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Transcript

Establishing Effective Boundaries in Clinical Practice · Pelvic PT Rising

• 0:02
  Speaker 1: In the last 10 years, our field has gone from an unknown specialty to a household name.
• 0:09
  Speaker 1: This brings unprecedented opportunities, but we need to rise up to meet them and give our patients the care that they deserve.
• 0:17
  Speaker 1: In order to help others get better, we need to be better.
• 0:23
  Speaker 1: 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.
• 0:36
  Speaker 1: Join us as we rise together.
• 0:39
  Speaker 1: 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.
• 0:54
  Speaker 2: Hey guys, welcome back to another episode of the Pelvic PT Rising podcast with Jesse and Nicole Cozine.
• 0:58
  Speaker 2: Hey, nicole, hello Well, pelviccon was incredible, we assume.
• 1:04
  Speaker 1: We think we are in our infinite wisdom for pre-recording some of this stuff, knowing that when we get back from PelvicCon we are going to be spent.
• 1:16
  Speaker 1: So we are super excited.
• 1:18
  Speaker 1: We assume that it's over, that it was awesome and Hopefully that's true.
• 1:23
  Speaker 2: I mean, with all the work going in the speaker lineups, all that's that, I cannot imagine that it is not going to go Great.
• 1:30
  Speaker 2: So if you guys were there, hopefully you guys can vouch for it.
• 1:33
  Speaker 2: If you weren't, we are.
• 1:35
  Speaker 2: We have about another week left for you guys to grab the recording of all of the amazing Speaker topics.
• 1:41
  Speaker 2: You can find that at pelvicconcom.
• 1:44
  Speaker 2: But we wanted to get back on track with the podcasting and had, or think, a really interesting topic today setting boundaries as clinicians.
• 1:54
  Speaker 2: And Obviously, nicole, I'm going to be asking more of the questions here, since I am not in fact a clinician, but I do think and talk and especially with our business side on mentorship a lot about boundaries and Talk to me about why you feel like this is so important, like why does it matter to make these boundaries in your clinical practice?
• 2:17
  Speaker 1: so, ultimately, if we Make boundaries and essentially boundaries we've defined, as is just decisions that you make ahead of time, and if we Do that well, then it just sets up our entire work life wonderfully for Decrease stress, decrease burnout.
• 2:39
  Speaker 1: It is one of the things that we talked about at the clinicians lunch with Jessica and I.
• 2:44
  Speaker 1: All y'all are burned, freaking out.
• 2:46
  Speaker 1: I think with the pelvic conner survey that we sent out beforehand, 98% of people at some point in their career had felt some level of burnout, and especially in our field, where we are Gathering information that's very personal, we are helping people with a very intimate region of their body.
• 3:05
  Speaker 1: They are telling us things that they probably have never opened up and shared with anybody else, including some of their most important family members.
• 3:15
  Speaker 2: When that happens, it's a recipe for boundaries to be blurred if we're not clear about them, and so that's why I think it's really important for us, as clinicians, to be aware of what are our boundaries, what are not, what boundaries don't we have, and Make that a better situation and I think one of the Misconceptions that people have and we start talking about boundaries is that they're all about saying no, that we're gonna get on here and tell you all the things you have to say no to, and and that is a little bit true, because I think most of us tend to err on the other side of this where we're our people pleasers, we're saying yes.
• 3:52
  Speaker 2: Too often it feels like conflict if we have to say no.
• 3:55
  Speaker 2: So in sense, that is true is that usually when we're talking about boundaries, we are talking a little bit more about, you know, being firm in those are saying no when that's appropriate.
• 4:04
  Speaker 2: But it's just as valid to have boundaries where you're saying yes when you're wanting to create a safe space or a great environment, or you're saying yes when you're asked for something.
• 4:15
  Speaker 2: So I want to eliminate some of that negative Connotation when it comes to boundaries.
• 4:19
  Speaker 2: It's not just another list of oh, they're gonna tell me I have to say no to all of these things.
• 4:24
  Speaker 2: Sometimes one you're saying no in order to say yes to something else, and sometimes a boundary simply is saying yes.
• 4:31
  Speaker 1: And I, you know, on that note a little bit, I feel like sometimes we assume that a boundary is.
