S3-E62-Ready To Boost Your Clinical Agility?

There’s a lot that can through us off our game during a clinical day and it’s critical to stay agile so we can problem solve effectively and get amazing outcomes for our patients.

In this episode, I’ll be talking about how we can get pulled away from a clinical flow state and the importance of navigating the inner self. I highlight some surprisingly easy ways you can stay flexible regardless of what gets thrown your way.

I also promised some more information on the 10 Cognitive Distortions which are interesting to read about to see if you identify with any.


Welcome to the unleash, your best clinical self podcast. I'm your host, Andrew Koppejan. If you're a physiotherapist or other movement professional, who feels like you're stuck in a rut, then my podcast is for you. This podcast is focused on helping you move from frustration to flow in your clinical practice. In each episode I'll share strategies, approaches, and my latest thinking on how to improve your clinical performance and keep loving what you do. This is episode number 62. This episode, I'll be talking about how to boost your clinical agility and provide some practical strategies on how to better respond to stressful clinical situations. Before I dive in, though, I want to let you know that I have a newsletter where I write about topics relating to improving clinical performance. Head over 360 clinician.com to sign up. I have two young boys and every night we read a storybook and I would say that one of the most read books in our library is called the Gruffalo. So wonderful little book that recounts the story of a very inventive and clever mouse who has to evade several forest creatures. And after he assumes that he's avoided all the dangers, he actually meets upon a Gruffalo. It's a rather terrible creature with knobbly knees, a poisonous wart at the end of his nose, and even purple prickles all over his back. My boys absolutely loved this book and I think it's become a favourite in many households. I thought about the resilience this little mouse showed in the story. It's not unlike the resilience that we actually need to experience in our clinical practice. One moment, we're feeling good about things we're joking with a colleague or a patient. Then that very next interaction we can find ourselves wondering how to respond to a patient who was crying because of their frustration with persistent pain. Often we can even have back to back experiences through our clinical day that can just really throw us off our game. Just last week, I had a situation where a patient booked in who I thought was a new assessment as they had created a new profile in my booking system. She looked familiar when I saw her but I didn't clue in that I'd actually seen her previously, just a couple months earlier. Then we sorted that out that she'd been in before and there was a bit of an awkward laugh about it, so it makes me feel a little more on edge. Then later in the session, the patient got teary-eyed because of her frustration of her slower than expected recovery. So talk about being thrown off guard. It can even be these little minor things, they stack up and all of a sudden you're just sort of feeling a little bit off centered. I think the reality is that things can actually change quite quickly. When things change quickly, we need to be flexible. We have to be able to adapt quickly. What we need is really what I call clinical agility. It's made me think of this great quote that I shared with a friend recently about the importance of staying flexible as clinicians. Now the article is about assessing professional competence, but I thought the quote could easily be applied when thinking about clinical agility. This is what the quote was it said, competence depends on habits of mind that allow the practitioner to be attentive, curious, self-aware, and willing to recognize and correct errors. So competence requires agility and I think that good clinical practice requires agility, but why is it important? I think it comes down to the fact that it helps us to stay centered. It helps us to be present in our interactions with patients and clients. We need this grounding so that we can respond with compassion and most importantly, we need to be able to make optimal patient decisions. Now the question is how do we stay clinically agile? I think it comes down in part to our ability to tune in what's going on around us but even as important is also to understand and tune into what's going on within us. And that is really a concept called self-monitoring. In an article by Epstein in 2008, they define self-monitoring as an ability to attend moment-to- moment to our own actions, curiosity, to examine the effects of those actions and a willingness to use those observations, to improve behavior and patterns of thinking in the future. Later on in the article, they phrase it as the ongoing habit of seeking, integrating, and responding to both external and internal data about one's own performance. When we look at these definitions, I think we can see that there's a process that actually takes place here. First off, there is an awareness of ourselves and how we're responding to the world around us. Second, there's this willingness to explore and engage with what's going on within us. And then third is this courage to then adapt and change based on this understanding. It's really in looking at bringing all three of those components together that we can really monitor ourselves and be able to adapt to what's going on within us. Now staying present and staying open sounds easy when our day is going well. But what happens when we start to run behind and feel overwhelmed? How do we stay open and present when our day starts to go sideways? And when we start to feel insecure, vulnerable, and ignorant. That really becomes the challenge. An important element of self-monitoring is attention. And it's something that I've written and talked about in previous work. I'd encourage you to check out my podcast episode number 58, where I dive into that topic. But today I'm going to talk about some other key things that are going to help you to stay clinically agile. First off. I think it's really important that we get comfortable with the contours of our inner selves. We all have physiological responses to stress. Whether that's feeling butterflies in our stomach, or we get this lump in our throat. Whatever it is. But learning what those feelings are for us can actually help us to become more aware of how we respond under stress. It also can be an indication that we may need to adjust how we're actually interacting in that situation. Where do you typically feel tension in your body? Do you experience cold hands? Does your heart start to race? Does your breathing become more shallow? Do you notice a change in your voice? I know for myself when I'm feeling off-center I actually feel a tension in my chest and a tightening of muscles around my throat. And to help understand these sensations, I think it's really important that we actually practice being present in our bodies in non-stressful environments. We really have to get comfortable with the contours of our inner self. There are many ways to develop the skill of being present in our bodies. I found that the body scan meditation is a simple, yet really practical tool to help build deeper awareness. The original body scan was introduced by Jon Kabat Zinn. And it was actually about 45 minutes long. But there are so many different variations now of the body scan meditation, that range anywhere from 1 to 20 minutes. In your clinical day being aware of your body sensations can actually be a really important gateway. To understanding what's going on for you in your mind. It's a really important aspect of self-monitoring. Here's the tension that we find ourselves in. We're always oscillating in