Estimated reading time: 17 minutes
Of all the skills and strategies I’ve learned in the past decade, goal setting has to be one of the most fundamental and revolutionary. It’s been a literal game changer for me, and completely overhauled how I approach explaining my treatment plans to patients.
Not only that, but it’s also helped me let go of a lot of needless frustration when patients didn’t do what I want, and allowed me to waste much less time and energy on strategies that simply weren’t working. What used to feel like an uphill struggle now feels like a leisurely stroll in the park.
It really is that different!
What is Goal Setting?
Simply put, goal setting is the process by which you and your patient agree on your aims for your treatment plan. You might think this would be obvious - to feel better and be healthier, right? Not quite... there’s a lot of nuance to doing it well, versus “sort of” goal setting. Many practitioners think they’re goal setting, yet don’t see most of the real benefits to it.
One of the most common reasons I come across is that the practitioner doesn’t truly understand what patient-centred care actually means. It’s become a bit of a trendy buzzword the past few years, resulting in many clinicians thinking they are more patient-centred than they actually are (no judgement here - I used to be one of them myself!) . I won’t go into a full discussion of that here, but I’d suggest checking out this post on the subject. Patient centred care is a necessary prerequisite for effective goal setting.
Benefits to Goal Setting
So why use this approach? Well, here’s some of the benefits for you and your patients:
- It improves the therapeutic alliance and the trust between you both. The benefits to this are too numerous to list, but it’s a major determinant in whether your patient actually gets better (and your business success in the long term!)
- Enhanced patient motivation to follow your advice and take an active role in their recovery
- Easier to get online reviews and referrals - and those reviews will be even more effective!
- Makes it clear why you might assess and address areas outside of their symptoms. Which can lead to more “Oh, I didn’t realise you did [insert body part]!” conversations (and referrals)
- By reducing their focus on the pain, you might find it’s possible to have a successful outcome to treatment even when the pain is still present. If they can achieve their goal, the resolution of symptoms is typically secondary.
- You spend far less time on trying to “educate” patients into your point of view / philosophy on health. (Disclaimer: I’m not saying you don’t educate them, just that you choose the most effective time and place)
- Never feel like you’re coming across as justifying, defending, or “selling” your care
On that last note, reduced clinician frustration is a big benefit to goal setting - one I personally can vouch for. Constantly trying to convince, cajole, or motivate patients into action gets draining after a while, and it’s all too easy to slide towards resentment and eventual burnout over time.
Finding the Goal
So, there’s some real benefits to finding out your patients' real goals for seeing you. Presumably, you can just ask them, right? Not so fast... Although you might occasionally get a good answer from a patient, the majority of the time if you ask them outright you’ll hear something like this:
“I don’t want to be in pain”
And whilst that’s true, it’s not their real underlying reason for seeing you. This is just the superficial layer. Beneath that is their real goal - they are coming to you because something is missing from their life, because of these symptoms. Who they are now and who they want to be aren’t the same person, or they aren’t living the life they want. They are hoping you can help them become that person, or live that life. That’s their goal.
Some example goals
“To be able to play with my grandkids again”
“To concentrate at work and earn that promotion”
“To get back to the gym, lose weight and feel more attractive to my partner”
If you just take their first answer at face value, you’re going to miss out on most of the benefits mentioned above. You need to find out the impact of their symptoms on their day to day wellbeing. The specific things that are missing from their life, because of this issue.
How to ask?
You may need to ask this in a number of ways. Some might respond to broad, open ended questions, whilst for others you’ll need to drill down to specifics. This element of your history can be a bit of a dance - if you just ask them the same question 5 different ways in a row, there’s a good chance they’ll get annoyed (“They're not listening to me, I just answered that!”).
This is a skill that takes practice. At the start, you may find you aren’t always getting a clear answer. It can be tempting to just assume “this patient has no goal”. Don’t do it! It’s okay if you haven’t found it at the start - sometimes patients are completely unaware of the real reasons for seeing you, and finding it is just as much a discovery for them as it is for you.
I had a patient several years ago who really didn’t seem to have one. He had a niggling 1/10 ache in his shoulder. Every time I tried to find out what effect this had on him, I’d get something like this:
“Not much - it doesn’t stop me doing anything, I’d just rather not have it.”
I actually gave up, assuming I’d found the only person who ever came here without a specific goal! It was only at the very end of the session, after the examination, that he sat back and said:
“You know, you were asking me about what effect this was having on my life… when I think about it, I can’t totally relax in the evening. When my wife and I sit down to watch something together in the evening, I’m never really comfortable. It’s always there, slightly annoying and distracting me.”
That was his goal. To be able to relax and enjoy his evenings fully with his wife. It just took him a while to think it through.
So don’t be disheartened if you don’t always get it. As you practice, you’ll get better and quicker at finding this information out, and showing your patients that you both want the same thing.
