The Secret Ingredients of a Great Clinician

 

What is the most important aspect of patient care? What are the secret ingredients that will make you better than John PT down the Road? What are the factors that will keep patients coming through your door instead of Bill, DC across the street? What will make you seem like a great PT in your patient’s eyes? Everyone is always looking for the next big thing to make them “a better clinician”. Manipulation, dry needling, instrument assisted work, postural restoration, kinesio tape, etc are all “tools” for this ever expansive tool box that we all seem to want. You know, the toolbox that will answer all the questions and treat those difficult patients that we couldn’t get better before we took that weekend course that “changed everything”.

Since I started taking students for rotations, and especially since I have started blogging, I’ve had a lot of people reach out to me and ask how I practice, what techniques I use, what I think is the best thing a PT can do or learn to make them better. Everyone wants to know what the secret to being a great clinician is. The funny thing is nobody except the students I have taken on rotation have even seen me practice…..sooooo why the hell does anyone think I know all the secrets of being a great clinician?

But you said in the title you were going to tell us the secrets to being a great clinician”….Well I am going to tell you what I think are the most important ingredients based on research and experience. It all boils down to two simple words “therapeutic alliance” or TA. For those of you who don’t know:

The therapeutic relationship (also therapeutic alliance, the helping alliance, or the working alliance) refers to the relationship between a healthcare professional and a client (or patient). It is the means by which a therapist and a client hope to engage with each other, and effect beneficial change in the client. (taken from good ole Wikipedia)

TA has been shown repeatedly to lead to improved outcomes in the research which can be seen here, here, here, here, and here. There is no doubt that making a good connection with your patient and building trust plays a huge role in the outcome they get with their treatment plan. In fact, there is a great write up hereon therapeutic alliance that is worth a read.

I would like to point out 3 ways in which I feel like we can EASILY improve our therapeutic alliance thereby increasing our patient outcomes.

• Listen- At the beginning of the rotation with my students I ask them “what is the most important thing a PT can do and be good at to help their patients?” I get answers like” become great a manual therapist”, “read research all the time so you are evidence based”, “do all your special tests to make sure you are treating the right thing”, or my personal favorite “use functional exercises”, etc. After they squirm for hours, days, or even a week (I’m terrible I know) I finally simply say “listen”. Slow down during your history and listen to what your patient is actually saying. Let them tell their story, as you may be the first person that has actually let them express their whole story with emotion. That in itself can be quite cathartic. When I do an evaluation it is very often 80% history and 20% examination. However, my experience with young clinicians especially, is that they are so concerned with checking the boxes, asking each question, and getting to all of their fancy exam techniques, movement screens, and special tests that they don’t allow the patient to tell them what is actually wrong.   

• Touch- Some people will disagree with this, but hey it’s my blog and my opinion here. Use manual therapy. No, not to break down tissues, put bones back in place, or unstick stuck stuff. Instead use manual therapies to “make space” as Matthew Danziger so eloquently put it in his article here. There is something quite powerful about human touch and the stimulus it imparts to the nervous system, and a multitude of studies show greater outcomes to interventions with the addition of manual therapy. Use manual therapy to decrease fear, decrease muscle guarding, increase relaxation, improve movement quality, decrease pain, increase participation in and success with more active strategies such as exercise, and strengthen therapeutic alliance. Crossing the chasm of how you believe your manual therapy works and the way in which you explain it to patients now becomes incredibly important. People like to be touched (hmm that sounds bad) and will often perceive more value out of your treatment. 

• Educate- There is great power in a patient knowing why they are doing what they are doing. Why am I doing this exercise? Why does this hurt? You mean my back doesn’t get out of alignment? So having “pronated feet” doesn’t mean I’m doomed forever? What do you mean discs heal? Really? Rotator cuff tears are a normal finding in pain free people my age? You mean my emotions and past experiences can influence my pain? Patients AND insurance companies don’t pay for us to give sets of arbitrary exercises to be completely followed out with a tech to fill time. They pay us because of our education and understanding of the human body. We possess a great deal of valuable information regarding the human body, injury, and recovery as health care providers. Use your time with your patients to educate them about their condition, their potential for recovery, about how amazing the human body is, about why they are doing what you have asked of them. Use education as a way to build a relationship with your patient. It’s you and your patient against their injury, and everyone would rather have a team to fight with rather than go it alone. I can guarantee you will see an increase in your outcomes, patient satisfaction rate, referral numbers, patient retention rate, and maybe even job satisfaction if you engage with and educate your patients. After all, you did get into this career because the human body interests you right?

In my humble opinion these 3 points are the SECRETS to becoming a better clinician. Not how good you can crack backs. Not how good you can release muscles. Not how good you can differentially diagnose the shoulder with the not so special tests we have for it. Not even how well you can program your patient’s  exercises with super cool periodization schedules and calculations of total volume progressed over the course of rehab. Great health care providers connect with their patients. They build an un-paralleled therapeutic alliance. Period. Listening, educating, and physical contact build therapeutic alliance, and therapeutic alliance gets people better. “Patients don’t care how much you know until they know how much you care.”

Thank you,

Jarod Hall, PT, DPT, CSCS

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