• 4:36
  Speaker 1: That situation arises and presents itself and it forces us to have to say something kind of to your point about having to say no.
• 4:43
  Speaker 1: But some of the things that we're gonna talk about are much more subtle boundaries that you create In order to not have to get to that point that the things that you can do that are a little bit under the radar, but that, when they all add up, create a very clear, boundary-driven place that you are working in.
• 5:08
  Speaker 2: So we wanted to think of these in a couple of categories, and the first one that you identified, nicole, was really physical boundaries, or taking charge of your physical space, of your treatment room, and I know for you that even starts from the moment a new patient walks in.
• 5:22
  Speaker 2: You're very explicit.
• 5:24
  Speaker 2: I need you to sit in that chair in the corner and keep your clothes on.
• 5:28
  Speaker 2: We're going to chat for a little bit.
• 5:30
  Speaker 1: Yes, I do not say it exactly like that, but you know, I think again this is where it gets a little bit more subtle and this goes a little bit to in answering questions that patients might have before they actually have to ask them.
• 5:43
  Speaker 1: But when I'm thinking about creating my physical space and creating my environment, in which I'm going to be treating somebody and inviting somebody into that space in order for them to be able to be open and share some very personal and intimate details of their life, the physical space needs to be welcoming, but it also needs to be clear where they are supposed to go.
• 6:05
  Speaker 1: And so it's not like I'm, you know, a dictator, being like Hi, sit down here, go over into the corner.
• 6:11
  Speaker 1: But I am saying, you know, having chit chat on the way down.
• 6:15
  Speaker 1: And then I do say, you know, when they get into the room and they're orienting themselves to the room, I say, hey, why don't you go ahead and have a seat in that white chair in the corner there?
• 6:23
  Speaker 1: And we're going to actually start by talking first and then we'll move on to the exam part if we're both on board with everything.
• 6:31
  Speaker 1: So again, we are pre framing for them that there is going to be a conversation that they're going to have to agree to.
• 6:38
  Speaker 1: That you're not just I don't want to walk into this room and have you in your gown or naked on the table or something like that and some of you guys might be chuckling to yourself when you're listening to this, but that's happened before to some of our staff members.
• 6:53
  Speaker 1: It's happened.
• 6:54
  Speaker 1: It happened one time to me never again, you know, when I wasn't very clear about what exactly was supposed to happen and that person was just like oh well, here's this table and they're going to have to look at my area.
• 7:09
  Speaker 1: So when I left the room, I came back in and someone's sunny side up on the table there.
• 7:15
  Speaker 2: So that story, but this, this is again another example of where you're you're using boundaries or you're using your language to make someone feel comfortable, to basically give them the opportunity that gives them the confidence to be able to sit down and have a conversation with you, to open up.
• 7:30
  Speaker 2: You're using that boundary to say yes to that kind of communication.
• 7:34
  Speaker 2: You know other ones that kind of fall into this physical space when Nicole is that you are consistent about leaving the room to have a patient change.
• 7:42
  Speaker 1: Yes.
• 7:42
  Speaker 1: So even if I've been treating somebody for a year or more and we're super comfortable with each other, they know what's going on.
• 7:51
  Speaker 1: They've been through it a million times, and I know that there are some of you out there where you have patients too, that'll be like oh my gosh, don't worry, you don't need to leave the room when they're changing.
• 8:02
  Speaker 1: And in fact I always say, oh, you know what In fact I do, and I'll be right outside and just crack the door when you're done.
• 8:09
  Speaker 1: And so that is an example of I don't care how comfortable that we are together.
• 8:16
  Speaker 1: Personally, I don't care how well this session is going.
• 8:19
  Speaker 1: That is a thing that I just never cross.
• 8:23
  Speaker 1: I never let someone change when I'm in the room.
• 8:26
  Speaker 1: That's just one of the things that I've set up for myself in that way.
• 8:29
  Speaker 2: And obviously draping falls into that category as well, although weirdly that's not something that I think is taught in any of the intro courses.
• 8:37
  Speaker 2: But draping important.
• 8:38
  Speaker 1: Yeah, draping super important, and that, again, you need to have your own boundaries.
