Hello and welcome to this episode of You Matter where I am once again with my great friend and colleague Joanne Elphinstone.

We are going to talk today about an aspect of your experience in the clinical room or one we hear about a lot, which is the the idea is my patient happy and there are some concepts that we're going to dig into around that, that relate to coaching.

But I'm just going to let that all unfold in the conversation.

So welcome again to you matter, Joanne.

Thank you.

So much.

It's delightful as always, to be here with you, our little our little space where we get to just jam on each other.

Exactly.

And that's what it's going to be.

This is not me interviewing Joanne.

This is just us having a conversation, isn't it?

So we both agree that is my patient happy?

Am I doing a good enough job?

Variations of that statement are something we hear quite often.

I'm thinking with coaching clients definitely, but with clinicians I work with posts I see online from clinicians.

Are you finding the same?

Oh, absolutely, Joe, you know it.

I would say that almost 100% of coaching clients that are clinicians and a lot of people when they come on to the GEMS courses as well.

The, the big thing that does start to surface is I'm worried that my patient is happy or satisfied and that's a a source of ongoing stress.

And then there's the the secondary aspect of am I good enough?

Because we've been on ourselves and as you know, we have you and I have talked a lot about this and this is so avoidable.

And it's not that complicated to be avoidable.

Yeah, and here's me going down possibly a rabbit hole straight away.

Bring me back if this isn't helpful.

But it's interesting, isn't it, how that is such an important thing for our patient to be happy?

Almost like that is the goal.

Where do we pick that up from?

Yeah, yeah.

Because actually, it's not about happiness.

Oh, you're frozen, Joan.

Oh, you're back again.

No, it's all right.

You're back.

You're back.

Probably.

Back.

Yeah, because if we take out the happy part and work out well, what is it that the patient, the patient doesn't come in to say, my goal is to be happy.

And that's the first interesting thing that we've already gone off track into our own little world of agenda when actually if we just start with what is the patient actually coming for?

What are what are their hopes?

What's their vision for this?

Yeah.

And that's the that's really important part of the framework that we work with, that you and I work with, isn't it?

We, Joanne and I teach this idea under the heading of agreements.

And it is what it says in the tin.

It's it's from the start making sure there is agreement between you and your client about what they came in for.

Absolutely.

And you know, it's so interesting Joe, because I, you know, since we obviously we've both been working with this for a long time and it's a part of both of our trainings from from way back.

And I would say that, you know, every single patient interaction, it's so interesting how agreements are what locate both of us in the session and give us a calm place to move from.

Because if we've actually both agreed on what's important today, that you've already probably agreed on what's important for the overall goal, but then at A, at a session level.

Yeah.

What's important today, if you both know that, then you don't have to keep wondering, well, is the patient happy because you've both agreed on where you're trying to go?

The other thing about that, though, is that people think that, right?

That's the commitment for the whole session.

But I think we've all been in a session where we're like, do you know what?

We were heading this way.

But it turns out, I don't think that's actually going to be the route today.

And somehow people feel like they've got to just make that first thing happen rather than going, do you know, I think there's going to be a better way forward here.

This is what I propose.

How does that sound to you?

And then the patient can choose, well, actually, no, I want to persist with this, which is fine because they've decided that that's what they want to do.

Or they decide, actually, yeah, I'd I'd be willing to look at another angle here, but you've made another agreement.

We make it and the other way as well.

Sometimes you find the decision is just taking a different course and at that point, rather than just going, oh, well, we seem to be going here and hoping that's OK.

You check in and go, oh, we seem to be taking a different tack here.

Is that OK?

Is that what you want to do?

And again, as you say, if they say yes, great, you can do it with confidence that that is what they wanted or you've just done a really good job of highlighting that.

Oh, no, actually, that isn't where I want to go.

Patient.

Let's let's get back to what I said.

So I don't know, there seems to be often a, a sort of thought that you shouldn't ask.

I hear lots, I have lots of conversations with, you know, from doing 1 to ones with people where they orbit a supervision or something and say, oh, you know, I didn't, we had these three sessions.

