S3-E64-The 5 enemies of clinical presence & 5 strategies to overcome them

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 64 and in this episode, I'm going to be talking about

the five enemies of clinical presence and five strategies to overcome them.

Before before I get started, I wanted to let you know that I have a newsletter

where I write about topics relating to improving your clinical performance.

Head over to 360Clinician.com to sign up.

All right.

So clinical presence it's a weighty topic.

Something that often can feel a little difficult to wrap your head around.

Before I dive in, I wanted to share a little bit about something

that I did in my twenties.

And that was actually becoming a raft guide.

I love rafting whitewater, and I grew up in a hometown where there was a

river that was great for rafting.

There are a number of rafting companies that ran the Chilliwack

river and I ended up getting a co-op placement for my university program

and ended up having the opportunity to actually do the raft guide training.

And I spent a lot of cold rainy spring days on the river

honing my raft guiding skills.

Some of that time was spent learning how to control the raft.

How to get the people in the boat to do what you want them to in terms of left

forward, right back to turn the boat.

In all those types of things.

Figuring out how to steer and all that.

But really a lot of the training wasn't about those mechanics cause once you

figure that out it wasn't that hard, but it was more about understanding how

to read the river and how to read the flow of the river and identify those

changes that happened in the river.

I mean, there's lots of different things.

Sweepers and eddies so you had to really be able to pick up on what was

going on further downstream so that you could set up the boat for success.

I was thinking the other day about my rafting time and it was just reminding me

of how challenging it can be to sometimes maintain flow in a clinical day.

And just be really present in the work that you're doing.

Sometimes it can feel actually a little elusive to experience flow.

And we do have those moments where we feel in the zone, things

are jiving, but it just seems that there's any number of things that

can throw us out of that place.

Unexpected distractions, tasks that just feel really challenging, patients

that are experiencing roadblocks and just like whitewater rafting you're

always having to constantly adjust to these ever changing situations and

course correcting on a continual basis so that you can stay in the flow of

the river and in your zone clinically.

So just like whitewater rafting, there's always this constant

adjusting to ever-changing situations.

And being able to course-correct on a continual basis just to stay

in the right part of the river.

Flow is that state where you're in the zone and it's often experienced in

various athletic and artistic pursuits.

It's really this idea of merging action and awareness, a place where your

thoughts and feelings become a little bit irrelevant and you're really just

dialed into the moment that you're in.

I think that flow requires two essential components.

One is the ability to manage and focus one's attention.

And the other is to engage deeply in the present moment with the

client or patient in front of you.

Optimizing one's attention to something that I've covered in

a previous podcast episode.

If you're interested in learning more, I'd encourage you to

listen to episode number 58.

Today, I want to talk about presence, clinical presence.

That ability to be deeply present is really what allows us to be able

to stay consistent in a place of clinical flow and improves our ability

to actually remain clinically agile.

So I want to start off with what is clinical presence, and I think it can be

thought of as space of being receptive with your senses to the present moment.

It's this idea of being available to oneself and to the other person in a very

bodily way, you're present in your body, with your thoughts, with your attention.

And then there's this element of being present with the entirety

of yourself in the interaction.

Researchers Mallet et al., write about presence in their article Clinical

Perspectives on the Notions of presence.

They talk about how it involves us ability to remain aware of and responsive

to the environment, both external environment and your internal environment.

While also being able to observe, attend, emphasize, and communicate

effectively with others.

There's a lot that goes into this definition of presence.

And I think it's really important to look at it from a number of different angles.

So why does it matter?

First off, I think that patients want and need to feel heard.

Presence is an important building block in creating a therapeutic alliance.

But beyond that, I think that clinical presence is necessary

so you can actually respond to your patient in these perpetually

changing moments of interaction.

What I want to do now is highlight what I see as the five enemies

that hurt clinical presence.

And things that I found from my own clinical experience.

Enemy number one is overattached thinking.

Staying present and engaged with the patient sounds easy enough until

we realize how easy it is for our thoughts to cause us to go astray.

I think about how easily I'm distracted when I'm doing a meditation, when there's

really no distractions in the room.

And just thinking about how easy it is to get distracted in a work environment.

And oftentimes it feels almost impossible to stay present because we

ended up experiencing over attached or what's called fuse thinking.

An experience where we can become so connected to our thoughts, we can't

actually separate ourselves from them.

Let's go through a little clinical example.

Let's say that I'm seeing a patient who seems standoffish in the session.

Not sure why.

I just get that sense.

I can think that oh, maybe the patient isn't happy with their treatment

and I start to go down that path.

I can actually become attached to this line of thinking.

And may actually find myself having a harder time responding to the patient.

What I find can happen then is that it's actually hard to

separate myself from that thinking.

Just even recognizing that, it's just a thought, it's just an impression

may not even be an accurate impression and it doesn't need to be followed.

But when we can uncouple ourselves from that thinking, we end up getting pulled

away from the present moment and it actually is hard to then be fully present

with the patient who's in front of us.

Number two is ego protecting beliefs.

In our case loads will have patients who aren't progressing as expected.

And I've found in my own experience, so that can weigh on me.