• 8:44
  Speaker 1: When do you glove?
• 8:46
  Speaker 1: When do you not love?
• 8:47
  Speaker 1: You know, I know some of you guys glove when you're touching someone's abdomen.
• 8:51
  Speaker 1: I personally do not, but I have a very specific way of draping, so that it almost reminds me not that I'm going to forget, but it's very clear that when I'm doing work on someone's inner thigh and I get to this point, that's fine for me to be not using a glove, and then if I go medial to a certain landmark, then yes, I am, and so that's very, very, very consistent across anybody that I see.
• 9:18
  Speaker 1: And that is a type of boundary because, as you know, some patients will be like hey, can you look at this?
• 9:26
  Speaker 1: Or they're trying to move the towel, or something like that, and it's like listen, this is my room.
• 9:31
  Speaker 1: While you're here, I'm in charge of the towel, right?
• 9:35
  Speaker 1: So there's certain little things like that that you can say.
• 9:38
  Speaker 1: That very much clearly articulate that there is a boundary there while they are working with you in your session.
• 9:46
  Speaker 2: And one thing I love that you said a little bit earlier, nicole, and I think it's worth reiterating, is that by being clear with these boundaries from the beginning, you're actually reducing the fact that you have to say that Like, when's the last time you actually had to say I'm the one who's in control of the towel?
• 10:03
  Speaker 2: You know, I bet it does not happen very often because you're so clear.
• 10:06
  Speaker 2: It's obvious not even from what you say, but just the way that you're confidently moving around the table.
• 10:11
  Speaker 1: Yeah, I mean I literally can't even remember.
• 10:13
  Speaker 1: I mean I know that it's happened before, but it's probably earlier in my career before I really had this down.
• 10:19
  Speaker 1: Yeah, I mean, I just feel like it's something that if you get in, it's a habit.
• 10:22
  Speaker 1: It's a habit that you have to get into.
• 10:24
  Speaker 1: This isn't something that just you're innately doing in the thing, and especially when it's not getting taught.
• 10:30
  Speaker 1: So it's something that you have to think about, think about deeply, and then decide what you're going to do and then implement that, and implement that in multiple scenarios with multiple patients.
• 10:40
  Speaker 1: And once you really get into your groove, it becomes second nature and then it becomes really clear when somebody is trying to take advantage of you or is trying to breach that boundary line, because you've made it so clear, you're consistent every single time.
• 10:57
  Speaker 1: Now you have n equals 100 patients that have had no problem you being in charge of the towel, as an example, and now you have n equals one of a person who's trying to fuck around and find out.
• 11:09
  Speaker 2: Yeah, and that makes it really clear.
• 11:11
  Speaker 2: It takes away any ambiguity from the situation.
• 11:13
  Speaker 2: So those are physical boundaries and great examples of those and, hopefully, things that you guys can think of in your own practice that are similar in what you're doing.
• 11:23
  Speaker 2: Next we have emotional boundaries, and I think this is a perfect example about how boundaries can both be yes and a no, because one of the things that you're talking about is wanting to create a safe, confidential, caring, empathetic place for patients to be able to share intimate details of their lives with you.
• 11:43
  Speaker 1: Totally, and I think that the tendency a lot of the time is for, because it's a social norm if someone shares something, then you almost feel obligated to share back.
• 11:52
  Speaker 1: But in this case, we want you to think of this boundary as sort of a one-way vow.
• 11:56
  Speaker 1: There are going to share with you all of the things and then you are going to only share things that you want to and that are appropriate.
• 12:08
  Speaker 1: So that's another example of, again, it's a boundary, a decision that you make in advance.
• 12:14
  Speaker 1: My patients feel like they know me very well, and they do.
• 12:18
  Speaker 1: It's not like I'm a different person to them, but I have chosen to share a limited amount of my life with my patients, and that has been very consistent across the board.
• 12:29
  Speaker 1: And so I am not an open book, and I want to also dispel the myth that in order to make a connection with your patients, you have to be an open book, because that is not the case and in fact, that can actually blur boundary lines and make a patient practitioner relationship more difficult if you don't have some of these emotional boundaries.
