The art of happiness: Communication and empowerment can keep patients content

A book by a Harvard psychologist can provide orthopedists with the capacity to provide hope and feelings of control for their patients.

This month’s column takes a slightly different twist; here we review a book that bears on the issue of disgruntled patients filing lawsuits against their doctors. The editors will attempt to tie in seemingly unrelated concepts regarding the concept of happiness to the risk of litigation.

Although the book Stumbling on Happiness, by Harvard psychologist Daniel Gilbert, appears to be unrelated to medicine, it can offer fascinating insights into patient-care quality.

Gilbert examines the way the human mind operates; its distortions of reality and its distortions of the future. He contends that unlike animals, humans spend a great deal of time preoccupied about the future and trying to predict it. By exerting some control over our futures, whether it is in terms of purchasing a cherished item or experiencing some state of being, humans attempt to be happy.

There are numerous ways in which the psychological studies cited by Gilbert could help an orthopedic surgeon improve his or her relationships with patients, and improve health care quality and the clinical decision-making process. The studies highlight the importance of patient education and informed consent in allowing a patient to feel empowered through controlling treatment decisions.

He states, “…people find it gratifying to exercise control — not just for the future it buys them, but for the exercise itself.” In other words, when the future arrives, a person may be less happy than anticipated; but the feeling of control itself contributes to the experience of happiness.

B. Sonny Bal

Lawrence H. Brenner

Responsibility and mortality

This is a powerful concept, and should be related to our everyday relationships with patients who often have pain, disability, and poor function. Gilbert cites as an example a study in which elderly residents of a nursing home were given houseplants. Half were told that they were responsible for the care and feeding of the houseplants. This group was described as the high-control group. The other residents were told that the houseplants were to be taken care of by the nursing home staff.

After 6 months, 30% of the nursing home residents in the low-control group had died, while only half as many residents in the high-control group died.

Empowerment

Gilbert refers to another nursing home study involving the welfare of nursing home residents. In it, student volunteers were paid to visit a group of nursing home residents. The high-control subgroup was allowed to control the timing and duration of each student’s visit. Thus, a resident in this group could say, “Please come visit me next Thursday for an hour.” In contrast, in the low-control sub-group, the students determined the time and scope of their visits; such as “I’ll come visit you next Thursday for an hour.”

After 2 months, it was observed that “… residents in the high-control group were happier, healthier, more active, and taking fewer medications than those in the low-control group.”

Several months later, the study investigators were disheartened to learn that a disproportionately greater number of residents in the high-control group had died. In retrospect, there was a logical explanation for the likely cause of the deaths. As Gilbert hypothesized, “The residents who had been given control and who had benefited measurably from that control, while they had it, were inadvertently robbed of control when the study ended.”

Anticipation

Other studies cited by Gilbert emphasize the importance of working with patients so they can anticipate the events of surgery. He describes a study in which subjects were divided into a high-shock and a low-shock group. Participants in the high-shock group received a series of 20 high-intensity, but safe, electric shocks and were warned 3 seconds before each shock. The low-shock group received three high intensity shocks and 17 low intensity shocks, all without warning.

The study data showed that although volunteers in the low-shock group received fewer volts than the high-shock group, their hearts beat faster, they sweated more profusely and they rated themselves higher on an apprehension scale than volunteers in the high-shock group.

Gilbert explained, “Volunteers in the low-shock group received shocks of different intensities at different times which made it impossible for them to anticipate their futures … apparently, three big jolts that one cannot foresee are perceived as being more painful than 20 big jolts that one can.”

The practical correlation of this observation to the world of elective orthopedic surgery is that by inference, the more prepared patients are for the events and sensations of surgery, the less pain and anxiety they will feel.

Communication

These studies raise one of the most compelling issues in medicine: Are we communicating with our patients in a way that empowers them to make decisions that they believe control their destiny? The studies in Gilbert’s book suggest that we have only begun to scratch the surface in medicine in answering this philosophic query that has profound practical implications.

Gilbert also explores the wide variation in the decision-making process that has often seemed inexplicable and capricious in a medical context. In that realm, one constant observation is the dramatic variation between physicians. Gilbert explains why we find it so difficult to make sense out of this variation.

In other fields, such as retailing, variability is used to shape consumer behavior. Thus, side-by-side comparisons between products are frequently used by retailers to improve sales; by stocking a few expensive items that make the less expensive items seem like a bargain. A similar example is the unscrupulous real estate agent who brings potential buyers to undesirable homes first so that the merely average home seems extraordinary.

Gilbert takes this analysis one step further by addressing the influence that the addition of extra, identical possibilities has on the physician’s decision-making process. He writes, “… in one study, physicians read about medication X and were then asked whether they would prescribe the medication for a patient with osteoarthritis. The physicians clearly considered the medication worthwhile, because only 28% chose not to prescribe it. But when another group of physicians was asked whether they would prescribe medication X or an equally effective medication Y for a patient with the same disease, 48% chose to prescribe nothing. Apparently, adding another equally effective medication to the list of possibilities made it difficult for the physicians to decide between the two medications, thus leading many of them to recommend neither.” He explains these observations in relation to the need for happiness; a key driver of which is the human need for any control whatsoever.

Happy patients

How does this relate to this column? The answer lies in understanding that malpractice claimants are unhappy patients, and providing patients with control and hope can reduce the number of potential malpractice claimants.

Malpractice claims are often brought because of decisions that physicians and surgeons make. Understanding the psychological reasons, as opposed to just the clinical reasons behind such decision-making may improve the diagnostic decision-making process, and enhance the physician-patient encounter.

We live in a medical environment obsessed with new technologies, and we endlessly study innovations to debate whether they produce more harm or good to patients. This scientific focus and discipline drives our profession, but it may be equally productive to assess the impact that the latest scientific research in psychology, cognitive neuroscience, and human behavior has on successful surgical outcomes. After all, the practice of really good orthopedic surgery is an art.

For more information:

• B. Sonny Bal, MD, MBA, is associate professor of hip and knee replacement in the department of orthopedic surgery, University of Missouri School of Medicine.
• Lawrence H. Brenner, JD, is on the faculties of orthopedics at Yale University and the University of Southern California and practices in Chapel Hill, N.C. Address all correspondence to Brenner at lb@lawrencebrennerlaw.com.

Reference:

• Gilbert DT. Stumbling on Happiness. A.A. Knopf; New York. 2006.