Interrupting Your Patient

Does the thought of interrupting your patient make you feel deeply uncomfortable?

As a field we pride ourselves on allowing our patients to tell their full story.  To ensuring they feel heard.  And that's critically important.

But....there's a need for us, as providers, to reclaim control of the conversation, finding the balance between deeply understanding patient narratives and being efficient in diagnosis.

We discuss the delicate art of interrupting; it's not simply about cutting them off, but doing so tactfully with the confidence of a clinician and the empathy of a caregiver. 

We explore how the phrase "push pause" can become a powerful tool in our hands during consultations.

Hopefully after this 'sode you'll feel more comfortable with interrupting your patient - when necessary - and have some practical tools to do it well.

So buckle up, as we navigate through these murky waters, hoping to emerge as better providers and better listeners.

Downtraining Masterclass

Wondering how to break free of your standard 'downtraining' with breathing or reverse Kegels?  Check out the $47 Downtraining Masterclass to learn about the three types of downtraining, new downtraining tools for all your patients and prioritize specific downtraining techniques to help your patients improve faster!  Check it out (www.pelvicptrising.com/downtraining) today!

About Us

Nicole and Jesse Cozean founded Pelvic PT Rising to provide clinical and business resources to physical therapists to change the way we treat pelvic health.   PelvicSanity Physical Therapy together in 2016.  It grew quickly into one of the largest cash-based physical therapy practices in the country.

Through Pelvic PT Rising, Nicole has created clinical courses (www.pelvicptrising.com/clinical) to help pelvic health providers gain confidence in their skills and provide frameworks to get better patient outcomes.  Together, Jesse and Nicole have helped nearly 200 pelvic practices start and grow through the Pelvic PT Rising Mentorship Program (www.pelvicptrising.com/business) and business courses to change the way pelvic health is administered. 

Get in Touch!

Learn more at www.pelvicptrising.com, follow Nicole @nicolecozeandpt (www.instagram.com/nicolecozeandpt) or reach out via email (nicole@pelvicsanity.com).

Check out our Clinical Courses, Business Resources and learn more about us at Pelvic PT Rising...Let's Continue to Rise!

Chapters

• 0:02 The Power of Interrupting
• 9:02 The Importance of Constructing Patient Stories
• 20:45 Interrupting and Maintaining Professional Boundaries
• 25:39 Balancing Interruptions in Patient Care
• 29:48 Keeping the Conversation Going

Transcript

Nicole: 0:02

In the last 10 years, our field has gone from an unknown specialty to a household name. This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve. In order to help others get better, we need to be better. This podcast will help you to become more confident with your patients, more successful in your practice or business and a leader in pelvic health, and we're going to have some fun along the way. Join us as we rise together. We're Jesse and Nicole Cozine, founders of Pelvic Sanity Physical Therapy and the creators of the Pelvic PT Huddle, and this is Pelvic PT Rising.

Jesse: 0:53

Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine. Hey, nicole, hello. Well, I am excited for this topic. It's a question that we've gotten before and, nicole, you talk a ton about the importance of communication and soft skills. It's in the essentials, it's something you actually train our staff on. But one of the interesting questions is all about interrupting your patient and I think, just to kind of set the stage here, I think there is a little bit of a pride in the pelvic rehab community about not interrupting, about not being like a physician who is, I don't know, on average interrupting their patient every 11 seconds, and I think that's a really interesting point. But the question I think we're having here is has the pendulum swung maybe a little bit too far? Are we a little bit too hesitant to interrupt and redirect a conversation than maybe we should be?

Nicole: 1:47

I think this comes from a lot of our identity crisis in the pelvic rehab field right now on. Are we or are we not in like the Western medicine world? Are we a holistic health care provider? Are we an allied health professional? Are we a little bit of all of the above? Then you throw in we have doctorates, but we're not physicians. But we've gone to school for a long time.

Nicole: 2:11

We have so much knowledge to impart, and so I feel like we're in this sort of I'm not really sure what my role is with patients, and am I the authority figure here or am I their guide and I'm going to guide them through this path and we're going to kumbaya all the way to better pelvic health? Like there is a place for all of the different areas and I think that we as pelvic rehab providers need to really grapple with like where do we fit? And if we fit into it doesn't. Actually, it doesn't really matter where we fit in that whole swing, but we need to decide how much information are we going to glean from our patient's stories and when are we going to take control back of the conversation if it gets derailed a little bit with the patient?

