The relationship between patient and therapist has a direct impact on the quality of treatment outcomes and, obviously, on patient wellbeing. There is a definite skill in knowing how to build rapport and also how to break rapport when needed.

The clinical setting presents various challenges. Developing and maintaining a strong rapport with patients goes a long way towards meeting these challenges.

This article will help you develop skills to improve the therapist-patient relationship. It focuses on developing empathy, and maintaining positive rapport, in a range of situations you might encounter in your everyday practice.

What constitutes exceptional empathy?

One of the essential elements of great rapport is empathy. It refers to the ability to understand, and share, to some extent, the feelings of others. Most clinicians think they have great empathy for their patients, but do they really?

Here are five aspects of exceptional empathy for you to consider. They points are taken from Miller and Rollnick’s book Motivational Interviewing: Helping People Change.

1. You effectively communicate an understanding of your patients beyond what they say in the consultation.
2. You show an interest in your patients’ perspective or situation
3. You attempt to put yourself in your patients’ shoes
4. You often encourage patients to elaborate, beyond what is necessary merely to follow a story
5. The complex reflections you make are mainly accurate

We all have our strengths, but most of us struggle with one or more of these points from time to time.

In the early part of my career, I did quite well with patients who had backgrounds, goals and values similar to mine. With many of the others, I struggled with points 3, 4 and 5 – not usually with the same patient, fortunately. If that ever happened they wouldn’t have remained my patients for very long.

One of the most challenging points, particularly for newly graduated clinicians, is being able to understand the perspective of their patient.

This takes time and effort, and requires a definite decision to do it. Most of us are comfortable in our ‘clinician’s shoes’ but, especially when things don’t go as expected, there is great value in seeing things from the patient’s perspective.

What you learn by doing this could be the breakthrough you need to make real connections with your patients, and help them in ways that go beyond exercises and hands-on treatment.

Maintaining rapport in challenging situations

Here are four situations that you might recognise. Each one presents a challenge.

1. Interrupting a patient without breaking rapport

Have you ever had patients who talk continuously, making it difficult to get the information you need to help them? It’s happened to all of us. How do we stop them talking or even rambling, without sounding rude? It can be a dilemma even for the most experienced clinician.

Margaret Potter et al. in ‘The physiotherapy experience in private practice: the patient’s perspective’ found that poor communication was one of the main things patients complained about when referring to a ‘bad’ physio experience.

Knowing how to interrupt patients, and still make them feel they are being heard, is a very effective communication skill.

How can you do it, and still get the information you need?

Here are some tips that might help you manage the talkative patient, maintain a good rapport, and still do your assessment:

a. Clarify patients’ expectations for the session.

At the beginning of the session, ask patients what they want out of the session with you today. It’s important to say ‘today’, as it gives direction for your current time together, not some time in the future.

This will give you both clarity about what is important to achieve in the time frame you have. More importantly, if or when you need to break the conversation, you refer back to what is most important to your patients  (see d. below).

b. Set a time frame

When you have a clear intention for the session you can acknowledge your patients’ need to talk about what’s going on, and that it is ok to do so. You will quickly recognise really talkative patients; that’s when you can implement this step.

Set a time frame for the purpose of listening to their story, and get their agreement to it. By doing this, you have also established the time when it is ok to interrupt.

c. Listen attentively

Now you have a direction for the consultation and some agreed time frames, you can give patients your full attention. People often get into the habit of rambling when they feel they are not being listened to.

Ask patients whether it’s ok to take notes you can refer back to. If patients agree, they will not feel a break in rapport when you start writing or typing.

There is so much information that can be extracted from a patient’s ‘story’. Patients usually indicate what is bothering them most. You might get answers to most of your questions and need go back only to clarify certain points. You might get your 24-hour picture so there’s need to go back. It’s likely that you will also get an idea of the problem’s irritability.

There will always be more information you need to complete your subjective assessment, but the better you are at attentive listening, the fewer questions you will need to ask.

Attentive listening is a skill that requires no or minimal interruption. Practice will improve your skill level. The best place to practice is in a social environment where there is no pressure. Keep working at it.

d. Use reflective listening

This involves repeating statements patients have made. It tells patients they are being heard. You don’t need to do this with every sentence; every now and then, as appropriate, will be enough. It’s important because you will probably need to cut them off at the designated time, and they will tolerate it better if they feel ‘heard’.

When using reflective listening, it’s of paramount importance to use the patients’ own words. If you make an assumption or interpretation, and use your words, patients will correct you very quickly. This will make you feel uncomfortable, so avoid it.

Your aims are to have the patient feel heard, to get the information you need in the allocated time frame, and to maintain rapport, even if you need to interrupt.

e. Wrap it up

Ok. It’s crunch time. You need to move on. This could be where it all falls apart. If you have completed the steps above, however, interrupting your patients won’t feel rude.

First, refer back to what patients said they wanted to get out of the session. Use a ‘because’ statement; it puts a frame around what you’re going to say next – that is, what’s important to the individual patient. Here is a suggestion:

“Because you said earlier that you want to …, I just need to clarify a few things, and then look at… Is that ok with you?”

You will use the words most appropriate to the situation. The key ‘because’ is powerful. It creates a frame for the interruption, and reminds patients why they came to see you.

2. Maintaining rapport when you don’t know what’s wrong with your patient

This is a dilemma for any clinician, particularly for new graduates. It can easily break the rapport between you and your patients.

