In this episode, I'll be talking about clinical presence. But what is it and why does it matter? I'll answer those questions and go over the 5 enemies of clinical presence that stand in our way. Afterwards, I'll leave you with 5 strategies to overcome them so you can improve your patient relationships, communicate more effectively, and ultimately experience less stress in your clinical day.
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Welcome to the unleash your best clinical self podcast.
Speaker:I'm your host, Andrew Koppejan.
Speaker:If you're a physiotherapist or other movement professional,
Speaker:who feels like you're stuck in a rut, then my podcast is for you.
Speaker:This podcast is focused on helping you move from frustration to
Speaker:flow in your clinical practice.
Speaker:In each episode I'll share strategies, approaches, and my latest thinking
Speaker:on how to improve your clinical performance and keep loving what you do.
Speaker:This is episode number 64 and in this episode, I'm going to be talking about
Speaker:the five enemies of clinical presence and five strategies to overcome them.
Speaker:Before before I get started, I wanted to let you know that I have a newsletter
Speaker:where I write about topics relating to improving your clinical performance.
Speaker:Head over to 360Clinician.com to sign up.
Speaker:All right.
Speaker:So clinical presence it's a weighty topic.
Speaker:Something that often can feel a little difficult to wrap your head around.
Speaker:Before I dive in, I wanted to share a little bit about something
Speaker:that I did in my twenties.
Speaker:And that was actually becoming a raft guide.
Speaker:I love rafting whitewater, and I grew up in a hometown where there was a
Speaker:river that was great for rafting.
Speaker:There are a number of rafting companies that ran the Chilliwack
Speaker:river and I ended up getting a co-op placement for my university program
Speaker:and ended up having the opportunity to actually do the raft guide training.
Speaker:And I spent a lot of cold rainy spring days on the river
Speaker:honing my raft guiding skills.
Speaker:Some of that time was spent learning how to control the raft.
Speaker:How to get the people in the boat to do what you want them to in terms of left
Speaker:forward, right back to turn the boat.
Speaker:In all those types of things.
Speaker:Figuring out how to steer and all that.
Speaker:But really a lot of the training wasn't about those mechanics cause once you
Speaker:figure that out it wasn't that hard, but it was more about understanding how
Speaker:to read the river and how to read the flow of the river and identify those
Speaker:changes that happened in the river.
Speaker:I mean, there's lots of different things.
Speaker:Sweepers and eddies so you had to really be able to pick up on what was
Speaker:going on further downstream so that you could set up the boat for success.
Speaker:I was thinking the other day about my rafting time and it was just reminding me
Speaker:of how challenging it can be to sometimes maintain flow in a clinical day.
Speaker:And just be really present in the work that you're doing.
Speaker:Sometimes it can feel actually a little elusive to experience flow.
Speaker:And we do have those moments where we feel in the zone, things
Speaker:are jiving, but it just seems that there's any number of things that
Speaker:can throw us out of that place.
Speaker:Unexpected distractions, tasks that just feel really challenging, patients
Speaker:that are experiencing roadblocks and just like whitewater rafting you're
Speaker:always having to constantly adjust to these ever changing situations and
Speaker:course correcting on a continual basis so that you can stay in the flow of
Speaker:the river and in your zone clinically.
Speaker:So just like whitewater rafting, there's always this constant
Speaker:adjusting to ever-changing situations.
Speaker:And being able to course-correct on a continual basis just to stay
Speaker:in the right part of the river.
Speaker:Flow is that state where you're in the zone and it's often experienced in
Speaker:various athletic and artistic pursuits.
Speaker:It's really this idea of merging action and awareness, a place where your
Speaker:thoughts and feelings become a little bit irrelevant and you're really just
Speaker:dialed into the moment that you're in.
Speaker:I think that flow requires two essential components.
Speaker:One is the ability to manage and focus one's attention.
Speaker:And the other is to engage deeply in the present moment with the
Speaker:client or patient in front of you.
Speaker:Optimizing one's attention to something that I've covered in
Speaker:a previous podcast episode.
Speaker:If you're interested in learning more, I'd encourage you to
Speaker:listen to episode number 58.
