HILLSBOROUGH - Lessley Chiriboga was a long way from the pressure cooker of medical school when she tried to coax a stubborn horse named Dane to follow her lead. She considered her posture and tone of voice. She tried to breathe normally. And she looked for clues from the horse that she was connecting.
"You can’t talk to them and they can’t talk to you about how they are feeling," said Chiriboga, 26, of Hightstown.
Chiriboga is one of dozens of medical students from Rutgers Robert Wood Johnson Medical School who have participated in Horses for Healers, a program that uses horses to teach budding doctors lessons in bedside manners. Here, they learn that even the most brilliant doctors need to pay careful attention not only to their patients, but also themselves.
The program's real-world applications are coming into focus. Health care providers in the age of Obamacare are increasingly getting penalized when their patients don't follow their instructions, whether it is to diet and exercise or to take their medication. And horses, uniquely sensitive to social missteps, make for good test cases; one false move by students can send them running for the hills.
These days, health care providers not only need to lead a horse to water, but they also need to make him drink.
"For their entire medical education, (students have) been evaluated, they've been videotaped, supervised," said Dr. Maria Katsamanis, a lecturer at Rutgers Robert Wood Johnson Medical School, who helps to oversee the program. "They come here and (we say), 'This is your opportunity to see who you are, your strengths and weaknesses. If that didn't work, we'll go out and try it again.'"
Peaceful setting
Horses for Healers is a two-day elective that takes medical students to Foxx Creek Farm, which spans 120 rolling acres in Somerset County, its peace broken only by the neigh of a horse.
The students primarily work with four horses – Syriana, a thoroughbred; Junior Mif, a quarter horse; Spring, an appaloosa-thoroughbred cross; and Dane, a Lipizzaner that was stubborn, at least the time that Chiriboga handled him. And they guide the horses through tasks, figuring out as they go what it will take to win them over.
Katsamanis and Christianna Capra founded Horses for Healers in 2012 as part of Spring Reins of Hope, a program that uses horses to help anyone from veterans needing therapy to corporations
In the horses, they have found perfect subjects. Horses are prey animals that are on constant alert for threats, not unlike patients who find themselves at the hospital or doctor's office, feeling vulnerable and afraid, the organizers said.
Students need to earn the horses' trust. But no matter how confident they let on, they get no mercy if they feel frustrated, distracted or anxious. The horses can see right through them, they said.
"The beautiful thing is, you will always get a reaction from the horses," Capra said. "And no reaction may be the reaction. But it will always be honest."
Learning about yourself
Dr. Savitha Rao, a resident at Rutgers Robert Wood Johnson Medical School, said she hadn't considered how important her own mannerisms were when it came time to treat a patient. With the horses, she needed to figure out how to break out of her natural timidity.
Rao stood up straight. She took a deep breath. She walked with confidence. And her horse followed.
"She turned around and she actually started walking with me when I walked back to the group," said Rao, 35, of New Brunswick.
There is evidence that New Jersey's health care providers need help. The Leapfrog Group, a watchdog organization, last week downgraded six of the nine hospitals in Monmouth and Ocean counties in part because patients gave their doctors and nurses poor marks for their communication skills.
Kerry McKean Kelly, a spokeswoman for the New Jersey Hospital Association, said consumers in the Northeast are notoriously tough judges. But there are financial repercussions. Doctors with strong personal skills are less likely to get sued for malpractice, Katsamanis said. And Medicare and private insurers have begun to penalize hospitals and doctors for care that isn't up to standards. Hospitals, for example, are docked by Medicare if their patients return within 30 days of being discharged.
It means health care providers need to make sure their patients trust them enough to follow their instructions.
It isn't easy, particularly for professionals who are pressed for time and are increasingly relying on technology to become more efficient. Patients might decide not to ask an extra question if they sense their doctor is in a hurry. Or they might feel like they aren't being heard if they see their nurse is distracted by a computer screen.
Practicing with actors
CentraState Healthcare System in Freehold Township recently started a laboratory for staff members to practice their bedside manner – both with mock patients and patients' families. Managers record the scene and then dissect it with the staff member. And managers remind their staff to use bedside visits to connect with the patients, asking not only how they feel, but also about their lives.
"What I think we're learning is, unfortunately, the world of health care is more driven by task-oriented steps for our clinicians rather than the interaction and bedside time they’d rather utilize," said Deborah Ventz-Migneco, CentraState's director of patient experience. "It's just the nature of health care."
Katsamanis began to notice a gap in the students' training a dozen years ago. She and other faculty members oversaw Objective Structured Clinical Evaluations, in which they observed students interact with actors pretending to be patients. The students would ask questions, checking off boxes. But the students' questions could come across without empathy, leaving the patients distressed.
A horse trainer herself, Katsamanis began to see promising equine programs in Arizona and California that taught medical students how to improve their bedside manner. She enlisted colleague Dr. Anthony Tobia to help her get the school's approval. And she brought Capra, the equine specialist, on board.
Four years later, some 60 students have come through the program, learning in just two visits that they need to come up with new ways to reach their patient. If their heart is racing, if they're breathing fast, if they aren't thinking and caring about their horse, the horse will back away. Chances are, so will humans.
"The thing of it is, not only horses can feel them, but your patients, you can’t fool them," Katsamanis said. "We can try to (fool them) with words, but they can sense us and that can mean the difference between a patient complying, coming to you, trusting in whatever recommendations you’re making, or not.”
At Foxx Creek Farm, Lessley Chiriboga found herself trying to distract Dane so that her classmates – and other horses – could complete the mission in front of them. There was no textbook to tell her what to do, leaving her with another important lesson: When it comes to bedside manners, the correct answer is, whatever works.
She took her horse aside. She started talking to him as if he was an old friend. She brushed his mane and patted him.
"I have no idea what I did, what I said," Chiriboga said. "But at some point he was perfectly content and fine staying with me."
Michael L. Diamond; 732-643-4038; mdiamond@gannettnj.com