This month we bring the thoughts and words of one of the Canadian physiotherapy world's deep thinkers, Jim Millard. For those of us looking for that final step in our mastery of the patient interaction, there is deep wisdom in this blog. Enjoy the read:
We are ultimately in the people business serving rehab, not in the rehab business serving people. We are in the people business! We serve people: People who are unique individuals with unique challenges. There will never be a recipe for treatment. No two people are the same and no two problems are ever the same. The clinical “problem” may be found in a textbook (ie: mechanical hip pain) but our patients' context will never be in a textbook.
“If Content is king then Context is queen. Conversation is the kingdom, and the Currency is human Connection.”
We believe that we tell stories, but often our stories tell us. This goes for our patients but also us as clinicians. Stories matter. Stories are both our sanctuaries and our prisons. John Launer, one of the key figures in Narrative Medicine, states that a consultation is really a conversation and our quest is to find and to create meaning. In clinical care two stories come together as one. That new story is built in the kingdom of communication and comes to life in the currency of connection.
Our clients and patients desire empathy and effective communication. At this intersection lies connection. Connection is the bridge to a strong therapeutic alliance. Connection and communicating may often be used synonymously. The truth is that we all communicate, however, it doesn’t mean that we are successfully connecting. As practicing clinicians, we need to communicate and connect with 100% of the patients we encounter, 100% of the time. We lead patients every day. We rely on sound communication skill to inspire and to positively influence others. Most of us assume that we do this well already.
Communication is defined by what has been understood, not by what we have conveyed. Communication skills are rarely reflected on, practiced, or specifically trained in our clinical healthcare professions. Connection multiplies communication. Through connection we can find the path to meaning. I've shared this journey in the following poem:
We meet Face to face Heart to heart This so called science a powerful Art In the sweet mystery of vulnerability The questions arise Voice, hands, posture, eyes Beyond mere words A language is spoken We meet at this altar of shared emotion Safe in the arms of empathy Bathing in this energy of being seen Weaving a bond of intimacy Given and received We meet at this crossroads of convergence Of who we are Of where we are A dance of meaning Both to follow Both to lead The fruit of relationships Grow from the seed of Connection
© Jamie Millard.
The work of Dr. Maxi Miciak shows that effective clinicians initiate connection with their patients. They create a sense of team on a deeper emotional level beyond just an interaction. Miciak also identified four conditions necessary to create a therapeutic relationship; being present, receptive, genuine, and committed. All speak to connection. Connection is the gate to effective communication.
Everything intersects at the story we co-create. All of the evidence, our skill, our compassionate care and meaning intersect at the story. Confluence. Confluence precedes influence. Confluence is the heart of being a clinician! A clinician, not a technician.
Being a clinician as opposed to a technician exists at the confluence of evidence, clinical skill, care, and communication. The confluence of art and science. The confluence of two experiences. The confluence of me and we. The confluence of two stories merging into one. We as clinicians are guided by evidence, our training, and the compassionate empathic communication of care. However, all of this is only as effective as how we create meaning for and with the patient. I believe that The Mulligan Concept beautifully demonstrates this confluence.
The context drives the treatment not the content per se. The patient’s unique impairment and how it affects their function becomes the treatment in itself. The patient helps define meaning. Treatment is guided by communication lived together as a team. We truly form a therapeutic alliance in every sense of patient/relationship centered care. We create a new story fueled by the foundation of connection.
John Launer calls finding and creating meaning, hermeneutics. The term hermeneutics is derived from the Greek word hermeneuo which means ‘translate’ or ‘interpret’. This originally pertained to the interpretation of classical texts. Launer and associates use the term hermeneutics to signify an approach that seeks to help clinician and patient find and create meaning in a context-specific manner. The perspectives and experiences of both are brought together during a therapeutic encounter to generate a new understanding. Far from just storytelling. It is creating a shared understanding that becomes a new story. Agreed upon truths and solutions are established by the process of dialogue itself. A confluence.
Treatment encounters are always a meeting of interpretation and translation. Our patients ultimately define if communication actually took place. Launer refers to “listening in order to speak” and “speaking in order to listen.” In the former, we only scan the words that patients are saying, looking for opportunities to jump in, to give advice and to rescue them. In the latter, we do the opposite: speaking only in order to give them more opportunities to explain their own views and how they make sense of their world. We collaborate on a shared understanding at the intersection of empathy, connection, and trust. To the clinician this understanding is a much closer approximation of the patient’s contextual reality. To the patient it is the deeper understanding of what matters to them with regards to their situation and what they need to do. It is far beyond the understanding of what is the matter with them. It’s about what matters to them! It is a conversation versus a consultation. Without this level of communication, adherence cannot be assured; with it, adherence is enhanced. Confluence leads to influence.
Creative writing and poetry have played a big part of my own self-reflection process. The writing and study of stories and poetry build empathy and narrative competence to not only get to know ourselves but to meet others where they truly are. Poetry has assisted me in navigating the uncertainty of being a clinician as it embraces the mystery of just being alive. We can never trade mystery for mastery. I shared this journey as a poetic odyssey in my book, Cuoreosity: The heArt of Being. Please reach out to me if you are interested in where coaching and therapy connect to help to create a more fulfilling practice or how poetry/creative writing can transform the resilience of ‘being” a physiotherapist.
Jim Millard DPT MClSc FCAMPT