Jesse: 3:06

I think a couple of the things contribute to this too as well, Nicole. One is that just you guys have so much more of a connection with your patients. You actually have the gift of time with your people. You start to know them a lot better. You start to frankly become friendlier with them, although you have a great episode all on how your patient is not your friend. But it can certainly seem that way, and I think that there are probably some gender differences here as well, just as a female dominated profession. Men on average interrupt more than twice as often as women do, and that I think that is another contributing factor to kind of your, I would say, reticence to break into a patient's story and interject and redirect to something that you might find more topical.

Nicole: 3:52

Even the title of this podcast, I bet you made you guys feel pretty uncomfortable interrupting your patient. What the heck is she gonna say about that? How terrible it would be to interrupt your patient. And what this podcast is supposed to help you with is challenge your viewpoints a little bit and then also make sure that you are being cognizant of the choices that you make as providers and the choices that you're helping your patients make, because really, one of the negatives of not interrupting your patient and to throw in a little caveat here, I am not saying that a patient's story is not very important. In fact, I feel like the pelvic health history of a patient is one of the most important things that you can gather in helping figure out the underlying why of what's going on with their pelvic floor symptoms.

Nicole: 4:42

But and this is a huge but there are a lot of negatives if the storytelling of the patient is not guided more by us. There is, frankly, quite a lot of wasted time and I know that that's like nails on a chalkboard Now it's like, oh my gosh, she's talking about interrupting the patient. She's talking about letting the patient tell their story as a waste of time. Not saying that, the idea of letting their patient tell the story as a waste of time. What I am saying, though, is that if we let the patient go on and on, and on, and on and on and on, we aren't helping them to give us relevant information. That's gonna help change what we do during their evaluation and subsequent follow up sessions. Some other negative things is that it cuts into hands-on time. A lot of times, we're making a decision between how much we're gonna get to do on an evaluation or how much hands-on time we're gonna do in a treatment session at the expense of the patient's storytelling. What are some other negatives that we've talked about?

Jesse: 5:44

Well, just your timeliness of now you're running over with the patient, because sometimes you're not really comfortable if you have a 60 minute evaluation, for example, getting to minute 55, they finish their story and then you have to be like, well, that was a great conversation, see you next time.

Nicole: 6:02

Right.

Jesse: 6:02

So if you're not comfortable with that, then you start running over and that affects your boundaries, it makes your day feel frenetic, it affects your next patient, which makes you feel guilty, which has that kind of cascading effect.

Nicole: 6:14

Which leads to burnout, which leads to all of the things.

Jesse: 6:17

And then I think, one of these other ones. It's a little bit more subtle but it gives somebody the idea that everything is equally valuable in what they're talking about. And I think sometimes that's like the active listening side, and I don't know this at all from a clinician side. So if I'm talking out of my ass, nickel, I'm sure you will let me know. But even from like when we're coaching with our rising mentorship groups, if we don't kind of break into like important parts of the story and ask follow-up questions and really dive in and just let someone talk, they think that everything that they've said in that period of time is equally valuable and they're not able we're almost helping them by the questions or by the interjections to hone in on.

Jesse: 7:00

Oh, that's actually really interesting. Wait, go back, you fell on your tailbone how many times. Like I feel like that conveys the importance of a story and it's a little bit more in that active listening side than the decision. Like I am not allowed to interrupt, I'm going to just allow this story to go wherever it goes. And then they've told their story but they literally have learned nothing because they just told their story. They already knew their story.

Nicole: 7:25

Right and I do think that there is value in having somebody and there's that catharsis about having somebody verbally say something. I think a lot of patients would say, oh my gosh, I feel so much better that I got to tell my whole story and all the things. But on the flip side of that is again I'm gonna ask the question is that giving us relevant information, relevant enough information to dictate what we do? Or does this lead us down the road of just giving everybody breathing at the first visit, like if potentially we can interject, interrupt a little earlier in the patient's storytelling? Then can we not get a little bit more valuable information so that our first go-to is, even if it is breathing, it's a little bit more specific, breathing to their problem, their story, their symptoms and such like that?