• 12:50
  Speaker 2: Yeah, I think Jill Coleman maybe coined the term, or at least has used it of knowables.
• 12:55
  Speaker 2: And what were some of yours, nicole?
• 12:57
  Speaker 2: I love how you think about it, as, hey, my patients can know these things about me, but then the rest of my life is actually pretty private yeah.
• 13:04
  Speaker 1: So it was.
• 13:05
  Speaker 1: I'm a former, or was a current NCAA basketball referee women's basketball.
• 13:11
  Speaker 1: I like wine, I live in San Clemente and like the beach and wouldn't have it any other way.
• 13:16
  Speaker 1: That kind of those are the three things we talk about.
• 13:20
  Speaker 1: Being from Southern California, basketball, slash sports and drinking wine.
• 13:26
  Speaker 1: Like I love doing those things Wine tasting where'd you go?
• 13:29
  Speaker 1: What'd you have for dinner?
• 13:30
  Speaker 1: What kind of wine did you drink with it?
• 13:31
  Speaker 1: Like all that kind of stuff.
• 13:32
  Speaker 1: And yes, I still talk about wine, even though I know it's a bladder irritant, because my patients can handle it, because we're getting better all the time.
• 13:40
  Speaker 2: Right, and things you're not doing, or you're not complaining about your mother-in-law, or you're not talking about your personal symptoms or issues that you've had in the past or what it was like when you were rehabbing from your surgery.
• 13:53
  Speaker 2: Right, you've made the deliberate decision.
• 13:56
  Speaker 2: Hey, here are the things that I'm open to sharing and here are the things that I'm a little bit more of a closed book on, and I would encourage you guys to think about what those are for you, whether you use those terms, but what are the things that you feel really comfortable connecting with patients about and what are some of the things that you'd actually prefer or you feel like really should remain private?
• 14:16
  Speaker 1: And think about how you're going to redirect the conversation if somebody asks you something.
• 14:21
  Speaker 1: And this was really apparent for me when I was going through a bunch of IVF stuff and we were having miscarriages all over the place and all of that and people were like, oh, are you going to have kids?
• 14:31
  Speaker 1: I decided that I was not going to talk with any of my patients about that kind of stuff because it's too hard, and so I would say, yeah, we're working on it, and then boom, go right into something else.
• 14:43
  Speaker 1: I would immediately switch the subject away from kids, so not asking them necessarily even about their kids yeah, we're working on it.
• 14:49
  Speaker 1: And then I usually go back to something critical, so that there's now two steps removed to come back to that question.
• 14:57
  Speaker 1: Right?
• 14:57
  Speaker 1: So now, if they ask me something personal that I don't want to be answering now, I take that and say answer it shortly, but without any sort of elaboration, and then move it to something clinical.
• 15:09
  Speaker 1: So if we have to go back to personal, now we're away from clinical and then back to personal, which is just a sign that somebody might not be picking up what you're putting down with the boundary situation.
• 15:19
  Speaker 2: Right, so being really consistent with that.
• 15:21
  Speaker 2: So that's on the emotional side.
• 15:22
  Speaker 2: Talking about communication, nicole, this is another really big one.
• 15:25
  Speaker 2: I know we train our staff about a ton and now I've heard you say it, I mean, I guess, six different times.
• 15:31
  Speaker 2: We have six different staff members now about how we communicate with patients.
• 15:36
  Speaker 2: I think one of the first ones is just the language in the session that you guys are going to be establishing a common language, that it's going to be anatomically correct and talk to me about that.
• 15:48
  Speaker 2: How do you set that boundary for people, frankly, myself included who would be very tempted to come in and use slang terms because they're either uncomfortable that's just how they talk in normal life.
• 15:59
  Speaker 2: Like you know, nicole, my balls hurt, like that's how I would say it.
• 16:04
  Speaker 2: I mean, I honestly would if I was in your office.
• 16:06
  Speaker 1: Well no, you would not actually say it one time.
• 16:09
  Speaker 1: But here's the thing.
• 16:10
  Speaker 1: This is where you know people that don't speak in anatomical terms.
• 16:14
  Speaker 1: It's easier, it's hard, to immediately go in there and be like and this is how, what we're the phrases that we're going to use.