Speaker:Today, I want to talk about presence, clinical presence.
Speaker:That ability to be deeply present is really what allows us to be able
Speaker:to stay consistent in a place of clinical flow and improves our ability
Speaker:to actually remain clinically agile.
Speaker:So I want to start off with what is clinical presence, and I think it can be
Speaker:thought of as space of being receptive with your senses to the present moment.
Speaker:It's this idea of being available to oneself and to the other person in a very
Speaker:bodily way, you're present in your body, with your thoughts, with your attention.
Speaker:And then there's this element of being present with the entirety
Speaker:of yourself in the interaction.
Speaker:Researchers Mallet et al., write about presence in their article Clinical
Speaker:Perspectives on the Notions of presence.
Speaker:They talk about how it involves us ability to remain aware of and responsive
Speaker:to the environment, both external environment and your internal environment.
Speaker:While also being able to observe, attend, emphasize, and communicate
Speaker:effectively with others.
Speaker:There's a lot that goes into this definition of presence.
Speaker:And I think it's really important to look at it from a number of different angles.
Speaker:So why does it matter?
Speaker:First off, I think that patients want and need to feel heard.
Speaker:Presence is an important building block in creating a therapeutic alliance.
Speaker:But beyond that, I think that clinical presence is necessary
Speaker:so you can actually respond to your patient in these perpetually
Speaker:changing moments of interaction.
Speaker:What I want to do now is highlight what I see as the five enemies
Speaker:that hurt clinical presence.
Speaker:And things that I found from my own clinical experience.
Speaker:Enemy number one is overattached thinking.
Speaker:Staying present and engaged with the patient sounds easy enough until
Speaker:we realize how easy it is for our thoughts to cause us to go astray.
Speaker:I think about how easily I'm distracted when I'm doing a meditation, when there's
Speaker:really no distractions in the room.
Speaker:And just thinking about how easy it is to get distracted in a work environment.
Speaker:And oftentimes it feels almost impossible to stay present because we
Speaker:ended up experiencing over attached or what's called fuse thinking.
Speaker:An experience where we can become so connected to our thoughts, we can't
Speaker:actually separate ourselves from them.
Speaker:Let's go through a little clinical example.
Speaker:Let's say that I'm seeing a patient who seems standoffish in the session.
Speaker:Not sure why.
Speaker:I just get that sense.
Speaker:I can think that oh, maybe the patient isn't happy with their treatment
Speaker:and I start to go down that path.
Speaker:I can actually become attached to this line of thinking.
Speaker:And may actually find myself having a harder time responding to the patient.
Speaker:What I find can happen then is that it's actually hard to
Speaker:separate myself from that thinking.
Speaker:Just even recognizing that, it's just a thought, it's just an impression
Speaker:may not even be an accurate impression and it doesn't need to be followed.
Speaker:But when we can uncouple ourselves from that thinking, we end up getting pulled
Speaker:away from the present moment and it actually is hard to then be fully present
Speaker:with the patient who's in front of us.
Speaker:Number two is ego protecting beliefs.
Speaker:In our case loads will have patients who aren't progressing as expected.
Speaker:And I've found in my own experience, so that can weigh on me.
Speaker:I found how easy it is to brace myself emotionally before those appointments.
Speaker:I start to, wonder how they're doing.
Speaker:Maybe anticipate that they'll probably still be doing poorly
Speaker:and are they even getting better?
Speaker:What am I going to do with them today?
Speaker:And to protect myself emotionally, I'll actually anticipate that they'll still
Speaker:be doing poorly, but the problem is what I've realized in myself is that that
Speaker:doesn't actually lend itself to being present and fully there with the patient,
Speaker:because in some ways I'm trying to guard myself from further disappointment.
Speaker:I guess the upside is it does protect my ego temporarily, but it does make
Speaker:it difficult to be fully present and open with the patient interaction.
Speaker:Enemy number three is a disconnected body.
Speaker:Clinical presence is something that ultimately is a bodily experience.
Speaker:Our presence isn't just a result of the words we say, but it's a space between
Speaker:two people in our physical bodies.
Speaker:Oftentimes we can be unaware of our own body language.
