and forced into this. The confluence of all of those will bring great things for Telehealth delivery as a system.
Drew Applebaum: It’s exciting to see where it might go and you know I never thought about that. It extends your reach as well to bring other people into your practice. Larry, writing a book is no joke so congratulations. If readers could take away one or two things from your book, what would it be?
Larry Benz: I think the biggest thing they could take away is the soft skills of today are the new hard skills and they are critically important relative to the patient and practitioner experience. I think the second thing is if you really want to enhance the clinical outcomes, the care and the experience for your patients, learn to talk to them, communicate and use other positive psychology interventions to make it better for everybody.
Drew Applebaum: And everybody out there, Larry has the numbers to back it up. Larry, it’s been a pleasure and I am so excited for people to check out the book. Everyone, the book is called, Called to Care. You could find it on Amazon and besides checking out the book, where can people find you?
Larry Benz: They could find me at calledtocarebook.com. LinkedIn is always a good spot. I am on Twitter @physicaltherapy. I am @physicaltherapist on Instagram.
Drew Applebaum: Thank you so much for coming on the show. I really appreciate it.
Larry Benz: Absolutely, thank you for having me.