I found how easy it is to brace myself emotionally before those appointments.

I start to, wonder how they're doing.

Maybe anticipate that they'll probably still be doing poorly

and are they even getting better?

What am I going to do with them today?

And to protect myself emotionally, I'll actually anticipate that they'll still

be doing poorly, but the problem is what I've realized in myself is that that

doesn't actually lend itself to being present and fully there with the patient,

because in some ways I'm trying to guard myself from further disappointment.

I guess the upside is it does protect my ego temporarily, but it does make

it difficult to be fully present and open with the patient interaction.

Enemy number three is a disconnected body.

Clinical presence is something that ultimately is a bodily experience.

Our presence isn't just a result of the words we say, but it's a space between

two people in our physical bodies.

Oftentimes we can be unaware of our own body language.

Our body posture and openness becomes so much more important,

especially when we're dealing with a challenging clinical interaction.

I've noticed for myself how my own body language starts to close off when I feel

uncomfortable with a patient interaction.

I think that a lack of awareness of our own body and body language can

definitely result in decreased connection and presence with our patients.

Enemy number four would be misguided intentions.

There was an interesting study that looked at family physicians

ability to be fully receptive to the complaints shared by their patients.

Interestingly patients were only able to complete their statement

of concerns 28% of the time.

Most surprising it was that the physicians in the study took an

average of only 23 seconds to redirect the conversation with patients.

Our intentions for our patient interaction can keep us actually from being present.

When we have a particular agenda we want to achieve or an outcome to produce.

It's really easy to then hijack the interaction between

ourselves and our patients.

We can miss those important cues from our patients.

And I think we can also end up rushing through an interaction to achieve

some of those predetermined goals.

And sometimes a treatment session is going to go a totally different direction

than we thought and we've got to be flexible enough to stay present and

let go of some of those goals that we maybe had prior to the session.

Enemy number five is environmental noise.

There's this interesting concept from engineering called signal to noise

ratio, and it's a helpful metaphor when we look at clinical environments.

If signal is our ability to stay present and connect with our patient, then what

is the noise that drowns out the signal?

I think first off actual noise from open-concept treatment areas is definitely

something that I've found can impact the ability to be present clinically.

Another noise factor is just the level of busy-ness in a clinical environment.

I've found myself having a very different internal state and

stress level when working say on a quiet Saturday then during a busy

transition time during the week.

Noise, I think can also come from technology.

With increased use of laptop charting, it can actually be a barrier, a physical

barrier, to being present with our patients because we ended up writing

notes while our patient is talking.

We're not making eye contact.

Where we have this physical barrier between us and our patients.

And even though political presence, I think can be difficult sometimes.

There are powerful ways to improve your clinical presence

for better flow and results.

What I want to do now is shift gears a little bit and talk

about some of the solutions.

I want to talk about five practical strategies that you can incorporate into

your life and clinical work that will help increase your clinical presence.

But before I jump into those strategies, I want to share that in my experience,

this kind of work often needs to start outside of the clinical setting.

It's easy to think that one can jump into challenging patient

situations and just press a button to better clinical presence.

I mean, it's possible, but not really likely.

And practicing these strategies I think is also really helpful in low stress clinical

situations, where you have a chance to build your confidence and just create

some momentum to better clinical presence.

The first strategy is quieting the mind.

I think our attachment to our own thoughts is a major barrier to clinical presence.

Our ability to separate ourselves from our thinking and observing our

thinking is really important so that we don't get distracted by every

train of thought that comes our way.

Meditation and breathwork can really help to create distance from your thoughts.

I think what it does also is help to take your thinking less seriously.

Which is a helpful way to create some necessary space to stay

present with your patients.

Oftentimes, we recommend meditation to our patients as a strategy to reduce stress.

But I think for us as clinicians, it's so much more than that.

My own life I've actually reframed meditation as a path to

improve my clinical performance.

Just like practicing certain manual therapy techniques can improve

your skill with manual therapy.

I think meditation can improve your ability to sustain clinical

presence and flow in your work.

Here are some suggestions on how to make meditation a bit more of

a regular practice in your life.

First off, it's important to keep it simple focus on a simple

meditation and have something that's easily accessible on your phone.

I found it really helps to keep things short, focus on meditations that are a

few minutes, up to 10 minutes in length.

I think when it's shorter, it's easier to stay consistent with the practice.

And then third, I think it's important to stay consistent.

Occasional meditation practice is fine it's good, but it's not

going to have a lot of impact.

The real transformation comes from having regular meditation practice.

Strategy number two is this idea of introducing the third person.

While it's nice to have someone to observe our clinical

interactions and provide feedback.

The reality is that more often than not, we're working on our own.

The strategy that I came across some time ago is this concept of introducing

the third person into the interaction.

It's a practice where you engage in another aspect of self and observing self.

It's a detached observation of oneself and the interaction.

So what does this look like in clinical practice?

I've been experimenting with this for a while now.

What it is, is just really being able to take moments during a patient interaction.

Typically I'll do this while the patient is talking.

And it's just an opportunity to observe your own body posture.

This could be just tuning into the tension in your face.

The position of your hands or leaning of your trunk.