I don't really know if it was going the right way or I did this thing.

And I don't really know if they were happy with that.

And almost to the point of being irritating.

I'll usually say, well, did you ask them?

And it seems to be just that people don't feel that they can, like we do the telling we don't do or we ask certain questions, but not those questions.

Absolutely, Yeah, we're very good at the telling and we think that's our job and we we think that's informing the patient and therefore that's part of what we should be doing as the expert in the room.

However, first thing are we the expert in the room?

Well, we're the expert on the stuff that we know and of course the patient is the expert on their first person experience and have so much insight to offer if we but ask them.

But I really picking up on what you're saying there, Joe, is for some reason we think we have to hold all of this inside and not actually share it.

And along with agreements, one of the huge parts of coaching for me is this idea of transparency.

Yeah.

Oh, you know, we could actually put that thought that's going on with us out into the room because as you say, it's just like, you know, sometimes let's say, you know, worst case scenario, you've taken that three sessions and you kind of don't really feel like it's going anywhere and then you're there worrying about it.

But it's so interesting when we say to the patient, right, let's just take stock here.

How do you feel we're going at the moment?

Like what do you, what's your feeling about where we are at the moment?

And it's so interesting because sometimes they're like, well, I just don't feel like we're really heading in this direction, in the right direction.

Fine, then you get to task more questions about what that might be.

But I've been really intrigued with how many times I've asked a patient in that situation, expecting them to say, you know, I'm not really, not really thinking we're going anywhere.

And then they kind of turn around and go, actually, I really want to follow this because I think there's something here or they tell me they're getting something out of it that I'm completely not expecting.

And that's intriguing too.

And if I hadn't been transparent and asked, I would never have known.

Yeah, both ways.

It's all information and stuff you can move on from.

Carry on same direction with change tack.

It opens up the options and it settles that part of you that is making up the answers to the questions that you're not asking.

Absolutely.

And I mean what better way to make somebody feel hood than you actually ask them and something and actually give them the space to express it.

Yeah, I had a conversation just today with a physio who said something really interesting and insightful.

She said, oh, should I tell you what?

I hate the biopsychosocial approach.

It was interesting because she's very good and experienced and very empathic clinician.

And she was saying that's the problem.

She said, you know, by the time I acknowledge the bio, the psycho, the social and all the other things that are going on, you know, then you know, which one of those do I decide to focus on?

Invariably I can get really stuck in the one that probably isn't the thing.

And then I'm spending, you know, 2 sessions on the fact that the patient's having a terrible time with their mum or something like that.

And so we had a conversation about agreements under the the question, which lots of people listening well have heard of the what matters to you most today in all of this?

And she said, yeah, now I do know that one, but it doesn't really work for me.

And we sort of battered around a few different variations.

And in the end, she liked to simply where should we focus today?

And she wanted some variation of where is my expertise best placed today?

And that probably isn't something you would say in those words to a patient.

But just like, OK, I could help you in a number of ways from the things we've talked about, where do you think my help is going to be most valuable today?

Something like that.

I knew exactly what she meant.

You know, we're taught to open up the smorgasbord.

And then what if you pick the wrong thing?

But it goes back to, you know, pick the the thing you have another conversation about which thing.

Absolutely.

And.

Even in those discussions, just as you say, Jay, sometimes someone will say something that you think, oh, and a little bell rings and you, you kind of hear a bit more.

And, and it may be that you say, you know, that there's something really interesting there that we can perhaps look at in a little bit more depth.

Is that something you're you're interested in?

Or shall we keep moving forward, you know, in the story or whatever it is?

And it could go either way because sometimes people are like, well, nobody's actually paying any attention to that.

That would be great.

And and so we do.

But we've had agreement and we haven't taken on because, as you say, we've got this kind of paradox of opening up all these things, but then deciding to take control somehow.

And of course, I know people will be listening, going, but isn't that our job to know which way to go?

Well, that's when we can wield our bit of knowledge and say, this is what I propose for this session and this is what we can realistically expect where we can get to.