Jesse: 8:24

You know, as you were saying that, nicole, it reminded me of something that you have said to a lot of people that I think sometimes a little light bulb comes on, but that your evaluation is not one visit. You're going to get more time with this person too. It's not all or nothing in the first 60 minutes. In fact, maybe that's a part of this is that you can't listen to their entire life story or their entire public health history, even if it was all 60 minutes. But I think maybe that's the pressure that people are putting on is this is the one time for them to tell their story and in reality, you've got the entire plan of care to ask questions, to draw them out, to help them realize things that they might not have even said at that initial evaluation.

Nicole: 9:02

Yeah, I think that the mindset shift here if this helps anybody out there, I'm hopeful the mindset shift is that when the person comes into my office, it's like you're my person, like we're going to be in this now together for a little bit of time because, quite frankly, even with the most simple quote, unquote pelvic floor issue, the pelvis itself is complex.

Nicole: 9:25

The body that we're living in is complex, the world that we're living in is complex, the job that we're doing is complex and so all of the things, even in the most simple presentation of symptoms, the complexity of the system is actually quite immense and so I'm not thinking like, oh, I need to hurry up and get everything out because I only have an X amount of time with this person, or anything like that.

Nicole: 9:49

It's just like all right, it's coming in with that like quiet confidence of I'm going to listen and then I'm also going to see where I want to know more information and actually, even though you might think, patient, that this is really important, I already know, with my hypothesis and what you've written down on your intake forms and how you're acting and what you've brought into me like I'm actually more interested for today and the next few sessions to hear more about this and we're actually going to table whatever conversation you were going to go and tell me that till next time to visit three, seven, 10, I feel like that's the goal is to sort of help them to construct their story in a way or tell their story in a way that's going to be meaningful through each of the visits of the plan of care that we have.

Jesse: 10:43

I think that's actually a really fascinating idea. This may be your next course or something. I think this is actually fascinating on almost helping them tell their story correctly, because right now they come in and they've got maybe they're those you know have a ton of information people and they've got all these visits with past doctors or these scans or this thing, and really one of the things that you're trying to do is help them put those pieces together into a coherent story that actually has a plot, that has a through line that makes sense to them, as opposed to these like random jumbles of. Even on the phone I hear this of like oh, all of my stuff just started and I ask was there anything that prompted this? I know totally out of the blue and I'm like, oh, nicole's gonna have fun with this one because it probably was not just out of the blue. You're going to help them construct a story.

Nicole: 11:32

Yeah, what's actually really interesting about what you just said is that for anybody who knows anything about EMDR therapy the theory behind what EMDR therapy and that's a psychology based intervention that uses bilateral processing and that is like literally what you're doing.

Nicole: 11:49

Actually you're helping the brain that is stored memories in different areas that scattered all in different parts of your brain.

Nicole: 11:56

You're reloading that into a thing system and helping it to reprocess that memory into one story and putting it in the correct part of the brain that does not have a huge fear response or stress response or whatever.

Nicole: 12:12

You're literally reprocessing it. Now, I'm not saying that what we're doing in this way by just helping, asking a different question and redirecting someone's evaluation story, I'm not saying we're doing EMDR, but that is very interesting to think of in terms of what your role is. Your role is to help them essentially process what they are coming in for and helping them to construct and glean other pieces of information that maybe they didn't think were important, that they were going to not tell you, but you got to ask follow up questions to get that to happen. Conversely, you might take what they were going to tell you for 25 minutes of the 30 minute eval that you have or something and be like you know what. I need that in like five minutes so that we can get to something else that I think was interesting on your intake form that I know has a has potentially a bit more impact of what we're going to do today, but to your symptoms, to what you're presenting like, etc.

Jesse: 13:10

So I think, just to bring this from the philosophical realm into like down to the streets here, nicole, talk to me about their evaluation, like when do you decide in there they're telling their story about when things happen?

