5 strategies to improve clinical presence

In yesterday's newsletter, I highlighted the importance of clinical presence and the five enemies that keep us from sustaining presence in clinical practice.

In this follow-up, I want to highlight five practical strategies you can incorporate into your life and clinical work that will help increase your clinical presence.

Before I jump into specific 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 press a button to better clinical presence. It's possible, but not likely.  As well, practicing these strategies in low-stress clinical situations can help build confidence and create momentum to better clinical presence. 

Strategy #1: Quiet the mind

Our attachment to our own thoughts is a major barrier to clinical presence. The skill in separating ourselves from our thinking and observing our thinking, is important to avoid being distracted by every train of thought. 

Meditation and breathwork can help you create distance from your thoughts. The practice of meditation helps you to take your thinking less seriously. This helps you to stay in the present. 

We can often recommend meditation to our patients as a strategy to reduce stress. But it's so much more for us as clinicians. 

In my own life, I've reframed meditation as a path to improve my clinical performance. Just like practicing certain manual therapy techniques can improve your skill in manual therapy, meditation can improve your ability to sustain clinical presence and flow in your work. 

Here are a few suggestions on how to make meditation a regular practice: 

• Keep it simple: Focus on a simple meditation and have something that is easily accessible on your phone.

• Keep it short: Focus on meditations that are 5-10 minutes long. When it's short, it makes it easier to stay consistent.

• Keep it consistent: Occasional meditation practice will be good but will have minimal impact. The transformation comes from the regular practice.

(If you struggle with meditation, email me to let me know and I can see about diving deeper into this topic with some additional resources). 

Strategy #2: Introduce the 3rd person

While it would be nice to have someone observe your clinical interactions with patients and provide feedback, the reality is we're often on our own. 

A strategy that I came across some time ago is the concept of introducing the 3rd person into the interaction. It is a practice where one engages in another aspect of the self - an observing self (Epstein, 2018).  It is a detached observation of one's self in the interaction.

What does this look like in clinical practice? I've been experimenting with that, taking moments during a patient interaction (typically while the patient is talking) to observe my own body posture. This could include the tension in my face, the position of my hands or lean of my trunk. This brief check-in and self-observation allows me to observe myself in the interaction and orient myself more fully to the patient in front of me. 

Strategy #3: Let go of the labels

With Enemy #2: Ego protecting beliefs, I talked about how we can protect ourselves from those patient interactions that can challenge our sense of self. Unfortunately our thinking can actually make it difficult to be fully present with the patient. 

More often than not I recognize that I engage in the distorted thinking of 'fortune telling'. Here's an example: 

"This patient probably won't be 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 rather than trying to protect my ego I can take a different path.  I gently remind myself that I'm fortune telling and I have no idea how the patient will present today.

Instead I remind myself "Be present with them today - whatever that looks like. I choose to be open."

There's so many ways that we can try to protect ourselves. And it's amazing how often we subconsciously attach labels to our patients. Pay attention to the labels you place on your patients (especially helpful when looking at your patient day sheet!) and see if you can let go of labels that create separation between you and your patients. 

Strategy #4: Set your intention

Coupled with the idea of removing labels is the importance of setting intention prior to seeing the patient. I've found that being clear with my intention before entering my treatment room is an important step I take to be in the right headspace. 

I've found creating a brief pause prior to entering the treatment room can make a big difference. Combining a couple of slow breaths with a simple mantra of "be present. be open." has made a big difference in my own practice. 

Another strategy that can help prior to seeing the patient is doing a quick chart review. Being familiar with the patient and their last treatment can definitely help with starting the interaction off well. 

Strategy #5: Ground yourself to the present

Grounding, a psychological concept to help return to the present moment, can be an important strategy in clinical practice.

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

Here are a couple ways to help you return to the present moment during a clinical day:

When charting - close your eyes for a moment, breathe and become aware of your bum on the stool. I've found this strategy a simple and quick way to reset after a patient interaction. 

A derivative of this strategy is one proposed by Dr Epstein in his book Attending called "Where are my feet?". The idea is that our feet ground us to the earth. As Epstein shares "Your physical presence stabilizes your presence of mind."

With this approach you ask yourself "Where are my feet?" Then give yourself a moment to feel your feet. (Are they flat on the floor? How do you feel your shoes? etc.) This can be a good strategy to practice first when you're eating a meal. And then graduate to practicing this exercise when you sit down to chart and then practice incorporating this when you sit down to take a patient history. 

What Next? 

I hope that these five strategies are helpful. Start small and keep experimenting with what works for you!

To better flow, 

Andrew