Learn about a unique training program helping medical students learn bedside manner using horses as the ultimate teachers.
“Remember, a horse doesn’t speak English.”
The professor at Rutgers Robert Wood Johnson Medical School (RWJMS) was instructing students. The class is designed to teach how horses’ non-verbal communication can improve the doctor-patient relationship. Both horse and patient respond similarly to a quiet, focused, peaceful approach.
Studying how a horse responds to the manner, tone, touch, and eye contact of a human helps future doctors become sensitized to what contributes to rapport. The approach to the patient can improve their willingness to provide information, confidence in the doctor, patient satisfaction, and even their health outcome.
All of those factors are important for patient-centered care.
Barnyard to Bedside
The course connecting the medical student to the horse for non-verbal skills was originally called “From Barnyard to Bedside Manner,” and began with Allan Hamilton, M.D., at the University of Arizona in 2000.
The inspiration struck during a medical round. Hamilton, a horse trainer, neurosurgeon, and professor at the University of Arizona had medical residents following him at the hospital when they rushed into a patient’s room following a series of stressful emergency conditions that had put them behind schedule.
The patient bolted out of her chair and shrieked. The atmosphere calmed with a smile from students and a handshake.
“But what if this had been a horse in a stall and we had stormed in without warning, like we had just done with this poor woman?” says Hamilton. “That horse would probably have kicked someone.”
Adaptations of this training have also been used at Stanford University and other healthcare colleges in the United States.
Hamilton considered what a horse needs when you’re approaching him to gain confidence and reduce fear; this is similar to what the patient needs. A human may be polite, but a horse will show you exactly how you affect his environmental sphere.
Beverley Kane, M.D., program director for Stanford University, expanded the Barnyard course foundation into training called “Medicine and Horsemanship,” an equine-assisted course for doctor-patient relationship. Its dual purpose is teaching a physician how to approach and communicate with a patient while also preserving the medical student’s well-being, since the stress of medical education with its long hours, urgent demands, and time pressures can affect patient care and the physician-patient relationship.
Part of the training is to set aside concerns and distractions before approaching the patient, the same state of mind needed to work with a horse.
Hands-On Horses
Maria Katsamanis, Psy.D., is a horse trainer, psychologist, scientist, and Clinical Assistant Professor of Psychiatry at RWJMS. She suggested a program similar to Hamilton’s to the department.
Rutgers formed a credit elective version of the Barnyard course in 2011, called “Horses for Healers: Improving Bedside Manners.” A new dimension was added, integrating psychiatry so medical students could hone their non-verbal skills, including gestures, touch, empathy, tone, attitude, and eye contact.
The two-week experiential course takes place at Spring Reins of Hope & Growth, an equine-assisted therapy program in Three Bridges, N.J. The lecture (didactic) section was eventually removed from the two-week course and more in-person equine education was added, a change based on student course evaluations requesting more hands-on time with the horses.
Katsamanis collected data to measure non-verbal skill for medical education both before and after instructive exercise in the course.
On the value of non-verbal communication, she says, “Without it, understanding is like an iceberg floating on water. You only see the surface of it; you are only getting 10 percent of the information.”
Taking a Pause
A course exercise called “Meet Your Patient” is based on meeting your patient where they are.
At a session, a third-year medical surgery student approached a horse with what is called “false confidence”: braced, not breathing naturally, and with an assertive energy. The horse walked away.
A psychiatry student, who was already well versed in clinical experience, went up to the horse, and the horse started following him. The third-year student observed others having success.
He asked the psychiatry student, “How did you do that?” He learned that he should try it a different way. Horses sense pressure and give feedback, and they can pull back and resist.
Students are encouraged to be introspective, to ask: “Did I really get there faster by pulling or pushing the horse?” They learn how to gently encourage the horse forward.
Part of the method is learning to “take a pause,” a concept Hamilton promoted as a horse trainer. The third-year student mentioned above took two or three minutes with the horse, in a softer approach, explaining to him, “Here’s what we’ll do. I’m going to be with you.” The method was the opposite of “We need to get here and do this.”
Not An Intellectual Exercise
The state of mind for gaining trust in the course applies to horse training as well. There is discussion about not approaching the horse—the patient—as an intellectual exercise.
Katsamanis explains that doctors are taught a mindset of “I am supposed to know everything.” Psychological self-disclosure is encouraged in the way doctors are trained.
Witnessing students’ successful solutions to working with horses and asking fellow students, “How did that work?” if they don’t know, is an important teaching tool in both the barnyard and the hospital environment.
Trustworthy Communication
The stress isn’t going to go away, Katsamanis says. But the students learn how to practice methods of reducing pressure. One way is called “adaptive breathing behavior.” Katsamanis instructs students to “breathe like a horse.” She asks them to whuffle, much like a horse when relaxed.
“Breath is a very important non-verbal biomarker because it’s the one that animals recognize,” says Katsamanis. “The breath, like heart rate (another biomarker), signals to animals about danger or any shifts within the herd. Interestingly, patients at bedside act similarly to prey animals. They are less likely to believe your words. Breath will convey what emotion is truly occurring. Breathing also influences heart rate. Breath is the one variable that all mammals share as a common denominator when it comes to non-verbal communication. We teach students how to be aware of the influence of [breath] and other biomarkers so that what they say truly lines up with their body language. Doing so will help align their communication.”
In an exercise called “billiards,” a horse enters the arena from his stall, moving freely. The student in the center goes to connect with the horse, approaching slowly, with a gentle voice, as they would need to do for a human patient.
Then he or she guides the horse towards the “pocket,” set up with a pole on the fence on one side and cones on the other side of the makeshift chute. There are groups of students that coordinate for this exercise, illustrating the team effect in a hospital setting. For example, if the receptionist, a nurse, or part of medical staff isn’t helpful, the patient experience and satisfaction with their doctor is further affected.
The exercise is analogous to contending with hospital-patient challenges. If something doesn’t work with a horse (patient) or a horse is nervous, the doctor can try different or less pressuring methods next time.
The Horses
The horses used for the medical program include a Lipizzan, an Appaloosa, a former reining champion Quarter Horse, a Thoroughbred ex-racehorse, and a gray mule. The equines all live in a herd and are only used for emotional therapy work, not riding.
Insights into personal relationships are drawn; for instance, the Quarter Horse may try to resist the direction of the student. The teacher says, “Where else in your life do you get pushed around?” and “You need to set boundaries.”
Authentic Response
In order to set up this kind of academic training, a college must have a person who is knowledgeable about horses and medical education. A psychology background is also important, and the school needs to have access to a horse herd for therapeutic education.
Experiential training with the horse can provide sensitivity to an animal who is direct in his response and not filtering through a polite manner. Since medical students practice with patients who are actors, they may not get to realize the breadth of necessary non-verbal skills. Future physicians learning from an authentic response discover how to respond both to humans and to the horse.
