The Four Laws Of Quality Care, Law I

Howdy! This is the first of a four-part series on what I like to call The Four Laws of Quality Care. I call it that because I believe these four components to be both the foundation and the house itself.

Let’s jump right into Law I: Rapport is the most important thing. Period.

Rapport is something that is talked about a lot, and most people would agree that it’s important. It’s something that I’ve spent a lot of time thinking about and talking about with colleagues, mentees, and mentors.

But I’ve noticed something unsettling over the years: my actions don’t always match my words.

While I talk about the importance and benefits of establishing and maintaining solid patient rapport, I don’t always practice that.

I don’t think that I’m alone in this (or at least that’s what I tell myself to feel better). So let’s try a quick thought experiment.

Think about some of the more difficult people on your caseload right now and ask yourself: do you have really strong rapport with all of them?

I don’t.

Why is that? Do I not actually believe that rapport is as important as I say it is? Do I feel that I have to choose between challenging my patients and maintaining good rapport? Do I have trouble putting the necessary elements into practice?

Let’s explore these three questions together.

Is rapport really that important?

The simple answer is yes.

I’ll give you two main reasons, one focusing on what research tells us and the other being a more selfish reason (which in my opinion is a great way to improve our behavior).

1. Rapport influences outcomes.

• Multiple studies show a link between communication with patients and health outcomes across a diverse range of healthcare sectors (1).

• A systematic review by Hall et al. found significant positive associations between therapeutic alliance and the patient’s global perceived effect of treatment, change in pain, physical function, satisfaction with treatment, depression, and general health status (2).

• Another well-done study found that therapeutic alliance was a predictor of outcome for all three groups; the higher the scores on the therapeutic alliance measure, the higher the scores on measures of pain, disability, function, and global perceived effect (3).

Think about that! Just the context of our relationships with our patients has effects on pretty much everything that we care about. I think that’s pretty neat.

2. Good rapport makes our jobs so. much. easier.

We spend time with people all day long. That’s what we do.

When we get along with the people who we spend time with, our day goes more smoothly. When we don’t, our day goes much less smoothly.

If you’d like to have less stress in your life, becoming more skillful with rapport can make your job (and life) so much easier.

Do we need to choose between having good rapport and challenging our patients?

This is something that I misunderstood for a very long time.

I used to think that having good rapport meant always being nice. I took this to mean that the moments calling me to challenge my patients required turning into the tough PT.

I eventually realized that this is a false dichotomy that I was boxing myself into.

Think about someone in your life who really had a positive impact on you. They could be a teacher, a coach, a mentor. Was that person your cheerleader, telling you how amazing you are and that everything is peachy? Probably not.

They probably encouraged you and celebrated your wins. But I'd be willing to bet that they also challenged you to think differently, act differently, and to reach your full potential.

That’s really what people are hungry for. We quickly tire of cheerleaders but LOVE being around people who blend celebration with challenge.

That’s exactly what we can be for our patients.

The art is in the balancing act: realizing that it’s important to both encourage, support, and empathize with people while also knowing when to challenge them and hold them accountable.

There is a very important nuance to this: we must challenge people and hold them accountable only within their own value system.

Pushing our values on people doesn’t work because our values mean nothing to them. But when we understand their values and what’s important to them, it’s meaningful and powerful when we challenge them. This is because we’re helping them to move toward that which is sacred to them.

So we don't have to choose between challenging our patients and having good rapport. In fact, challenging people within their own value system can actually strengthen rapport.

How can we improve our rapport with our patients?

I want to start out by saying, as someone who has been fully nerding out on communication, counseling, behavior change, and the like for years, there is a TON out there—tons of systems, strategies, techniques, all aimed at improving communication, therapeutic alliance, and fostering behavior change.

And these are helpful, for sure. Learning that there are certain ways of talking with people that can help them get unstuck was a big insight early in my career.

But underneath the strategies are simple principles that can be harnessed to help us to build and maintain solid rapport.

The bedrock of an effective therapeutic relationship comes down to two elements: compassion and curiosity.

To explore this for yourself, ask yourself two questions:

1. Can you think of any patients with who you had great rapport, but compassion and curiosity were not present?

2. Can you think of any patients with who you had poor rapport, and compassion and curiosity were abundantly present?

When I think back to the patients with who I had great rapport, compassion and curiosity were present and abundant. When I think back to the patients with who I did not have good rapport, I had either lost my compassion, lost my curiosity, or both.

And this makes sense;

how can we truly help people if we don’t have compassion for them?

And just to be clear, I’m not talking about empathy.

Compassion is a sense of concern that arises when we are confronted with another’s suffering and feel motivated to see that suffering relieved. Compassion is one step further than empathy, in that it connects the feeling of empathy with acts of kindness, generosity, and other expressions of our altruistic tendencies (4).