Jesse: 13:25

When do you decide that I'm going to need to interrupt? And I will say this one thing that we learned early on, as we had employees before you really got your training system down, is that we would sometimes have patients come out who were complaining that they had talked to the entire evaluation and they hadn't gotten any of the hands on care or any information that they were coming in for. And I always thought that that was, frankly, a little bit dumb. It's like nobody had a gun to your head and was like okay, lady, keep talking. But that's such like an ignorant statement from me, because they don't know they're the patient, they don't get that every minute that they are relaying their story is a minute that you're not evaluating, that you're not treating, that, you're not explaining things and going on, and so, given the opportunity that they don't even have the ability to make an informed decision, because they just they don't really get what it's like to work with you.

Nicole: 14:18

Yeah, and before I actually started teaching this and my onboarding and in essentials and all that stuff, you know, what was happening, is that that exact thing that Jesse was saying was happening. But it was interesting when I went back to the therapist and I was like, hey, what happened was so, and so it was like, oh my gosh, we had the best session ever. She really told her whole story and it was just like this massive miscommunication between what the patient was expecting and that, what the therapist thought was happening, and it was. I was like man, like this is really interesting, because each person thought that the therapist thought that they were doing a great job, that patient thought that everything was going great until it wasn't, and then now both people are super surprised that the other person is pissed off. And it was just a really like a light bulb went on.

Nicole: 15:09

For me that was like, oh, we need to assume the responsibility of an authority figure, of a clinician, of still having that piece to you. That is going to not just be like I'm just going to let this person keep talking, but that you're actually going to be like I'm going to get the best version of this story. That's going to help me to help that patient best and that's the goal. And so if you think about that, then you are to answer your question, interjecting pretty quote unquote early for us as pts and ot's that want to let them talk for forever and as long as they want to, but way longer than 11 seconds. So I would say, if I had to say a number, I would say if your patient is talking for eight to 10 minutes without you saying anything, maybe even five without you having some question, some redirection, some hey, tell me more about this Then you really need to check how comfortable you are and how good are you at asking those questions, interjecting, interrupting and redirecting.

Jesse: 16:26

Absolutely, and just from having now talked a lot on this podcast guys, we're 350 episodes in like talking for 10 or 15 minutes in a row consecutively without anybody saying anything or asking questions. That's a shit ton of time. Like that gets really uncomfortable really fast at Thanksgiving dinner when Uncle Bob is going on all about whatever crazy thing that he thinks is going on with the world and aliens and Roswell in Area 51. Like once that hits 10 minutes, that's a long time to be talking.

Nicole: 16:58

You know, and I will say this you bring up a great point there, because I feel like the patients don't even really understand what they're doing. They have no concept of time. They lose time in their storytelling. It is the first time that they're able to go more than 11 seconds or two minutes before they're interrupted, because we are going to give them that. But what we can't do is allow them to really swing so much further so that everything, if they say, if they're allowed to say everything and allowed, I use that word loosely but if we, if we have them say everything, then everything means nothing. So we really need to take pieces of their story and help them to construct it in a way that's going to give them a ha moment or bring realizations to them.

Nicole: 17:51

I mean, your, your treatment starts at minute two when you are redirecting something away from my low back surgeon 25 years ago to the tailbone fall that you had three years ago.

Nicole: 18:10

The fact that you care more about the tailbone fall than the back surgeon that did their dystectomy when they threw out their back like that, they were mad that they had that surgery and all the things like the fact that you are asking a little bit more about their tailbone pain because of their recent onset of their stress. Urinary incontinence like that, means something. Or you could turn that vice versa you could not care about their tailbone as much as you care about the fact that they are perseverating over a 25 year old surgeon's history. That's part of your evaluation. But in order to get to that, you have to ask more follow up questions before they get 30 minutes into their story. And now you're running out short on time. You're nervous. You don't know what to do Now, all of a sudden, all you do is you hurry up with the internal exam and you give them some freaking breathing and you skip your last 10 because you let that get eaten up.

Nicole: 19:08

Right. And so then now no one's had a good session, really. The patients still leave scattered as scattered as they were before. They still have a scattered story in their brain. You have a scattered evaluation, you haven't gotten shit done, and so everybody's sort of like, well, let's go on the next visit. And then the patient isn't bought in and you're sort of wondering what the heck's going on and being all worried about what they think about it, and or you think you did a great job and they don't have anything to show for it. So the whole moral to this podcast is that you need to get good at skillfully interjecting and redirecting and asking questions, which essentially comes down to you interrupting your patient in a meaningful way that's going to help them to tell you more informative information.