It's really a very quick brief check-in and self observation.

Just to see am I present in my own body?

But I'm also just orienting myself to be more fully present and interactive

with the patient who is in front of me.

Strategy number three is to let go of labels.

With enemy number two, I talked about ego protecting beliefs.

And I talked about how we can protect ourselves from those patient interactions

that can challenge our sense of self.

And unfortunately, I think our thinking can often make a difficult

to be fully present with the patient.

More often than not all, I recognize that I engaged in distorted

thinking of fortune telling.

For example, this patient probably won't get better.

I better be ready for that.

They're probably going to tell me that nothing has improved this past week.

I don't know what I'm going to do for them today.

And then rather than letting my ego try to protect itself,

I can take a different path.

I can remind myself gently that I'm fortune telling, and I really have no idea

how the patient is going to present today.

Instead I remind myself to just be present with them, whatever that looks like.

I just choose to be open.

And it's a bit of a mantra, right?

When you start to notice yourself going into that fortune telling mode.

What I do is I remind myself, oh, Catching myself, fortune telling

again, I'm just going to be present.

I don't know how they're going to be today.

I'm going to be open to whatever comes my way.

I think that's a really helpful way to nudge yourselves to greater

presence, to a place of being ready to be present with our patient, rather

than trying to protect ourselves and create those self-defense mechanisms.

I think there's so many ways that we can try to protect ourselves.

Oftentimes we'll subconsciously attach labels to our patients.

And I think paying attention to the labels we place on our patients can especially

be helpful and I find this as often, something that can happen when you're

looking at your day sheet for the day.

Just see if we can let go of those labels and really strive to again,

nudge ourselves into not define those patients by their body part, by the

lack of progress they're experiencing.

And seeing if we can just let that go and just be like, oh, I'm seeing Sue today.

Okay, great.

I'm looking forward to that.

You know, and really trying to be intentional with letting go of labels

that are actually going to impact our ability to be present with them.

Strategy number four is setting your intention.

Along with this idea of removing labels is the importance of setting

intention prior to seeing the patient.

I found that being clear with my intention before entering the treatment

room is really a helpful step in being sure that I'm in the right head space.

I found that even creating a brief pause before I enter the treatment

room can make a big difference.

And combining a couple of slow breaths with them.

A simple mantra of be present.

Be open.

I found that really has made a big difference.

So again, before I go into the treatment room, I'll just pause.

Breath in breath out.

Then I'll remind myself, be present, be open.

And it takes literally less than five seconds, but it really

can help to set that intention.

To be present with whatever the patient brings for you today.

Another strategy that can help prior to seeing the patient

is doing a quick chart review.

I know it's easy to just gloss over that too quickly, but I find that

even taking that extra 30 seconds.

Just being really familiar with what their last treatment was and where you

want to go for the day can really help you to start off on the right foot.

So you're not scrambling trying to read through notes and then what

ends up happening is it's actually really hard to just be present to

what the patient is saying to you.

Strategy number five is ground yourself to the present.

Grounding is a psychological concept of helping to return to the present moment.

It can be an important strategy in clinical practice.

And I think of it as making contact again with the physical world.

So when you're charting, this is one example is you might close your eyes

for a moment, breathe and become aware of your bum on the stool.

You're reconnecting to the ground, you're reconnecting to

your awareness of your body.

And I found that this strategy is just a really simple way to

reset after a patient interaction.

During a busy clinical day, we won't necessarily have time to

do a five minute meditation.

Right.

But I think you can just do a few breaths after you've had a patient

interaction and just again, tune into your body as you do that.

There was another strategy that is really a derivative that Dr.

Epstein wrote in his book Attending and it's called, where are my feet?

And the idea is that our feet ground us to the earth.

And as he shares your physical presence, stabilizes your presence of mind.

I think that's a really solid quote and this idea that grounding

helps to stabilize our thinking and, what's going on internally.

So with this approach.

You ask yourself, where are my feet?

Like physically, literally you give yourself a moment to feel your feet.

Are they flat on the floor?

How do you feel in your shoes?

And this is something that can even be good to practice again, outside of

the clinical environment, you might practice this when you're eating a meal.

And then you might graduate to practicing this when you sit down to chart.

And then you may actually incorporate this when you sit

down to take a patient history.

I hope that these five strategies are helpful.

Start small.

And I would say, keep experimenting with what works for you today.

So a brief recap from today , I covered the five enemies of clinical presence.

The first was overattached thinking.

The second was ego protecting and beliefs.

The third was this disconnected body.

Number four was misguided intentions.

And number five was environmental noise.

Then I follow that up with five strategies to overcome those enemies.

The first was to quiet the mind.

Number two was to introduce the third person in your interactions.

Number three was to let go of labels.

Number four was to set your intention.

And number five was to ground yourself to the present.

Thanks for hanging out with me today and hearing about how to improve your clinical

performance through better understanding how to optimize clinical presence.

Make sure to subscribe on iTunes or Spotify to stay up

to date on future episodes.

And if you enjoyed the episode, I'd definitely encourage you

to leave a review on iTunes.

I'd really appreciate that.

Here's to less frustration, more flow and better clinical results.