How does that sound to you?

And sometimes a patient comes in and, and yesterday I, I had two female patients, two women, 2 exhausted women going through lots.

And one we would normally be moving her back work on in a certain direction.

And she's just white with exhaustion.

And, and I looked at a few things and she's really locked up.

She's been crouching over a computer blasting out high stress work, just like, shall we just look a little bit and see if we can help you to move a little bit more freely?

Can we take a bit of tension out of your system?

She said that would be great.

And Lissa, dare I say it, I did some hands on work with her.

We looked at the movement wheel that was really, really stuck beforehand.

We did some work, we talked while we were doing it.

We got some breathing happening.

We got back up.

She had colour in her face and she said I feel so much better.

And she was standing in herself in a way that was no longer stressing her back.

So actually her back much less painful.

She also got the experience of understanding the relationship between where she puts her body under stress and why creates more pain.

She made that agreement.

You know, it wasn't saying, ah, we have to, you know, move on forward with your program.

She just like this is what I need.

And, and when she left, she left very satisfied and even next time for us to pick up the reins.

Great programmes going.

And I can see how that kind of interaction, in a very natural way, it provides the opportunity at the end for your patient to reflect on really how successful you've been on your agreed aims in that treatment session.

As opposed to, I'm thinking back with a wry smile of my Maitland days where you were taught to do your, however many Mobes, it was stand them up, retest the movement which you decided was the problem, and then somehow try and convince yourself and then that that was different.

And it was all predicated on something you had decided from the start, something you then decided to do and then reassess.

And you know, lo and behold, the if the patients are people, please, if they'll sort of smile at you and agree.

But as many times as many other times, just look at, you're quite confused.

And of course, that's that's such a confusing process, isn't it, that your patient probably feels no understanding of or involvement in and no ability to reflect.

Well, is that better?

Whereas if you actually agreed what it was you were trying to change at the start, then it's much easier for the patient to assess at the end whether it has changed or not.

Absolutely.

And look at the difference in patient agency.

So the first example is absolute passive, isn't it?

The patient is utterly passive in the entire interaction versus the second situation where the patient has been active in the choice and engaged in what's actually happening and why, and then able to actually give that feedback at the end.

So arguably in both scenarios, there has been some form of of manual therapy.

1 is very passive and the other one is actually actively a way for them back into their bodies again, a way for them back into understanding what's happening and actually leaving with.

She left with a far greater understanding of the relationship between stress and why her back pain gets worse and.

What might help next time?

Absolutely.

And you know, I, I look at it and see the, the struggle people have with this is, but I'm the expert.

I'm supposed to be the person who drives this forward, has the plan, you know, and, and all of that.

And I think sometimes people get into a little bit of an identity crisis.

You see, if I'm not actually driving at all, am I?

Am I fixing them?

And so that kind of relates to that thing as my job is to fix them.

So then again, we have the patient as the receiver and you can have that dynamic, but that is going to lead you to an entire lifetime of.

But is the patient happy?

And therefore have I been good enough AD?

Infinitum.

Yeah.

And I think, John, the biggest distinction in this approach is as you said at the start, the the number of times you repeat and revisit the agreement.

Because lots of people do talk about the great phrase, what's most important to you today or what have you come here for today?

What can I do for you?

People will often say, Oh yeah, I do that at the start, but that's the only time.

And it's almost like that's a new box to tick.

But then you're back in the world of, OK, so I've done that bit right now I'm back to default fixing.

And it's that willingness to go back again and again and again and keep keep agreeing, keep checking in, keep being vulnerable enough to put stuff back on the table rather than just gloss over any misunderstandings or discomfort on your part or their part.

It's it, I think it really is that that continuity, which is where you see the value of agreements.

It's not just a one off.

I'm I'm listening to you in the first instance, it's I'm listening to you and I'm every time things change, I will listen to you again.

Absolutely, absolutely.

And it's it is really interesting because this I mean, agreements, it sounds easy, doesn't it?

I mean, there are skills to learn.

It does sound like, oh, it's fine, I'll just keep asking.

