I issued this clinical challenge recently on facebook:

“With your next couple of patients, keep track of how many of your statements and requests to them are actually demands. They may be polite demands, but demands nonetheless. These will be statements like, “tell me about your back pain” or “show me bending forward” or “Do 10 reps of this exercise next” or even “I want you to do…” etc.

The next part of the challenge was to try to not make any demands (even polite demands) in your next interaction. To do this we must take a different approach that is inviting or advising instead of demanding.

Why is this an important exercise to try?

Much is made of the value of self-efficacy and for good reason. It is the concept that a person feels that they are the ones who are driving their outcomes. I feel that it is similar to, or a combination of two other strong prognostic indicators: locus of control and recovery expectations. When it comes to issues with painful movement, we want people to feel that they got better, did so of their own accord, and were responsible for the outcome themselves. To make this clear, think about the converse of this: the person feels better, but feels that they were not in charge of the process and someone else was responsible for the outcome. “I had do what the physical therapist told me and they got me better.” Interestingly, you can read any number of marketing guides that tell you to encourage that very type of statement. That’s a big problem, but that’s for another post.

So, back to the challenge. When we make demands it assumes that we are in a position to demand something. We are taking a role in which we have power over someone else that allows us to tell them what to do. Again, we often do this very politely and with the best intentions in mind. But, if the goal is a patient operating with a high degree of self-efficacy you can see the problem here. It puts them in a subservient role and is not consistent with our goal of a self-efficacious positive outcome. Patients often come in assuming this role on their own and seek out someone to tell them what to do and be responsible for their well being. We’ll address that in the next challenge.

Habits are hard to break and I still catch myself in this all the time. So, I offer some suggestions as you try this.

1. Asking is better than demanding.  Instead of saying “tell me about your back pain” you could try saying “what brings you in today?” or “What can I help you with?” or “I understand that you’re having some problems with your back.”
2. Making statements is different than making demands. Saying that “I understand that you are having some problems” is a true statement about what you understand and makes no demands. Others that I often use are “I’m curious what it looks like when you pick something up from the floor. Could you show me?”
3. Getting permission is getting informed consent. This might be the difference between “I’m going to do some tests on you” and “I’d like to do some test. Is that OK?” or “That sounds like something I should take a look at. Is it OK if I roll up your sleeve and take a look?”

These may sound over the top careful, and honestly most patients probably don’t feel bullied or pressured. That is not the point of this exercise (although those are definitely not ok). The point here is that we want self-efficacy. We want our patients in that role and in order for that to happen we can’t steal it from them by assuming a role of power. The first step is that we assume they are self-efficacious and treat them accordingly. Next we can even steer them in that direction. That will be the next challenge.