Jesse: 19:58

Now I know this is something that you go and train our staff in, so I've heard a little bit of what you talk about. I think I've heard you talk about this more in the evaluation, just like you did, but the same thing holds true in follow-up visits, and one thing that I've heard that you talk a little bit about is not letting that get into the friend zone or the social conversation where you're afraid to interrupt them, because you guys do have a great rapport and they're telling you about their life and they're telling you about the trip they just took to Hawaii and you don't want to ever interject there. Talk to me about what do you think about that? When it's in a follow-up visit, you already have rapport. You're legitimately interested in their life a lot of times. When do you interject or interrupt there?

Nicole: 20:42

Yeah, I would say just as frequently, to be quite honest. So I feel like this is where, if you're going to make a change here, it's the easiest thing to do is make a change in the evaluation. I feel like that's the biggest time when their quote, unquote subjective report takes the most amount of time. I know that's a generalization, but if you're going to make a change, I would try to make it in the evaluation. But also to Jesse's point, I think that there is just as much nuance and importance and finesse that needs to happen as you get closer and closer to your patient and, like Jesse mentioned before, we have a podcast that your patient is not your friend. And I think that as we get closer to our patients really as our patients get closer to us first usually, and then we get closer to our patients it's really difficult to interrupt even more now, because now we're invested in whatever story they're telling us. It's like they went to Disneyland and we know that they went to Disneyland with their mother-in-law, who you know they really didn't like and they've always had a problem with and actually some of the friction that they have with their husband is because of this, and they're having painful sex, and so you've now gotten invested into their relationship and part of their relationship problem is the mother-in-law. Now they're going to Disneyland and like how was it? And I want to know was there any drama? Did she say anything? Passive-aggressive? All of that stuff is interesting. It's sometimes it's relevant to their symptoms if it causes a huge stress response and nervous system upregulation or destabilization in their you know, both pelvic floor and relationship. But so we care about that story. I care if there was a piece of drama that happened, but we still have an obligation and we cannot forget our role. So we still have an obligation to interject, interrupt If that story is happening. Right. I'm talking in this objective the first five minutes and I'm like okay, how's your pelvic floor? What happened? I know you went to Disneyland. You must have been walking a lot, etc. Did you leak, did you have pain? What happened? She tells me we're like, okay, this is what we're going to do. Boom, boom, boom. This is what the outline is for the session today. Let me go change. Get on the table. Great, now she starts with the story.

Nicole: 23:05

Now I'm treating, because I've known her for a decent amount of time, and we're looking here, we're looking there. We're doing the things we do internal, you know, and I'm now. I'm like, ooh, something is happening, I'm feeling something. This is important. I need to stop this conversation in order to so that it doesn't get lost, so that I can get information about what she's feeling, what she's not feeling, you know. Does she feel that radiating anywhere Is there? Does she feel that release Like? I have to get that information so I know how to proceed to see if I'm on the right track and I cannot, as a clinician, lose myself in this drama of her mother-in-law so that it derails me from what I'm saying and so, or for what I'm doing in the treatment, and so that is where the follow-up visits for interruption is just as important. So I need to say hey, so-and-so. Oh, my gosh, I cannot. It is like cliffhanger time right now. I cannot wait until we get to hear to the end of that story, but I do want to point out I need you to pay attention right now for these next like few minutes.

Nicole: 24:09

Here we're at a really interesting point on your pelvic floor. We're working here. We're working here. This is, I'm feeling this. Do you feel that I need you to breathe? Relax, blah, blah, blah, do whatever, right. And then great, cool. And then, once you get to a point, too, where you've gotten enough information, feedback, all the things, then you'd be like, all right. So what the hell did she say? You know what's your husband do? Oh my gosh, you know. Did you find him out later? And then, but you can never lose sight of your role, right, your role is not their friend. Your role is not to hear that and be like, yeah, what a bitch. Right, your role is to handle what's going on at the pelvic floor and still do your job in that session and subsequent sessions.

Jesse: 24:56

Love it. So I want to talk a little bit about how to interrupt and, nicole, because I've clearly interrupted at least twice as many times in my life as you have, I'm going to mansplain to you how to interrupt. Okay, first thing, in the mansplaining posture, I got the legs right here.

