The following are some thoughts combined with an excerpt from an email conversation I had with Mike Studor, PT, MHS, NCS, CEEAA, CWT, CSST, FAPTA.   His question are likely on the minds of many of our colleagues.

The novel Corona-virus, COVID 19 Pandemic of 2020 has dramatically changed how we do anything and everything. It has plunged us into an existence that is contrary to the human condition: isolation.  As humans, we are not designed to be isolated. We are social animals equipped with nervous systems specialized to connect, interact and create within a social network (family, tribe, clan, etc.). Yet, at this historic moment, we are asked to perform “social distancing” to protect ourselves and others from the spread of the virus.  I strongly pronounce that “Social distancing” is the wrong phrase. Truly, the intent and behaviors we need to exhibit should be physical distancing. We need to be physically distanced from each other, not socially. This is not a “thought virus”, this is a physical virus that only spreads through physical contact with physically contaminated objects.  The wrong kind of distancing as significant consequences to our health.

For new readers, I am a physical therapist whose Mission is to explore the science of relationship to improve healthcare.  Read more

Question: As a physical therapist, what value do I provide?

I’m gonna use this and the following questions to geek out a bit.  My field of study is the neuroscience of the relationship between the patient and the provider.  I think that most would agree that an “outcome” is more than the technique we perform on a patient.  We as physical therapists (and medicine as a whole) strive to get “better outcomes”, but are not exactly sure how.  I do not believe that we fully understand all of the “attribution factors” that create a successful outcome. And until we have additional empirical research to firm it up, we are relying on ideas and theories.   For now, I believe that the best investment in understanding how to optimize clinical outcome is an N=1 model where the outcome is determined by the therapeutic alliance between the PT and the patient.

Questions: I am compelled to ask myself, if the building, the equipment, the milieu of our clinic went away – where is the value? 

Answer:  Value to who?  The obvious answer is “to the patient”, but I would also suggest that there must be value for the provider.  We must move beyond the myth of a “patient-centered” model of care. It must be relationship-centered. The success is in the provider “showing up” fully for the encounter to listen, to connect, to synthesize the patient’s experience into her own and to co-create a treatment plan.  The provider must be fully invested or she is relegated to being a technician performing a procedure. The clinic space, the equipment and the milieu are all a part of the treatment experience, both for the patient and the provider. When you take those elements away, what remains is the relationship, maintained in whatever way possible.  In my opinion, the value can be described to what happens between the patient and the provider in a therapeutic alliance.  

Question:  More importantly, “where WAS the value?” in the mind of the patient [during the in-clinic appointment].  

Answer:  That depends on the mind of that patient (N=1). As mentioned, we have brains fully equipped to connect with others, and circuits dedicated to “mind reading”.   However, the challenge we face is thinking that we know the “minds” of others; when in reality, we are constantly making assumptions about the minds of others (I explain the neuroscience of this part of the nervous system in my courses).  This assumption process is important and efficient for high-paced human interaction, but not always accurate. To truly understand the value in the mind of the patient, we have to ask.

Question:  If I or we did not convey an experience that was valuable beyond the tangibles of the in-person visit (my hands, our equipment, etc) then what value did the patient take from the experience?  

Answer:  YES, this is critical!  I believe strongly that the physical therapist is more than a proceduralist!  PT’s improve function by getting people moving. We offer essential “mechanical” interventions (moving a patient’s body part manually and through activation of nerves and muscles), but I maintain that is only part of the “value”.    Although we are trained as mechanics and we facilitate movement, the patient must ultimately be the one who integrates the movement into their lives. A physical therapist, at his or her best, is guiding the patient in a process of integrating mobility into his or her life.  The saying I commonly use “The best surgeon cannot heal a cut.” The patient does the healing, we have a specific role in that healing process. A successful relationship between the patient and provider activates a bunch of neurological processes that affect “healing”.

Question: In the in-person clinical setting, was our interaction personally valuable enough to them that they feel that I can give them some value when we are physically removed?

Key phrasing is “personally valuable enough”. This captures the essence of “patient-centered”, although I think that patient-centered does not actually work.  The question might better be, “what does this patient ‘personally value’, and can I give them enough of it so that they actually perceive it and stay engaged in a treatment plan?”  When I know that, the next questions are easier…

In summary, if a PT has already established a meaningful relationship with the patient, then that engagement can continue in telehealth, but will require some additional skills to maintain that relationship.  If not, then the perceived value, by both, may not be worth the effort.  And a New Patient to the practice can also have a valuable experience, when it’s done “properly”.

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Having “patient success” with telehealth depends upon many factors.  The skills we teach for success with an “in-person” engagement are similar for an online engagement, but requires a whole new understanding of how patients relate to the provider using technology.
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The human brain is a complex meaning machine designed to “make sense” of the experience.  Humans are social beings and have evolved in the context of social groups and psychological constructs that have enabled tremendous advancements.  This “socialness” is possible with a brain that is designed to connect with others, interpret intentions and “feel” the emotions of others. These neural mechanisms are the foundation of successful human interaction.  

