Part 2: Ready to boost your clinical agility?

December 12, 2022

On Saturday I wrote about the critical role that self-monitoring plays in our ability to develop clinical agility - that ability to respond and adapt to ever-changing challenges that we encounter when working with patients. 

I highlighted the key role that our emotional state plays in our ability to stay in a place of equilibrium and the powerful role our thinking has on our emotions. 

I want to pick up where I left off and walk through an example. 

Let's say you're doing an assessment, and it's becoming more complicated than you expected. As your history-taking goes longer than expected, you start to feel a tightening in your abdomen and you can feel your breathing change. 

A cognitive triangle begins to take shape:  A thought, in this case "I'm never going to figure out what's going on in this session," leads to feelings of anxiety and frustration, which leads to increased stress. This results in the behaviour of tuning out the patient as you become distracted by your anxiety and find yourself feeling rushed and unable to process your objective assessment data points.  This can lead to confusion about your diagnosis, reinforcing the belief that you can't handle this type of situation.  

This is an example of experiencing a cognitive distortion, specifically jumping to conclusions.  You may also engage in another cognitive distortion - that of all-or-nothing thinking - where you tell yourself that you're no good at seeing these clinical presentations or even that you're no good at physiotherapy.

You know something is off, but it's foggy.

In those moments, it can be challenging to decipher what's going on.

You feel off.

You experience various unpleasant emotions, but you're unsure of how to proceed or what to do with what's going on inside. 

In those situations, it is helpful to jot down something to help you remember the situation and then carve out a few minutes at the end of your day to review it. 

I often find in looking back that I can identify a general emotion or visceral experience, but I'm not sure what's going on from a thinking or belief standpoint. 

A process that can help better understand your inner world and shift your emotional experience is outlined by psychiatrist Dr. David Burns in his book The Feeling Good Handbook.

Here are the four steps with clinical examples for each step: 

Step 1: Write down the situation

I felt really irritated when my patient came back for a 3rd visit without having completed any of their exercises. 

Step 2: Record your negative feelings and then rate those feelings

I feel frustrated (70/100), angry (30/100)

Step 3: Use the triple-column technique 

Step 4: Re-evaluate your feelings and beliefs

My frustration is down from 70 to 30, and my anger is down to a 10. I'm feeling better about this situation, and next time when I have a patient struggling with their exercises, I'm going to avoid making it about me and instead, I'm going to become curious about what's going on for my patient. 

What happens if I'm drawing a blank? 

Sometimes it can be hard to know the automatic thoughts that are associated with your feelings. A simple solution outlined in the book is that of drawing a stick figure.

Then ask yourself what is making this stick figure unhappy.

I know it sounds ridiculous, but I promise you it works! 

 This process can help you articulate what’s going on below the surface and will help you gain clarity of the underlying thoughts shaping your feelings. 

It's a wrap.

By understanding what triggers you, and by reflecting on your thinking and feelings, you can become better equipped to handle these situations in the future. By thinking through the cognitive triangle and working through the 4 step process outlined in this newsletter, you can start to make important shifts in responding to clinical situations. 

The process of recognizing unhealthy thinking patterns is a powerful way to improve your skill with self-monitoring to become more clinically agile.

To better flow, 

Andrew