Clinical presence and achieving flow

I love rafting whitewater.

And when I had the chance to become a raft guide in my twenties while working at a rafting company, I took it.

I spent countless cold, rainy spring days on the river honing my raft-guiding skills. Outside of the mechanics of controlling a raft, the training was focused on reading the river.

The training was not about memorizing the river or knowing every boulder. It was about learning to read the flow of the river and identifying changes in the flow of the river. This knowledge would allow you to quickly adjust your raft position and set up for success further downstream.

It reminds me of trying to maintain flow in a clinical day.

Flow in our day-to-day work can feel elusive.

Those fleeting moments where we feel 'in the zone'. It seems any number of things can throw us out of this zone. Unexpected distractions, tasks that feel too arduous, challenging patients...

Just like whitewater rafting, there’s a constant adjusting to ever-changing situations. Course correcting on a continual basis is needed to stay in the right part of the river.

Flow is that state of being where you are in the zone - often experienced in various athletic and artistic pursuits. As Csikszentmihalyi (2014) highlights there is a merging between action and awareness - a place where irrelevant thoughts and feelings are paused from one's experience.

I believe clinical flow requires two essential components - one is the ability to manage and focus one's attention and the other is to engage deeply in the present moment with the patient in front of you.

Optimizing one’s attention is something I covered in a previous blog post here. Today I want to talk about clinical presence.

Improving your ability to be deeply present allows us clinicians to engage in consistent clinical flow and improves our ability to remain clinically agile.

What is Clinical Presence?

Clinical presence can be thought of as a place of being receptive with your senses to the present moment . It also encompasses the notion of being available to oneself and to the other person in a bodily way. And finally, there is an element of being present with the entirety of yourself in the interaction. It involves the ability to remain aware of and responsive to the environment, both external and internal, while also being able to observe, attend, empathize and communicate effectively with others (Malet et al).

Why does clinical presence matter?

First off, your patients want and need to feel heard. Presence is an important building block in creating a therapeutic alliance.

But beyond that, clinical presence is necessary so you can respond to your patient in perpetually changing moments of interaction.

In today's newsletter, I want to highlight the 5 enemies that hurt clinical presence that I've found from my clinical experience.

Enemy #1: Over-attached thinking

Staying present and engaged with a patient sounds easy enough until we realize how easily our thoughts can cause us to go astray. I think about how easily I am distracted when doing meditation without distractions!

Often times it feels impossible to stay present because we end up experiencing over-attached or fused thinking - an experience when we become so connected to our thoughts that we cannot separate ourselves from them. (It's a concept introduced in Acceptance and Commitment Theory).

For example, I’m seeing a patient who seems standoffish in the session. I begin to think that the patient may be unhappy with their treatment to date. I find myself becoming attached to this line of thinking and find myself having a hard time responding to the patient and planning my treatment. I become so attached to this thinking that I cannot separate myself from my understanding that it is a thought, an impression that does not need to be embraced or followed.

Unfortunately, when we can't uncouple ourselves from our thinking, we end up getting pulled away from the present moment and will find it difficult to remain present fully with the patient in front of us.

Enemy #2: Ego protecting beliefs

In our caseloads, we have those patients who are not progressing as expected. And they can weigh on us. I’ve found how easy it is to brace myself emotionally before those appointments. I wonder if they will still be struggling. And to protect myself emotionally, I anticipate that they will still be doing poorly.

This response is a way to protect myself from further disappointment. Projecting this to my upcoming patient visit can temporarily protect my ego, but it makes it difficult to be open to the patient interaction and pulls me away from being fully present.

Enemy #3: Disconnected body

Clinical presence ultimately is a bodily experience.

Our presence isn't just a result of the words we say, but it's a space between two people and our physical bodies. Often times we can be unaware of our own body language. Our body posture and openness becomes all the more important when a challenging clinical interaction is in front of us. I've noticed how my own body language closes off when I start to feel uncomfortable with a patient interaction. A lack of awareness of our own body and body language can result in decreased connection with our patients.

Enemy #4: Misguided intentions

There was an interesting study that looked at family physicians' ability to be fully receptive to the complaints shared by their patients. Interestingly, patients were only able to complete their statement of concerns 28% of the time. And most surprising is that physicians in the study, took on average only 23 seconds to redirect the conversation with patients.

Our intentions for a patient interaction can keep us from being present. When we have a particular agenda to achieve or an outcome to produce, we can hijack the interaction between ourselves and our patients. We can miss important cues from our patients and also rush through an interaction to achieve our preconceived goals.

Enemy #5: Environmental noise

There's an interesting concept from engineering called the signal-to-noise ratio. It's a helpful metaphor when we look at clinical environments.

If signal is our ability to stay present and connect with our patient, then what is the noise that drowns out the signal?

First off, actual noise from open-concept treatment areas is something I've found can impact clinical presence.

Another noise factor is the level of busyness in the clinical environment. I’ve also noticed that the level of busyness in the clinical space can also make a difference. Observing your own internal state while working on a quiet Saturday can be very different than a busy time during the week.

Noise can also come from technology - the increased use of laptop charting is an example. It can be a barrier to being present with our patients as we're focused on writing notes while the patient is talking.

Are you ready to improve your clinical presence?

Tomorrow, I'm going to share some powerful ways to help you improve your clinical presence for better flow and results.

To better flow,

Andrew