It’s that combination of the feeling or concern or empathy with the acts of kindness that makes the difference with people. It’s like saying: "I hear you, I feel your pain, and I want to help."

It’s also important to realize that compassion isn’t the same as being nice or doing the work for people. In fact, oftentimes the most compassionate thing to do is to challenge people and hold them accountable to their values and goals.

Similarly,

how can we truly help people if we aren’t curious about them—if we think we’ve got them “figured out”?

I notice this a lot when I hear people complain about their patients (myself included). We speak as if we know exactly what the person needs and are so perplexed as to why they won’t just listen to us.

I don’t know about you, but despite being a very self-reflective person, there is much of myself that I’m still getting to know. So the idea that I could have another human being figured out—in all of their complexity—and that I know what the right thing for them to do is, really is ridiculous.

When we’re truly curious, we understand that we’ll never have all the answers. We will instead look to the patient for their take—acting as a partner or guide, versus a leader or fixer. That’s how you empower people—by working with them, not on them or for them.

When we take a curious stance and form a partnership, we learn more and the patient learns more. It’s a win-win!

What are the practical steps?

The simple answer to the question of 'how?' is practice.

We basically want compassion and curiosity to become a habit—a habit of mind.

In the context of a habit of mind, two main challenges arise:

1. Forgetting (in the throes of a busy day in the clinic, for example)

2. Giving up (usually by failing to see the positive effects of our efforts)

Let’s look at some simple strategies to help overcome these barriers.

• The Routine Reminder — Choose something that you already do as part of your routine (e.g. using hand sanitizer before each patient) and pair it with your intention (to be compassionate and/or curious). Each time you do your normal routine, remind yourself of your intention.

• The Visual Reminder — Type your intention on a virtual sticky note on your computer desktop, or write it on a real sticky note and place it on your workstation. Visual reminders are some of the most powerful, as the majority of our sensory receptors are dedicated to sight.

• The Reward Reflection — At the end of the day (and perhaps during lunch), take a few moments to assess how well you remembered and implemented your intention(s). During times where you did remember, how did it feel? During times where you ‘lost’ your compassion or curiosity, how did that feel? What may have caused that to happen? Simply taking stock of the effects of our actions can have profound effects on our behaviors. Especially when our actions result in positive feelings.

• The Caring Sharer — There are few things more effective than maximizing our social resources to change our behavior. Find somebody at work that is interested in improving their practice too. The two of you can discuss your intentions, hold each other accountable, and discuss how things went at the end of the day. The beauty is, you and your co-worker will inevitably influence those around you to be more compassionate and curious!

• Just Be Here — This ‘strategy’ involves tapping into the innate curiosity that we all possess. For one of your upcoming new patients, take a history without writing anything down. No lists of questions, no prompts — nothing. Just be curious about what’s going on and what you might be able to do to help.

Try one of the above, or stack them on top of each other—whatever sounds good to you!

It’s important to be honest with yourself about what is realistic at this point in time. There’s a saying about starting new habits: make it so easy you can’t say no.

One more thing to please keep in mind: be nice to yourself. Changing our behavior is hard, and often what we first discover when trying to change is how often we’re ‘messing up.’

Being mean to ourselves is the opposite of helpful when we’re trying to change our behavior, so please be gentle and practice seeing ‘mess-ups’ as ‘opportunities for growth.’

In Summary:

• Having strong rapport fosters better outcomes and makes our jobs easier

• Challenging people within their own value system can actually strengthen rapport. But we must challenge people and hold them accountable within their own value system

• Compassion and curiosity are the bedrock of an effective therapeutic relationship

• Compassion and curiosity can be thought of as habits of mind and can be trained, like a muscle.

• Changing our own behavior is hard. Starting easy and being nice to ourselves are helpful in this process.

Thank you so much for reading. I’d love to hear from you! Please let me know your thoughts in the comments below, and use the share button to share with friends who you think would enjoy too!

Sincerely,

Andrew

Click here to dive right into Law II & continue the fun!

References:

1. Jesus, T. S., & Silva, I. L. (2016). Toward an evidence-based patient-provider communication in rehabilitation: linking communication elements to better rehabilitation outcomes. Clinical rehabilitation, 30(4), 315-328.

2. Hall, A. M., Ferreira, P. H., Maher, C. G., Latimer, J., and Ferreira, M. L. (2010). The influence of the therapist—patient relationship on treatment outcome in physical rehabilitation: a systematic review. Physical therapy, 90(8), 1099—1110.

3. Ferreira, P. H., Ferreira, M. L., Maher, C. G., Refshauge, K. M., Latimer, J., and Adams, R. D. (2013). The therapeutic alliance between clinicians and patients predicts outcome in chronic low back pain. Physical therapy, 93(4), 470—478.

4. Jinpa, Thupten. A fearless heart: How the courage to be compassionate can transform our lives. Avery, 2016.