Using the Goal
So you’ve found their goal… now what? First, show them you found it! Making this crystal clear between you is the first step once you’ve discovered what their reason is for seeing you.
“So, our goal is to get rid of this shoulder pain so you can get back to squash”
It might sound obvious, but unless you do this, there's a risk that:
- They might not realise you’ve really heard them, or
- They might not realise themselves that this is what they want from you!
Also include this information whenever you’re summarising what you’ve discussed - at the end of the history, or when you outline your treatment plan. You want to keep reminding patients that you’re working on this together, and make sure they keep their “eyes on the prize”.
During the Examination
It can also be useful to relate any examination findings to them in the context of their goal:
“Do you feel how your upper back feels so stiff? That’s going to mean your shoulder has to work harder, so when you swing the racket it’s putting too much force into the shoulder muscles and aggravating your pain.”
“If that joint is inflamed, it’s going to make the muscles around it stiffen to protect it, and that’s why it spasms sometimes when you lunge for the ball.”
This often gives the impression you’re being even more thorough with your assessment, even without you having to do any more tests or investigations. Additionally, it can allow you to start with some simple patient-specific education before you’ve even outlined your plan.
When giving at-home advice or active care
Similarly, you want to relate any active care you give them to the goal as well. Make a clear connection between whatever you’re asking them to do and the outcome they want. So instead of doing planks to “strengthen their core” or “make their chiropractor happy”, they’re doing it to “get back on the squash court sooner”. This applies equally well to smaller lifestyle changes, like drinking more water or taking breaks from sitting. Show them how it will get them where they want to be.
The reason for this is that it helps tap into more “intrinsic” motivations for the patient - ones that arise from within themselves. The opposite is “extrinsic” motivation - doing something in order to earn an external reward, or avoid a negative consequence (like being told off by their chiropractor). Extrinsic motivators aren’t always bad, and are useful in certain situations, but tend to be more short lived. Intrinsic motivation helps to avoid that all too common situation, where initially enthusiastic patients stop performing their self care as soon as their pain is gone:
“The pain isn’t there to remind me now”.
If they experience setbacks or flareups
Reminding patients of their goal can also be useful when they experience setbacks, or express frustration at a slower than expected recovery. Reminding them that you’re both still aiming for the same thing, and that you’re still seeing progress, tends to carry more weight than simply telling them you are seeing changes in their function. Often these patients just want reassurance that you aren’t worried about their progress:
“I understand John, it’s been 3 weeks and you still have the pain at night. You’re frustrated that it’s still waking you up during the night, because you’re more irritable with your family in the morning and can’t focus at work as well. But if we keep going, and you keep the stretches up, I’m confident we’ll get you there”
Note I didn’t try and change his mind or defend myself here - all I did was show empathy, remind him I knew what he really wanted, and reassure him that I’m still confident that we’ll get there.
Supercharge Their Goal
If you just follow the steps above, you’ll likely find you develop much better rapport with your patients, and that they’ll naturally trust you more and follow your advice more often. But there are some additional advanced steps you can take to really cement these effects and “supercharge” your communication. They take more practice and effort but, when done well, really pay off. In fact, you might want to just focus on the earlier sections first and come back to this later.
The two strategies here take opposite approaches to achieve the same aims - getting your patients crystal clear on what achieving their goal actually looks like. The first aims to zoom in, putting their goal under a microscope to get the specific details nailed down. The second zooms out, putting their goal into the context of their life - their values, and what truly matters to them.
Strategy 1: SMART Goals
SMART is an acronym for the qualities of an effective goal. When clarifying their goal and outlining your plan, make sure it incorporates the following 5 features:
1) Specific
What exactly does their goal looks like? Are you both clear on exactly what the finish line looks like? For example, if the patient wants to get back to running, how far do they want to run? How often? On the flat, or up and downhill? How quickly?
2) Measurable
What are the quantitative features of the goal? For the above example, that’s obvious - distance (and possibly time). But what about a more qualitative goal, like a patient whose headaches make them irritable with their family? In these cases, you can ask your patient how they might measure it? In this example, the patient told me they wanted to leave the house without having shouted at anyone. We then tracked how many mornings this occurred per week - an objective measurement of a subjective experience.
3) Attainable
Be very careful here! What matters in this case is not whether we think it’s attainable, but whether the patient does. If you disagree, the patient is right until proven otherwise! Don’t be one of those clinicians who takes things off the table forever for your patient. I can’t count the number of times I’ve heard “I used to run, but I started getting knee pain and the doctor said I can’t run anymore”. This may well be the case, but by telling your patient this, you’ve just guaranteed it and removed all hope. Be open to being proven wrong!
Now, if you have a 78 year old arthritic and osteoporotic patient who wants to run the London Marathon, it might well be unachievable. But instead of dashing their hopes and making that certain, start smaller (see “Chunking”, below).