Even after 30 years of consulting, there were times when I was not sure what the problem might be. When this happens, focus on two things:

• Honesty
• What you do know

Focus on honesty

Being honest with patients is paramount in building rapport. They will respect you for it and it takes a lot of pressure off you.

Patients can always tell if you’re not sure, so you might as well be up front about it. No health practitioner knows everything. You can tell patients you’re not 100% sure about what’s going on, but you have many options to look further into what’s happening.

Think of all the support systems you have, including:

• Peer discussions
• Journal reviews
• Book reviews
• Getting a second opinion within the clinic

Focus on what you do know

Patients draw confidence from all the things you can tell them you are clear about. After you’ve completed your assessment you will have a general idea of the presenting problem’s irritability, the 24-hour pattern and what structures are most likely to be involved. You can give patients the information you are clear about, without having to put a label on the condition.

Sometimes it will take a few sessions to work out what’s going on, and you can let the patient know this. It is common and normal.

You might need further investigations before you can ‘diagnose’ a condition. Organise them, if appropriate.

The expectation that you need to know everything is pressure you don’t need. Talk to more experienced clinicians, and you will see you’re not alone.

The major advantage of experience is that the frequency of not knowing goes down.

3. Using affirmations to support your patients

What does ‘affirming’ mean, and why you should affirm your patients?

To affirm is to recognise and acknowledge that which is good. To affirm is to support and encourage your patients.

When patients are undergoing long and arduous rehabilitation programs it’s easy for them to get disheartened and feel like giving up. No matter how positive people might be, there are times when they will feel down and tend to focus only on what’s not working.

To be effective when using affirmations, you must affirm what is true; therefore you need to listen and understand what your patients are telling you. Do not make anything up; they will recognise it and rapport will be broken.

How can you make affirming statements?

You need to notice, recognise, and acknowledge what’s positive:

• Have patients made an effort since the last treatment? Make a positive comment.
• Have they done exercises but they didn’t work out? Make a positive comment about their intention.
• Did patients complete tasks? Make a positive comment
• Were they discouraged, but still came back in for treatment? Comment on their persistence
• Are they feeling as though they’re failing because they haven’t completed all the set tasks? Comment on their positive traits or attributes. Reflect on how far they’ve come since the beginning of the treatment.

4. Building rapport with patients from other cultures

As society becomes more diverse, this becomes even more important. It’s easier to build rapport between people of the same culture. It’s also easy to assume that your rapport building skills will work equally well with people from other cultures. Often, they won’t. 

If your clinic welcomes people from a range of cultures, or you work in hospital environment, you will find it useful to understand some variations in cultural norms. Your aim is always to build rapport and trust with your patients, to increase the chances that they will:

• follow your advice
• be more likely to get better treatment outcomes
• come back to see you
• recommend you to their family and friends

After doing some research, I have put together Rapport Building Checklists for Australian patients, and for six other cultures. You might find them interesting and helpful. Here are 3 selected points from each of these checklists: 

Australian

• Be prepared to make eye contact when the other person is talking
• Tone and physiology say more than the spoken word. Click here to read an interesting article on the art of spotting hesitations through facial expressions
• Be aware of your position in relation to your client. Standing over someone is interpreted as a threat

Chinese

• Avoid constant and direct eye contact until rapport has been established
• Non verbal cues are an important part of communication for Chinese people
• Appearing stoic and showing emotional self-control are highly valued. Be aware your patients might not show pain

Filipino

• Make eye contact
• Introduce yourself and communicate that your goal is to promote well-being
• Offer follow-up calls or surveys; this is taken as an act of caring

Indonesian

• A handshake is the most common greeting. Never shake with the left hand
• If you are being introduced to several people at once, always start with the eldest or most senior person
• Be aware that many Indonesians believe that the head is the ‘seat to the soul’. Consequently, never touch the head, or even good-naturedly pat the head of a child. If treating or touching the head, get permission first

Japanese

• Eye contact is indirect at first meeting
• Nodding is important and indicates you are listening
• Business cards are very important. Accept a card with the right hand and treat it with respect. Don’t write on it or put it in your pocket

Muslim

• Shaking hands is not common between Muslims and non-Muslims of the opposite sex. This is normal and not a sign of disrespect
• Maintaining eye contact might make Muslim women feel uncomfortable
• Touching of the feet is considered disrespectful. Discuss this before treating the foot or ankle

Vietnamese

• Encourage them to ask questions. They might avoid this for fear of appearing stupid
• There might be an expectation that diagnosis and treatment will happen on the first visit, with little examination or diagnostic tests. Discuss this, as appropriate
• Patients might expect treatments to cure them immediately. You might have to explain how long a treatment is going to take before they get better

Building rapport is a crucial part of being an effective health professional. Every human being has a need to feel connected to another. That is especially true when people feel vulnerable. Taking the effort to understand variations in cultural norms is likely to help you build a very successful business.

Take the next step

To learn more about motivational tools through effective communication download my eBook

“Improving Patient Motivation In Physiotherapy”

I wrote this eBook in response to the most common question I get asked and that is “How do I motivate my patients?”

Would you like to be a more effective communicator and build better rapport with your patients?

Are you keen to develop your expertise even further?

Perhaps your staff would benefit from communications training.

I can provide materials and a range of services – as educator, coach or mentor.

Things you can do right now:

Download PDFs on the building rapport with different cultures, including my Rapport Building Checklists

Connect with me to find out more about the training opportunities I can offer to your practice.

---