Nicole: 25:16

The head, bobbing the hands going, you know the first thing you're going to want to do when you interrupt somebody.

Jesse: 25:21

Nicole, let me tell you you probably don't know this. This is a trick that us men use.

Nicole: 25:26

Yeah.

Jesse: 25:27

You're going to acknowledge it's your interrupting. Hey, I'm interrupting you, can you tell Because I'm interrupting you and then explaining why and I actually stole these from Nicole, so I don't know if these are correct or not, but Nicole talked to me about that. You said, like, acknowledge that you're doing it, explain why I love that you do that example and that followup. Right, that was exactly it. Like, hey, I'm going to have to put a pause on that. I want to hear how that story ends. But this is really important right now because of this.

Nicole: 25:53

Yeah, and you guys do you know how many times I say hey, push pause. It's like it's as if they're doing like a recording and I'm like, hey, push pause on this for a second, push pause. And so I need you to come up with something that you say you can steal, push pause. I say push pause, and they're like, oh why? And I'm like, ooh, something's happening with what your pelvic floor is doing or something's happening, and I need to know information until I proceed, because I need to know do you feel this radiating into your rectum or do you feel it radiating down your leg? Because those answers will vastly change what I do next. And so I'm usually saying, hey, push pause.

Nicole: 26:31

I really want to hear the rest of that story. Holy crap, this is crazy. But I need you to take a deep breath and pay attention now, because this is where I am and this is what I'm doing, and this is what I've been doing and this is what I'm going to do, or whatever you need to say. So, jesse man's blaming to me, my own thing is pretty on point. But, yes, you want to acknowledge that you are interrupting and then explain why it matters and what you're doing, and sometimes you might never get to that story the end of the story of the mother-in-law and the Disneyland trip and whatever because you could now be so into it that you are down another path. And then you've made them forget about that for a second, which is also therapeutic in its own right right. You're not up regulating their nervous system.

Nicole: 27:20

Talking about that, you are redirecting them to get into their body and pay attention, or you do what you need to do and then you can have them go right back to telling the story if that's appropriate. The amount of variations in this are totally unlimited, but I do. The whole thing is that you need to remember what your role is. Your role is as a clinician, to figure out what's going on, to decrease their symptoms, to continue to challenge that system, to lead them to a better life without pelvic floor dysfunction. So we've got to make sure that we don't lose sight of our role in the relationship, and that really is. If you assume the role of the clinician in the relationship, then it doesn't become an interruption, it just becomes hey, simply, I need to know this information really quick. So you got to push pause on your story here because I'm at a critical point in my process that I have not forgotten and gotten derailed with your story.

Jesse: 28:25

I love the idea of the push pause button. I'm gonna try that on your mother the next time she is over here. We'll see how that goes. Wish me well everybody. If I disappear, if you guys don't hear from me for a while. I want a full investigation. As always, I want a full investigation. But a couple of the things I really just want to pull out and call.

Jesse: 28:43

I thought that was really fantastic about having the basically I love that phrase that quiet confidence. I think maybe that's starting to help define that role in between traditional Western medicine and physicians who have the confidence but not the quietness, and maybe people in the Allied health. Another way. We always say that is like the empathy and the authority, like that's something we're always trying to balance. You taught me that like what you think about as clinicians. We've actually implemented that at the front desk, so I kind of have an idea of what that is. But if you are just listening, that is all empathy and no authority, and so maybe that is a little bit uncomfortable to break in, but something to be thinking about in your role. Can we assume more of that authority, which might mean more of an eruption?

Nicole: 29:32

Then that is okay, and I want us to get away from thinking that as in a negative connotation, but potentially more as a necessary means to an end of achieving helping your patient achieve optimal pelvic health.

Jesse: 29:47

Perfect. If you're picking up or putting down, please reach out, let us know. We always love hearing back from you guys. If you have pushback on this, if this doesn't feel right, this is a great thing. We would love to have conversation about these important topics and where we draw the line. There's no one perfect answer to anything, obviously, but when you see the pendulum swinging maybe a little bit too far on one side, cool, let's draw attention to it so we can at least be really deliberate about what we believe and then implement that in practice. So, as always, we want to keep this conversation going.

Nicole: 30:19

And let's continue to rise, arc 11.