4) Relevant
The goal should be relevant to the patient. If you’ve followed the above steps, this should be a redundant point! However, I choose to define this one a little differently - make all of your advice relevant to their goal. Anything you recommend should be geared towards getting them back to what they want. This should be made obvious to them. Those breathing exercises are to calm their system down, so they get a better nights sleep. The side planks will help them lunge for the ball on the tennis court without setting off their pain again. Cutting down in drinking will reduce inflammation, so they aren’t waking up so stiff and sore and struggling to get dressed. You probably have other reasons for suggesting these, but focus on the ones most relevant to them.
5) Time-Based
You should let your patient know when you expect them to achieve their goal! This can feel a bit uncomfortable, especially if you haven’t done it before. You’ll have to stick your neck out a little. However, you're not promising anything. Patients know you can’t make guarantees, just like they know you can’t work miracles. But if you don’t set an expectation of the time, it can get disheartening when they don’t see immediate change themselves. They want to know when you’ll be reassessing things, and when you expect to see improvement. This will always be an estimate, and it’s fine to let your patient know that (but with some confidence, of course). Also, if the goal will take a while, you don’t need to pick a specific date at the start. Which leads me nicely on to…
"Chunking" - Breaking Goals Down
Essentially, this is where you take a SMART goal and break it down into smaller steps. This has the benefit of making it seem less daunting (for you both!), and also improves their motivation and commitment. It does this by providing more opportunities for your patient to achieve a mini-goal, creating a nice hit of dopamine in their brains. Dopamine is one of the main neurotransmitters involved in motivation (here’s a quick breakdown of how it works), and the more we can trigger its release, the more motivation our patients feel.
For example, a patient who wants to be able to get up and dress themselves quickly and without help could start by being able to put their own socks on, sat down on the bed, with 50% less pain. Then with 75% less pain. Then you could include trousers, progress to standing, all with gradually reduced pain levels and in less time.
One important aspect here - you want to make the first mini goal very easy to achieve, and ideally have it happen in the first 2-3 weeks. It can be a very small, modest target, but it will be the most important one. If the patient falls at the first hurdle, their overall motivation will take a bigger hit than if they fall at the 3rd or 4th. So go easy on them!
Strategy 2: Value-Based Care
Whilst SMART goals get you to drill down on the specifics, Value-Based Care is all about the opposite - zooming out and looking at why their goal matters to them. This takes more work, and isn’t something you can always get to in their first visit. Some patients will need a bit more time to trust you and open up. Respect this, and don’t try to force it.
Essentially, this is about finding out why this goal matters to them. What are the underlying values behind this goal? What kind of person do they want to be? How does it relate to their ideal identity?
Below are some potential examples - note different possible values may underlie the same goal!
Goal: Get back to the gym and get fit again
Possible Value: Maintain their independence and vitality
Possible Value: Improve their self esteem by losing weight
Goal: Get a good night's sleep
Possible Value: Be a productive member of their team at work
Possible Value: Be a good parent to their children
Goal: Complete a marathon
Possible Value: To achieve recognition amongst their peers
Possible Value: To seek and overcome challenges for themselves
A note on asking “Why”
Discovering the value that underlies their goal is not always as straightforward as it seems. The most obvious route would be to just ask them “why do you want to achieve that?”. However, the direct route is not always successful here, for a couple of reasons. Much like discovering their true goal, the patient may not be consciously aware of the value it relates to. You may simply get the reply “because I want to!”.
Another risk here is that the patient perceives it as a subtle challenge - “why would you want to do that?”. Despite your best intentions, there is always the risk of misunderstanding with this question. If they perceive it as a challenge, it will immediately decrease the trust and rapport between you.
So how do we ask? Again, there are a few different ways here. A simple one is to acknowledge that the question might seem unusual:
“I appreciate this might seem like an odd question for a health profession to ask, but why do you want to start running?”
Another approach is to find out what it’s like for them currently, being unable to achieve that goal:
“What’s it like for you when you can’t run?”
Sometimes you can dig through a couple of layers with this question - when they answer, you might ask “What’s that like?” again. Similarly, “How does that feel?” can go deeper. Be sure to remain aware of how these questions might make the patient feel - for a relatively closed, emotionally inexpressive patient they might seem quite strange. Make sure to pick your moments, and consider whether it’s worth attempting these at all.
If you’re unsure whether you should ask these questions or not, another approach can simply be to suggest an underlying value. During your conversations, if you start to get a sense of why this might matter to them, bring that up:
“I imagine not being able to work makes you worried you can’t provide for your family”
You might feel a bit nervous here - what if you get it wrong? Don’t worry, you often will, but that’s totally fine! If your intention is to truly understand this patient, they will sense that, and forgive pretty much any misunderstanding. And 99% of the time, they’ll correct you by giving you the right answer anyway
“No, it’s more that I’m worried my colleagues will think I’m slacking off and making it up”
Once you know the underlying value, you can use it much like the goal itself - reflecting it back on occasion to boost their motivation or remind them how well you now understand them.