Speaker:Our body posture and openness becomes so much more important,
Speaker:especially when we're dealing with a challenging clinical interaction.
Speaker:I've noticed for myself how my own body language starts to close off when I feel
Speaker:uncomfortable with a patient interaction.
Speaker:I think that a lack of awareness of our own body and body language can
Speaker:definitely result in decreased connection and presence with our patients.
Speaker:Enemy number four would be misguided intentions.
Speaker:There was an interesting study that looked at family physicians
Speaker:ability to be fully receptive to the complaints shared by their patients.
Speaker:Interestingly patients were only able to complete their statement
Speaker:of concerns 28% of the time.
Speaker:Most surprising it was that the physicians in the study took an
Speaker:average of only 23 seconds to redirect the conversation with patients.
Speaker:Our intentions for our patient interaction can keep us actually from being present.
Speaker:When we have a particular agenda we want to achieve or an outcome to produce.
Speaker:It's really easy to then hijack the interaction between
Speaker:ourselves and our patients.
Speaker:We can miss those important cues from our patients.
Speaker:And I think we can also end up rushing through an interaction to achieve
Speaker:some of those predetermined goals.
Speaker:And sometimes a treatment session is going to go a totally different direction
Speaker:than we thought and we've got to be flexible enough to stay present and
Speaker:let go of some of those goals that we maybe had prior to the session.
Speaker:Enemy number five is environmental noise.
Speaker:There's this interesting concept from engineering called signal to noise
Speaker:ratio, and it's a helpful metaphor when we look at clinical environments.
Speaker:If signal is our ability to stay present and connect with our patient, then what
Speaker:is the noise that drowns out the signal?
Speaker:I think first off actual noise from open-concept treatment areas is definitely
Speaker:something that I've found can impact the ability to be present clinically.
Speaker:Another noise factor is just the level of busy-ness in a clinical environment.
Speaker:I've found myself having a very different internal state and
Speaker:stress level when working say on a quiet Saturday then during a busy
Speaker:transition time during the week.
Speaker:Noise, I think can also come from technology.
Speaker:With increased use of laptop charting, it can actually be a barrier, a physical
Speaker:barrier, to being present with our patients because we ended up writing
Speaker:notes while our patient is talking.
Speaker:We're not making eye contact.
Speaker:Where we have this physical barrier between us and our patients.
Speaker:And even though political presence, I think can be difficult sometimes.
Speaker:There are powerful ways to improve your clinical presence
Speaker:for better flow and results.
Speaker:What I want to do now is shift gears a little bit and talk
Speaker:about some of the solutions.
Speaker:I want to talk about five practical strategies that you can incorporate into
Speaker:your life and clinical work that will help increase your clinical presence.
Speaker:But before I jump into those strategies, I want to share that in my experience,
Speaker:this kind of work often needs to start outside of the clinical setting.
Speaker:It's easy to think that one can jump into challenging patient
Speaker:situations and just press a button to better clinical presence.
Speaker:I mean, it's possible, but not really likely.
Speaker:And practicing these strategies I think is also really helpful in low stress clinical
Speaker:situations, where you have a chance to build your confidence and just create
Speaker:some momentum to better clinical presence.
Speaker:The first strategy is quieting the mind.
Speaker:I think our attachment to our own thoughts is a major barrier to clinical presence.
Speaker:Our ability to separate ourselves from our thinking and observing our
Speaker:thinking is really important so that we don't get distracted by every
Speaker:train of thought that comes our way.
Speaker:Meditation and breathwork can really help to create distance from your thoughts.
Speaker:I think what it does also is help to take your thinking less seriously.
Speaker:Which is a helpful way to create some necessary space to stay
Speaker:present with your patients.
Speaker:Oftentimes, we recommend meditation to our patients as a strategy to reduce stress.
Speaker:But I think for us as clinicians, it's so much more than that.
Speaker:My own life I've actually reframed meditation as a path to
Speaker:improve my clinical performance.
Speaker:Just like practicing certain manual therapy techniques can improve
Speaker:your skill with manual therapy.
Speaker:I think meditation can improve your ability to sustain clinical
Speaker:presence and flow in your work.