As part of precision language training, one can learn the power of presuppositional language.  Presuppositional language is a linguistic proposition that employs a pre-existing belief to infer an unspoken truth.  In other words, the language we use in the sentence assumes a condition is already existing. We see this kind of language frequently but you may not recognize it unless you really listen for it.  

As an example:  “How hungry are you?”

This sentence presupposes that you are hungry, and depending upon the context of the discussion, but also primes the receiver’s brain in a way that sensitizes them to  and the degree to which they are hungry.  

One language set I often use in the clinic is “What questions do you have?”  When I use this with patients, I am intentionally communicating that I am assuming they have questions and it is a good time to ask them.  Contrast this question with “Do you have any questions?”.  The first question is more likely to get the questions rolling, especially if I use a body language that communicates I am interested and willing to ensure they are comfortable with the instructions I have provided. 

A short story: My wife had arthroscopic knee surgery awhile back.  She woke up in the recovery room and the well intended nurse entered the room eager to help.  The first thing she asked, without even looking at my wife was, “How bad is your pain?” I was in the corner of the room thinking “NOooooo!”.  And before my wife could answer, the nurse said, “honey, I’ll give you some pain meds but it’s gonna make you nauseous.” And sure enough, first the pain and then the nausea! 

There are ways to use this language skill in the clinic to “prime” the patient’s brain toward the desired state for a successful treatment.  As an example, instead of first asking the patient “how is your pain today?”, you can ask “What progress have you noticed since your last visit?”  The latter invites the patient to “search their minds” for examples of progress, whereas the former brings them right to the pain experience. Try it!

In summary, words create an experience!

• When healthcare providers understand this concept, they recognize that what they communicate (words, tone of voice, body language) all contribute to the patient’s experience, and strive to learn the necessary communication skills to connect with patients. 
• When healthcare leaders understand this concept, they recognize the need to engage with colleagues in a manner that inspires performance to meet organizational and personal goals.
• When healthcare organizations understand this concept, they design cultures and systems designed to engage all members of the organization in a process of alignment to the organization’s Values and Mission. 

As the Healthcare System rapidly shifts toward a value-based reimbursement model, providers and organizations must find innovative ways to engage patients to actively participate in their own care.  This will require that all healthcare providers learn the skills that connect with patients, their teams and the desired outcome.

It is time!

The methods providers generally use to motivate patients include giving advice, directing, or persuading with logic. Unfortunately research informs us that information alone does not automatically motivate patients to action. Behavior is more likely to be shifted by engaging patients’ emotions and values.

Although there is not just one magic bullet that inspires patients to take more responsibility in their health care, there is one piece of information you must know – what your patients really want. With the right questions, your patients can recognize the discrepancy between their current behavior and the deeper values they hold. Then patients are likely to get moving on their own behalf.

So begin by sincerely asking this first question:

What will get to happen for you, once you ________ (feel better, have healed, are experiencing relief, etc.)?

One of our trainees asked this question of a patient with back pain who was doing very little between sessions to improve her condition. The patient replied, “I will get to connect with my friends again.”

The provider then asked the follow up question –

What’s important to you about connecting with your friends (their goal)?

The patient lit up and said,  “I love having fun.”

Once the provider understood what motivated his patient, he could incorporate connecting and having fun into the treatment process as well as link doing the home exercise program with making progress toward her deeper values.

After this interchange, the provider told our team that not only did his patient get actively involved in exercising and improve, but that he himself enjoyed the treatment process more.

So consider your current patient case load and ask yourself, “Do I know what each of my patients really want?”

Notes:

Leventhal, H (1971) Fear appeals and persuasion: The differentiation of a motivational construct. American Journal of Public Health, 61, 1208-1224.

Rokeach, M. (1973) The Nature of Human Values. New York: Free press.

About Us and Patient Success Systems

John Woolf, PT, Beth Haggerty, LCSW and Terry Hickey, MS are the creators of Patient Success Systems. Together, we have developed a breakthrough, step-by-step approach designed to help health care practitioners develop psychologically-informed practices to improve patient compliance, dramatically lower no-show rates and improve overall patient outcomes.

“Would you like to learn more simple ways health care practitioners can improve outcomes through motivational language and behavior change techniques?”

Check out our web site, http://www.PatientSuccessSystems.com, for free articles, resources and to sign up for our free report “8 Simple Things to Say to Get Your Patients Improving Fast and Action Guide so you save time and frustration by intervening effectively.

The three main perceptual positions are Self, Other and Observer.

• To experience the Self position, ask yourself, “What do I think, what are my feelings, my ideas and my observations?”
• To consider an issue from the Other position, imagine stepping into someone else’s shoes, taking on that person’s feelings, perceptions and world view.
• To experience the Observer position, step out of your Self position and see the situation from a distance, witnessing in a neutral way.

What is the purpose of being in the Self position? What good does it do?

The Self position allows others to connect with you and enables you to set effective boundaries with staff, co-workers and patients. Speaking from the Self position gives other people a sense of who you are and where you stand. Some compassionate providers tend to over-focus on patients or cope by over-extending with difficult patients. Using “I” language shows patients your perspective and strengthens the therapeutic relationship.