• 16:21
  Speaker 1: Here's a list of the nouns that we're going to be calling our genitals.
• 16:25
  Speaker 1: It's not that, but it is noticing, it's using anatomical language yourself.
• 16:31
  Speaker 1: Then it's noticing when someone doesn't do that and then correcting them in the moment, either through conversation or, if it needs to escalate, actually saying hey, in this session, I'm really going to ask you to be using anatomical language for the body parts.
• 16:46
  Speaker 1: In that case, the taint that you just called it is actually called the perineum.
• 16:52
  Speaker 1: And then, now that you've said that, your expectation about that?
• 16:56
  Speaker 1: Now, if they say it again, then we know that they're crossing a boundary.
• 17:02
  Speaker 1: If we don't say that and we just say, try to move on and ignore that they said anything like that, then if they say it again, then there's no way of knowing what their intention was with that.
• 17:13
  Speaker 1: It can be completely not even crossing their mind that it might be inappropriate or it could be trying to provoke something, but the bottom line is that you're responsible for creating that boundary for a patient that doesn't know any better.
• 17:28
  Speaker 2: In that way, and then the other big area of this that I think a lot of folks get in trouble with especially new business owners, but this might be you as well, if you work in another clinic is communication outside of the sessions, and we actually have whole policies with this for our team, and we train this For just this reason.
• 17:48
  Speaker 2: Because this is a boundary, people can try to get more access to you, and I know this is one of those ones where the boundary is a little bit about, yes, where you are usually More accessible than their physician might be.
• 18:00
  Speaker 2: You might be open to email or even talking with somebody on the phone or a text, but there have to be boundaries around that right, otherwise that's going to get abused.
• 18:09
  Speaker 2: People are gonna push the boundaries there.
• 18:11
  Speaker 2: They're gonna be trying to get you know physical therapy services between their sessions, and so for us, one of the ways that we do this is with our email policy any email back to a patient, no matter how long it was.
• 18:22
  Speaker 2: We even if you've got that 12 paragraph, iliad and Odyssey talking about everything that's happened to them since you saw them last your response should be three sentences.
• 18:32
  Speaker 2: First sentence is something nice about thanks for reaching out.
• 18:36
  Speaker 2: Second sentence is if you can answer it in a single sentence, then answer the question.
• 18:42
  Speaker 2: I'm surprised that those exercises are giving you a hard time.
• 18:45
  Speaker 2: Make sure to stop doing those.
• 18:48
  Speaker 2: Period and third sentences will definitely discuss this when we see you at your next appointment on Tuesday.
• 18:55
  Speaker 2: That's it for any email.
• 18:57
  Speaker 2: It works.
• 18:57
  Speaker 2: If you guys are ever Writing an email that is more than three sentences, what else are you writing?
• 19:02
  Speaker 1: No, why wait?
• 19:03
  Speaker 1: What LC writing?
• 19:04
  Speaker 1: So emails?
• 19:05
  Speaker 1: What do you do with your phone policy?
• 19:07
  Speaker 1: When do you call patients back?
• 19:09
  Speaker 1: For business owners that are busy, maybe that's a blocked time for Staff members.
• 19:14
  Speaker 1: When can you do that?
• 19:15
  Speaker 1: When is that a part of your job for us?
• 19:18
  Speaker 1: Texting I text my friends.
• 19:20
  Speaker 1: I don't text my patients, so that is just completely off of the table.
• 19:24
  Speaker 1: The other thing is Instagram DMs.
• 19:26
  Speaker 1: There's a lot of patients that follow us at pelvic standing.
• 19:29
  Speaker 1: There's patients that follow me personally, which is fine.
• 19:32
  Speaker 1: There's not a boundary there.
• 19:34
  Speaker 1: I don't have anything private.
• 19:35
  Speaker 1: I do want to be spreading pelvic health knowledge to everyone and people can follow me.
• 19:40
  Speaker 1: I make a point to not directly follow my patients.
• 19:44
  Speaker 1: Every once in a while I'll make an exception for that if they're in the field or in the industry.
• 19:49
  Speaker 1: But if anybody is talking to me about anything Clinical with their case in an Instagram DM, I say, hey, thanks so much for reaching out, but we're gonna make sure to move all of that stuff to email and or in your session and then that's it.