Speaker:Here are some suggestions on how to make meditation a bit more of
Speaker:a regular practice in your life.
Speaker:First off, it's important to keep it simple focus on a simple
Speaker:meditation and have something that's easily accessible on your phone.
Speaker:I found it really helps to keep things short, focus on meditations that are a
Speaker:few minutes, up to 10 minutes in length.
Speaker:I think when it's shorter, it's easier to stay consistent with the practice.
Speaker:And then third, I think it's important to stay consistent.
Speaker:Occasional meditation practice is fine it's good, but it's not
Speaker:going to have a lot of impact.
Speaker:The real transformation comes from having regular meditation practice.
Speaker:Strategy number two is this idea of introducing the third person.
Speaker:While it's nice to have someone to observe our clinical
Speaker:interactions and provide feedback.
Speaker:The reality is that more often than not, we're working on our own.
Speaker:The strategy that I came across some time ago is this concept of introducing
Speaker:the third person into the interaction.
Speaker:It's a practice where you engage in another aspect of self and observing self.
Speaker:It's a detached observation of oneself and the interaction.
Speaker:So what does this look like in clinical practice?
Speaker:I've been experimenting with this for a while now.
Speaker:What it is, is just really being able to take moments during a patient interaction.
Speaker:Typically I'll do this while the patient is talking.
Speaker:And it's just an opportunity to observe your own body posture.
Speaker:This could be just tuning into the tension in your face.
Speaker:The position of your hands or leaning of your trunk.
Speaker:It's really a very quick brief check-in and self observation.
Speaker:Just to see am I present in my own body?
Speaker:But I'm also just orienting myself to be more fully present and interactive
Speaker:with the patient who is in front of me.
Speaker:Strategy number three is to let go of labels.
Speaker:With enemy number two, I talked about ego protecting beliefs.
Speaker:And I talked about how we can protect ourselves from those patient interactions
Speaker:that can challenge our sense of self.
Speaker:And unfortunately, I think our thinking can often make a difficult
Speaker:to be fully present with the patient.
Speaker:More often than not all, I recognize that I engaged in distorted
Speaker:thinking of fortune telling.
Speaker:For example, this patient probably won't get better.
Speaker:I better be ready for that.
Speaker:They're probably going to tell me that nothing has improved this past week.
Speaker:I don't know what I'm going to do for them today.
Speaker:And then rather than letting my ego try to protect itself,
Speaker:I can take a different path.
Speaker:I can remind myself gently that I'm fortune telling, and I really have no idea
Speaker:how the patient is going to present today.
Speaker:Instead I remind myself to just be present with them, whatever that looks like.
Speaker:I just choose to be open.
Speaker:And it's a bit of a mantra, right?
Speaker:When you start to notice yourself going into that fortune telling mode.
Speaker:What I do is I remind myself, oh, Catching myself, fortune telling
Speaker:again, I'm just going to be present.
Speaker:I don't know how they're going to be today.
Speaker:I'm going to be open to whatever comes my way.
Speaker:I think that's a really helpful way to nudge yourselves to greater
Speaker:presence, to a place of being ready to be present with our patient, rather
Speaker:than trying to protect ourselves and create those self-defense mechanisms.
Speaker:I think there's so many ways that we can try to protect ourselves.
Speaker:Oftentimes we'll subconsciously attach labels to our patients.
Speaker:And I think paying attention to the labels we place on our patients can especially
Speaker:be helpful and I find this as often, something that can happen when you're
Speaker:looking at your day sheet for the day.
Speaker:Just see if we can let go of those labels and really strive to again,
Speaker:nudge ourselves into not define those patients by their body part, by the
Speaker:lack of progress they're experiencing.
Speaker:And seeing if we can just let that go and just be like, oh, I'm seeing Sue today.
Speaker:Okay, great.
Speaker:I'm looking forward to that.
Speaker:You know, and really trying to be intentional with letting go of labels
Speaker:that are actually going to impact our ability to be present with them.
Speaker:Strategy number four is setting your intention.
Speaker:Along with this idea of removing labels is the importance of setting
Speaker:intention prior to seeing the patient.