Being in Self position helps you strengthen connection with yourself, and therefore to others. The Self position requires you articulate what matters to you and reflect on the unique experiences that have created your values. Stepping into the Self position allows you to better understand WHY something is important to you, developing self-understanding. This self-understanding allows appreciation for others’ points of view.

How can I step into this role? How can I tell if I am really acting as Self?

1. Use first person language, such as “When I do…” instead of “When you do…” Also, using third person language such as, “People get angry when…” doesn’t speak to your values and your being in the same way as “I get angry when…” does. Choose first person language to amplify your own experience.
2. Make physical gestures toward your self. For example, if you say, “I believe in my mission,” while gesturing in the direction of your heart, the statement will resonate deeply with you. Saying “One should believe in his mission in order to be successful,” just doesn’t carry the same weight. The gesture itself helps create the experience. Using “One” or a generalized “You” keeps it out there, but using “I” embodies it, and adding a gesture makes it even stronger.
3. Be fully in the experience and experience your passion. In order to experience passion, you have to be strongly in Self position. If you lack passion, you may have difficulty adopting a strong Self position.

The Self position is important when you want to deepen self-understanding and express your perspective. However, to express your self without regard for others would be unproductive. As you gain knowledge about how and when to step into all the perceptual positions effective relating results.

Also remember that exercising the Self position will be more challenging —yet ultimately rewarding—for providers who were discouraged early on from expressing themselves with words such as, “Don’t rock the boat,” or “Don’t say things that are going to hurt other people’s feelings.”

In summary, The Self position strengthens personal connection, ultimately allowing providers to set effective boundaries with patients, and improve outcomes.

The research is clear: patient success is linked to the quality of the relationship between provider and patient. Knowing how and when to step into and balance each of these perceptual positions is fundamental to creating a positive therapeutic alliance.

Watch for more on Perceptual Positions in upcoming newsletters.

The three main perceptual positions are Self, Other and Observer.

• To experience the Self position, ask yourself, “What do I think, what are my feelings, my ideas and my observations?”
• To consider an issue from the Other position, imagine stepping into someone else’s shoes, taking on that person’s feelings, perceptions and world view.
• To experience the Observer position, step out of your Self position and see the situation from a distance. In short, an Observer’s primary function is to witness in a neutral way.

What is the purpose of being in the Observer position? What good does it do?

It is time to step into the Observer position when you think to yourself, “I need to step back,” “I need more breathing space,” or “I need to look at this with fresh eyes.”

The Observer position allows you to:

Think creatively because you see things “as is.” By stepping outside of yourself, you view situations objectively, gaining new perspectives and possibilities.

Manage powerful feelings. Feelings can become overwhelming, leading to negative judgments about yourself and patients. So especially with difficult patients, the Observer position is important to utilize. As you gain some distance, you better engage your cognitive skills, and can take a more neutral—and less critical—stance to improve understanding. Also, effective utilization of the Observer position is an antidote to burnout in which providers re-experience the stressful feelings of their patients.

Improve. By stepping back and witnessing what you’re doing, you make appropriate adjustments. Without the usual attachments to self, you can more easily shift and change.

Advance problem-solving and systemic thinking. The Observer position’s view is broad allowing you see and better understand your relationship to the larger system you operate in. It also allows you to consider how changes you make will affect the system.

How can I step into this role? How can I tell if I am really acting as an Observer?

Overall, the Observer’s internal voice is curious and questioning. You could call it a “Mr. Spock” angle. You’ll know you are in the Observer position when:

1. You see yourself interacting with someone else. This creates an Observer position, since you can’t be yourself and an observer at same time.
2. You experience curiosity and neutral questioning. If you find yourself commenting negatively and judging you have left the Observer position. In the Observer role, you want to report the news, stick to “just the facts” rather than inject your feelings and editorialize.
3. Your physiology reflects the role. For example, your breathing is calm and your muscles relaxed. You might even tilt your head as you think about things. If you find yourself clenching your fists, you’ve reverted to the Self position.

In summary, The Observer position engages a provider’s best thinking particularly with difficult patients and in times of stress. The Observer position also provides a place to improve and rejuvenate so providers relate even better to their patients.

The research is clear: patient success is linked to the quality of the relationship between provider and patient. Knowing how and when to step into and balance each of these perceptual positions is fundamental to creating a positive therapeutic alliance.

Watch for more on Perceptual Positions in upcoming newsletters.

If not, that’s okay. We’re on it for you.

We’re hosting a 2-day introduction to strategic communication for PT’s and clinic owners on March12-13, 2011, and we’re excited to show you how to implement a few key communication and language tools that will:

1)     dramatically reduce no-show rates

2)    increase patient compliance and

3)     make your workplace a sought out refuge for people who get results.

Find out of this event is for you and your practice here at the IAOM site here: Strategic Communication as a Clinical Tool – Level I

If you have questions or want to inquire about a special rate for your entire PT staff, just give us a quick call 520.547.1058, Toll Free: 877.549.0506 or email Info@PatientSuccessSystems.com and we’ll be glad to answer your questions.

John, Beth & Terry