But as you say that that vulnerable space is sometimes difficult to sit with if you're thinking drive this forward.

But I mean, we've all been in a situation with a new patient and it quickly becomes evident that this subjective is complex and long.

And you're starting to worry about the time I've got to get an objective and some treatment.

And, and what's super interesting at that, there is a moment there where, you know, I've often had to say to the patient, OK, the what we can realistically do today is I can hear, I'd like to hear all of it because all of it actually is really important.

We will have enough time to do that and have a look at some evaluation and get a clear picture of, of what our next step is going to be.

Is that OK with you?

Now the patient gets a choice and gets to say then, well, actually I'd really like to have a couple of things to go away with.

Fine, you know, I can say that's fine.

We will have to then not be able to hear all of the story this time.

We can come back and you can reflect and then we can look at that a bit more next time in order to make the space for us to do a couple of things for you to take home with.

Is that does that sound OK with you?

So in both instances, no matter what they come back with, it doesn't matter as long as then you frame it so everybody knows what's going to happen and we don't have expectations that have been missed because they were never brought into the ring in the first place.

And the power of that last bit you said, is that OK with you?

I was sort of in my head playing the part of people listening to this suggestion that you might have to, you know, the patients talking and they're really getting to their story.

And they're probably, you know, looking very thoughtful and introspective.

And then you come in and go effectively, I need to cut this short.

And I could feel my stomach going, Oh, and then the is that OK with you?

That's that's what eases the way for both of you.

You're not dictating, you're calling something out into the open and then checking in at the end.

And you know, for people who do find it difficult to, well, just in that instance, if you think you would find it difficult to stop a very verbose patient and suggest that we might need to stop that story today and come back to it.

Just that last bit, is that OK with you?

It's kind of a, it isn't there for a softener, it's there for the agreement.

But in terms of our own comfort with a slightly uncomfortable situation, it's really helpful.

You know, haven't we all be in that place where you don't like, you know, that if you cut them off, that's going to create an issue and stuck with that?

We've all had that patient.

And to be honest, often that patient can have some really valuable information that you're kind of like storing.

But yeah, I mean, sometimes, you know, as I said, I gave a, a couple of choices and maybe they'll ask, well, what, what would you prefer we do with this time that we have, we have this much time.

What is your preference for that?

And now let's see if that, you know, we can make that work for what the overall objectives are.

So they have to, you know, there's a choice, they're making a choice.

And again, you know, that gives us that opportunity to go, OK, when we get to the end of our session, have we done what we set out to do?

Absolutely.

So hopefully people are hearing that this process has obvious benefits for your patient in terms of being heard properly and being given choice and also being challenged to make choice.

But for you as a clinician, there are so many benefits in terms of settling that part of you that wonders and worries about it at home and takes that thought into the next patient and cumulatively starts to build up this concern of is this patient happy enough?

Are my patients plural, happy enough?

Am I good enough?

This this process amongst other things that we teach alongside agreements, but I think you and I both agree agreements is absolutely fundamental to starting the process of creating this framework which actually keeps you safe and grounded as well as benefiting your patient.

Absolutely, absolutely, Joe.

I mean, yeah, it is.

It's kind of really creates that wonderful start point.

But there is a container then.

And as you say, you know, when we look at what the the pillars are that we have for coaching unhealed, we're actually like taking, taking that journey.

But all of those pressure points that come up as clinicians, there are there are principles that can help you to ground the interaction again.

Yeah.

So that things can then start to move forward, because I think we get to that point sometimes in a session where everything kind of grinds to a halt.

I'm not really sure where to go next, but we just know we don't feel good about that.

Yeah.

And actually, there are simple techniques which do take a little practice and we do obviously, you know, coach everybody on this, but they're not complicated, well known in some ways, communication techniques, but knowing how to place them in a clinical setting so that you're really upholding, you know, your own ethics.

You're also upholding the evidence base because hey, this is the absolute key to being patient centered, which is a a term we see bandied around a lot, but not a lot about how do we actually do that?

Yeah.

Just being nice to people is not the same thing as being patient centered.