our clinical day between a place of discomfort and comfort. A large part of this oscillation is a result of where we're at emotionally. Managing our emotions well can actually help us to stay in a healthy place where we can operate in an optimal level for ourselves. That's really the definition of flow where we can be in between the extremes of discomfort and comfort. Oftentimes it seems that our emotions can carry us away without any rhyme or reason. A useful concept and understanding what affects and influences our emotions, is this a tool called the cognitive triangle, which highlights how our thoughts influence our feelings and our feelings influence our behaviors. When we can identify and challenge existing beliefs and thoughts that we experienced during the day, then we can actually start to create a new path to follow in the future. Now there are lots of different types of cognitive distortions that can impact and affect our emotions. There's 10 that are really common and I'll make sure to include in the show notes, a link that you can read more about them. In a nutshell, the ten are: all or nothing thinking overgeneralization, mental filtering, discounting the positive, jumping to conclusions, magnification, emotional reasoning, and the use of should statements. So I wanted to just walk through an example clinically to just talk about how this actually takes place. So let's say that you're doing an assessment and it's becoming more complicated than you expected and as your history taking goes on longer, you start to feel this tightening in your stomach. You start to feel your breathing change and a cognitive triangle begins to take shape. Thought in this case is I'm never going to figure out what's going on in the session, can start to lead to feelings of anxiety and frustration, increased stress and this starts to result in the behavior of tuning out the patient because you're now becoming distracted by your own anxiety and you find yourself feeling rushed and unable to really process the data points that you're getting in your objective assessment. Now you can actually start to get confused about your diagnosis and then that can actually reinforce the belief that you can't handle this type of complex patient situation. When we look at things here, we can see that there is a cognitive distortion of jumping to conclusions. And there is another cognitive distortion of all or nothing thinking where you're telling yourself that you're no good at seeing these kinds of clinical presentations or that you're no good at clinical practice. So you can see how this can really easily take place in a clinical situation. It's important to be able to nip that in the bud before we go down that whole pathway. The challenge that we can experience in our clinical work and we're trying to decipher what's going on. Is that we know that something is off, but we're really not sure what's actually going on. And what I find is that in those situations, It's often best to just jot down something that you can then go through at the end of your day and review in more detail. I'll often find that in looking back that there's a general emotion or a visceral experience but I'm not sure what's going on from a thinking or belief standpoint. A process that I've found helpful in terms of being able to work through some of these things, was outlined by psychiatrist Dr. David Burns, where he walks through some cognitive behavioral therapy strategies in his feeling good handbook. There's four steps to his approach, which was A) write down the situation and then record the negative feelings that you have regarding that situation. Then use what's called the triple column technique where you basically write down the thought that comes to mind or the automatic thought. The cognitive distortion that's underneath that, and then a more rational response where you can reframe that initial thought that you had. Then what you do is then you reevaluate your feelings and beliefs after you've gone through that process. Now I want it to go through an example of how to use the triple column technique. Let's say that you've got a patient who's come back after a few visits and they still haven't done any of their exercises. You might have the automatic thought of why can't this patient get their act together? They don't even listen to what I say. They should listen to me. And so we've got a couple of distortions going on there. One is this mental filter, a distortion, and the second is the should statement. They should be listening to me. Then it's really about reframing things and looking and say, okay, what's a more rational response or a way to reframe that automatic thought. A response might be like, there might be a lot of other things going on for that patient right now and while I'd liked this patient, do their exercises, it's really their decision at the end of the day and it might be a good idea to actually talk about how to move forward with this patient. That's one example of how to go through the triple column technique. Another example, related to this situation, you might have the thought I must not be a very good therapist if my patient can't even do a few exercises every week." Again, what we're doing here is we have this emotional reasoning distortion and we're also overgeneralizing things by thinking that I'm not a good therapist because of the actions of a patient. So a more rational response that we can reframe things is it's not fair for me to make a judgment about myself because of something that is another person's decision. Another statement alongside that might be, there's so much that goes into being a good therapist. It's important not to put so much weight on this one particular patient circumstance. It really can be helpful to get this down on paper so you can actually see things more clearly and not just have these thoughts running around in your head. Now sometimes you're going to have a situation where you still don't really understand the thoughts that you have behind the feelings you're experiencing. A simple solution that he outlined in this book is the idea of drawing a stick figure. Then what you do is you ask yourself, what's making the stick figure unhappy. I know it sounds ridiculous but I've done it and I promise you, it actually is really effective. It's a really good way to go a little deeper with things. All right to wrap up today's episode. I want to just briefly review what I just talked about. First off, it's really helpful to understand and listen to what's going on in your body when you're dealing with challenging situations in your workday. Really starting to tease out how you respond to stress will start to give you a signal in terms of what you should be paying attention to. Then you want to think about identifying the distortions in your thinking that may be contributing to some of the emotions that you're feeling that are leaving you more in a place of discomfort than in a place of comfort in your work day and the cognitive triangle is a really helpful framework to understand how thoughts influence emotions, which influence behaviors and actions. Using the four step process that Dr. Burns has talked about, it's something that you can actually look through in more detail in my blog post. You can then look at how to start to work through these things so you can respond more appropriately in the future, which is going to allow you to be more clinically agile in those challenging clinical situations. Thanks for hanging out with me today and hearing about how to improve your clinical performance. Make sure to subscribe on iTunes or Spotify to stay up to date on future episodes. If you enjoy this episode, I truly appreciate you leaving a review on iTunes. Here's to less frustration, more flow and better clinical results till next time.

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