• 20:03
  Speaker 1: And then, if they keep doing it, then that's a conversation that I'm gonna have with them the next Time that they come in.
• 20:07
  Speaker 1: Hey, I know that we follow each other on social media.
• 20:09
  Speaker 1: Hey, I know that you follow me on social media, but we're just gonna need to make sure that anything clinical is gonna be off of Instagram and to the ways that you can communicate with me here, which is emails and being in the session and that's such a perfect example.
• 20:24
  Speaker 2: Nicole, I love the idea of we talked about boundaries being decisions that you've made beforehand.
• 20:29
  Speaker 2: I think that kind of thing a patient DMing you let's just use that as an example can cause a lot of stress, because people are taking it on a case-by-case basis.
• 20:39
  Speaker 2: Oh, do I like this person?
• 20:41
  Speaker 2: Are they usually respectful?
• 20:43
  Speaker 2: What's their actual problem?
• 20:44
  Speaker 2: Is it a real issue?
• 20:46
  Speaker 2: Is it something I can answer really quickly?
• 20:47
  Speaker 2: Maybe I could just send them another YouTube link with the next video in their exercise progression.
• 20:54
  Speaker 2: Right, and you're having to think about every single thing is like a one-off.
• 20:58
  Speaker 2: Every single thing is a case-by-case basis and when you have these boundaries I do not discuss clinical things with patients on Instagram DM Then it becomes really easy.
• 21:09
  Speaker 2: I All you're asking yourself is this clinical?
• 21:11
  Speaker 2: If yes, then do this.
• 21:13
  Speaker 2: If no, then cool, respond appropriately.
• 21:15
  Speaker 2: But it takes out all the guesswork, all the ambiguity, because you've already had that and it doesn't matter that you really like Katie and she's a really cool person and you'd love to help her, because you're not the kind of person who conducts pelvic rehab via instagram dm.
• 21:32
  Speaker 1: Totally simple and it's so easy, so you keep it easy it is so easy.
• 21:38
  Speaker 2: So one other big boundary setting that we're actually going to talk about next time on the podcast is actually being on time, starting your sessions, ending your sessions on time how to hold that boundary.
• 21:48
  Speaker 2: That's one that we've seen a lot of people have a big struggles with, whether you are an employee somewhere or especially if you have the ability to do whatever the heck you want as a business owner.
• 21:58
  Speaker 2: Sometimes that is a very much a double-edged sword.
• 22:01
  Speaker 2: So we're going to talk about that next time On the podcast being on time, starting and ending that way, and that specific boundary.
• 22:08
  Speaker 2: So that's that, if you guys were at Pelvicon Thank you guys so much for being there with us.
• 22:14
  Speaker 2: We look forward to that literally the entire year.
• 22:17
  Speaker 2: So I am very, very confident in saying that we had an amazing time and we hope you did as well.
• 22:24
  Speaker 2: And if you were not there, remember the recordings are going to close on next Tuesday.
• 22:29
  Speaker 2: That is going to be the last chance to get those.
• 22:31
  Speaker 2: Uh, that is going to be on the 19th of September.
• 22:34
  Speaker 2: So make sure you head to pelviconcom and grab those, nicole.
• 22:38
  Speaker 1: Make sure to listen to the next podcast, too, because I feel like being on time is such, and it's a good example of a boundary, and one that we don't typically think of as being a boundary, and I was notoriously Terrible at this for a long time, so I have a lot to say about it.
• 22:52
  Speaker 2: It gives me so much pleasure talking to nicole about something she wasn't good at, guys.
• 22:56
  Speaker 2: I I've been looking forward to this one for a while.
• 22:59
  Speaker 2: So, as always, we appreciate you guys who are listening so much.
• 23:02
  Speaker 2: We appreciate the reviews.
• 23:04
  Speaker 2: We love reading those.
• 23:05
  Speaker 2: As always, feel free to reach out to nicole.
• 23:08
  Speaker 2: Shoot her an email center at the end.
• 23:10
  Speaker 2: No boundaries there, guys, but as always, we want to keep this conversation going and let's continue to rise.