But in this way, as you say, interestingly, if we can locate the patient with these techniques, we also locate ourselves in a place where we can retain our own equanimity.

Yeah.

And not end up at the end of the session going, oh, not really sure how that went.

Ishan will come back.

All of those kinds of things, which I know so many people, you know, all of you out there listening, who hasn't had that feeling?

Yeah.

And I think that's maybe just as a final point, that's the proof in the pudding, how you feel when you walk away from these interactions.

It's in some ways it's similar to the coaching principle of boundary setting.

And I always say to people, don't judge how you feel about the conversation you had, judge how you feel when you walk away from it.

Because anyone can learn a script of words and learn to deliver them.

But that isn't the problem.

You know, you're all intelligent people.

You can find words.

It's whether you can deal with the feelings you get after an interaction that's the issue.

And you know, if you, if you fancy it, play with some of these techniques and then just where do you walk away?

Think, OK, how do I feel about that?

How do I feel in my body?

How do I feel about the content of the session?

What's going on in my mind?

And I really hope it won't be.

Is my patient happy?

Am I good enough?

Absolutely.

Because I mean, we're not saying that we, you know, we don't care how people feel, but whether there's a big difference between someone walking out feeling like, you know, there's some satisfaction of that they've listened to and that they're, what they've come with has been respected and taken into account.

And that they have been involved in the shaping of that session from beginning to end.

There's a there's something that someone leaves with there which is not quite the same thing as, are they?

Happy.

Because sometimes someone leaves feeling quite thoughtful and not sure how they feel because they've been introduced to to a thought that maybe they haven't had.

And.

Sometimes they're not that easy either.

You know, we have sometimes tough conversations and maybe the patient doesn't leave happy, but they don't necessarily leave unhappy or dissatisfied.

They leave thoughtful but not, you know, so there's, there's that huge difference, you know, that distinction between whether they're happy or whether they do feel that they've had some value from the session.

Yeah.

That's.

Do what we agreed.

Yeah, exactly.

Then that's just to, well, you know, we have so much to to share, don't we?

We yes, and we believe in it and we want to help people.

Yes, Joanne mentioned coaching appealed a couple of conversations ago and then agreements is part of the five pillars that Joanne mentioned.

We've we've taken this array of coaching, these coaching skills and what we realise because we are both coaches ourselves trained I guess in regular coaching, we realise that there's huge benefit in distilling these skills down so that they're directly applicable in the clinic room because it isn't the same as a coaching session.

You are to an extent an expert in the room and therefore the way you use coaching skills needs to respect that and be interwoven in a very particular way That wouldn't be the same as a regular coaching session.

So that's what Joanne and I did over a period of two years and lots of coffee and cake in Monmouthshire.

We thrashed out how to distil these coaching skills for specifically for clinicians.

Absolutely, because I mean, the bottom line with coaching is it's it's basically sound communication skills.

Yeah.

And sound communication, some self connection, you know, to understand the feelings we're having that maybe framing how we're perceiving the stories we're telling ourselves about what's actually going on.

All of these things are are, you know, embedded in these, these, these pillars, these principles that we're talking about.

And hence that's why it's called coaching and peeled because there's so much out there now people are talking about coaching and there's courses, huge amounts of information, but a lot of it is really not specific to the clinical setting.

And So what we've done is we have literally unpeeled the concepts, which we both know very well.

We've had to do great big multi hour exams and all sorts of things on that.

We know that stuff, but we're also clinicians ourselves and we work with those clinicians.

So yes, we've peeled away all the stuff that you don't really need to know and then clarify the things that are going to be the most powerful for you to be able to apply directly immediately into your clinic setting.

Yeah.

And agreements is just one of five of those.

So I think we're going to come back and maybe have a similar conversation about other pillars.

But for now, I hope you enjoyed this conversation and I will put in the coaching notes details of the next time we're going to run the coaching unpeeled course if anybody's interested.

Thank you so much, Joe.

Thank you everybody for listening.

Hopefully that has been cool.

Thank you, Joe.