Speaker:I found that being clear with my intention before entering the treatment
Speaker:room is really a helpful step in being sure that I'm in the right head space.
Speaker:I found that even creating a brief pause before I enter the treatment
Speaker:room can make a big difference.
Speaker:And combining a couple of slow breaths with them.
Speaker:A simple mantra of be present.
Speaker:Be open.
Speaker:I found that really has made a big difference.
Speaker:So again, before I go into the treatment room, I'll just pause.
Speaker:Breath in breath out.
Speaker:Then I'll remind myself, be present, be open.
Speaker:And it takes literally less than five seconds, but it really
Speaker:can help to set that intention.
Speaker:To be present with whatever the patient brings for you today.
Speaker:Another strategy that can help prior to seeing the patient
Speaker:is doing a quick chart review.
Speaker:I know it's easy to just gloss over that too quickly, but I find that
Speaker:even taking that extra 30 seconds.
Speaker:Just being really familiar with what their last treatment was and where you
Speaker:want to go for the day can really help you to start off on the right foot.
Speaker:So you're not scrambling trying to read through notes and then what
Speaker:ends up happening is it's actually really hard to just be present to
Speaker:what the patient is saying to you.
Speaker:Strategy number five is ground yourself to the present.
Speaker:Grounding is a psychological concept of helping to return to the present moment.
Speaker:It can be an important strategy in clinical practice.
Speaker:And I think of it as making contact again with the physical world.
Speaker:So when you're charting, this is one example is you might close your eyes
Speaker:for a moment, breathe and become aware of your bum on the stool.
Speaker:You're reconnecting to the ground, you're reconnecting to
Speaker:your awareness of your body.
Speaker:And I found that this strategy is just a really simple way to
Speaker:reset after a patient interaction.
Speaker:During a busy clinical day, we won't necessarily have time to
Speaker:do a five minute meditation.
Speaker:Right.
Speaker:But I think you can just do a few breaths after you've had a patient
Speaker:interaction and just again, tune into your body as you do that.
Speaker:There was another strategy that is really a derivative that Dr.
Speaker:Epstein wrote in his book Attending and it's called, where are my feet?
Speaker:And the idea is that our feet ground us to the earth.
Speaker:And as he shares your physical presence, stabilizes your presence of mind.
Speaker:I think that's a really solid quote and this idea that grounding
Speaker:helps to stabilize our thinking and, what's going on internally.
Speaker:So with this approach.
Speaker:You ask yourself, where are my feet?
Speaker:Like physically, literally you give yourself a moment to feel your feet.
Speaker:Are they flat on the floor?
Speaker:How do you feel in your shoes?
Speaker:And this is something that can even be good to practice again, outside of
Speaker:the clinical environment, you might practice this when you're eating a meal.
Speaker:And then you might graduate to practicing this when you sit down to chart.
Speaker:And then you may actually incorporate this when you sit
Speaker:down to take a patient history.
Speaker:I hope that these five strategies are helpful.
Speaker:Start small.
Speaker:And I would say, keep experimenting with what works for you today.
Speaker:So a brief recap from today , I covered the five enemies of clinical presence.
Speaker:The first was overattached thinking.
Speaker:The second was ego protecting and beliefs.
Speaker:The third was this disconnected body.
Speaker:Number four was misguided intentions.
Speaker:And number five was environmental noise.
Speaker:Then I follow that up with five strategies to overcome those enemies.
Speaker:The first was to quiet the mind.
Speaker:Number two was to introduce the third person in your interactions.
Speaker:Number three was to let go of labels.
Speaker:Number four was to set your intention.
Speaker:And number five was to ground yourself to the present.
Speaker:Thanks for hanging out with me today and hearing about how to improve your clinical
Speaker:performance through better understanding how to optimize clinical presence.
Speaker:Make sure to subscribe on iTunes or Spotify to stay up
Speaker:to date on future episodes.
Speaker:And if you enjoyed the episode, I'd definitely encourage you
Speaker:to leave a review on iTunes.
Speaker:I'd really appreciate that.
Speaker:Here's to less frustration, more flow and better clinical results.