Goal SettingGoal setting was used by physiotherapists to activate and motivate patients, to determine what meaningful therapy would be for the patient and to set discharge limits (Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Rindflesch, 2009Rindflesch AB 2009 A grounded-theory investigation of patient education in physical therapy practice Physiotherapy Theory and Practice 25: 193–202. [Taylor & Francis Online], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]). Goal setting seemed particular of physiotherapists’ interest, as patients did not spontaneously mention goal setting as important for patient-centered physiotherapy. Patient-centered physiotherapists, however, tried to allow the patients to define their own goals in collaboration (Larsson, Liljedahl, and Gard, 2010Larsson I, Liljedahl K, Gard G 2010 Physiotherapists’ experience of client participation in physiotherapy interventions: A phenomenographic study Advances in Physiotherapy 12: 217–223. [Taylor & Francis Online], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). This was done by facilitating them and guiding them, using education and dialogue to determine the patients’ goals (Larsson, Liljedahl, and Gard, 2010Larsson I, Liljedahl K, Gard G 2010 Physiotherapists’ experience of client participation in physiotherapy interventions: A phenomenographic study Advances in Physiotherapy 12: 217–223. [Taylor & Francis Online], [Google Scholar]; Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Rindflesch, 2009Rindflesch AB 2009 A grounded-theory investigation of patient education in physical therapy practice Physiotherapy Theory and Practice 25: 193–202. [Taylor & Francis Online], [Google Scholar]; Thomson, 2008Thomson D 2008 An ethnographic study of physiotherapists’ perceptions of their interactions with patients on a chronic pain unit Physiotherapy Theory and Practice 24: 408–422. [Taylor & Francis Online], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). Goals were mostly created in collaboration between the physiotherapist and the patient (Leach, Cornwell, Fleming, and Haines, 2010Leach E, Cornwell P, Fleming J, Haines T 2010 Patient centered goal-setting in a subacute rehabilitation setting Disability and Rehabilitation 32: 159–172. [Taylor & Francis Online], [Web of Science ®], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). However, some physiotherapists made no or little mention of patient-centered goals (Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Communicative abilities of a patient-centered physiotherapist meant being receptive to what the patient has to say, correctly interpreted, and giving explanations in a way patients understand (Fleiss and Cohen, 1973Fleiss JL, Cohen J 1973 The equivalence of weighted kappa and the intraclass correlation coefficient as measures of reliability Educational and Psychological Measurement 33: 613–619. [Crossref], [Web of Science ®], [Google Scholar]; Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). Purposefully changing communication styles depending on the patient (Hiller, Guillemin, and Delany, 2015Hiller A, Guillemin M, Delany C 2015 Exploring healthcare communication models in private physiotherapy practice Patient Education and Counseling 98: 1222–1228. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]). Having the ability to explain in lay terms, directly speaking to the patient, listening, and asking appropriate questions were of importance (Cooper, Smith, and Hancock, 2008Cooper K, Smith BH, Hancock E 2008 Patient-centredness in physiotherapy from the perspective of the chronic low back pain patient Physiotherapy 94: 244–252. [Crossref], [Web of Science ®], [Google Scholar]; Kidd, Bond, and Bell, 2011Kidd MO, Bond CH, Bell ML 2011 Patients’ perspectives of patient-centredness as important in musculoskeletal physiotherapy interactions: A qualitative study Physiotherapy 97: 154–162. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Pashley et al, 2010Pashley E, Powers A, McNamee N, Buivids R, Piccinin J, Gibson BE 2010 Discharge from outpatient orthopaedic physiotherapy: A qualitative descriptive study of physiotherapists’ practices Physiotherapy Canada 62: 224–234. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]; Potter, Gordon, and Hamer, 2003Potter M, Gordon S, Hamer P 2003 The physiotherapy experience in private practice: The patients’ perspective Australian Journal of Physiotherapy 49: 195–202. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Personal communication and communication skills were far more important than the provision of scientific facts (Trede, 2000Trede FV 2000 Physiotherapists’ approaches to low back pain education Physiotherapy 86: 427–433. [Crossref], [Google Scholar]). By personal communication, a bond was established and the therapy shifted from therapist to patient centered (Hiller, Guillemin, and Delany, 2015Hiller A, Guillemin M, Delany C 2015 Exploring healthcare communication models in private physiotherapy practice Patient Education and Counseling 98: 1222–1228. [Crossref], [PubMed], [Web of Science ®], [Google Scholar]).

Figure 2. Proposed framework for patient-centeredness in physiotherapy.

McAllister et al. highlighted the importance of the clinical consultation as a conversation, paced and directed by both participants [5McAllister M, Matarasso B, Dixon B, et al. Conversation starters: re-examining and reconstructing first encounters within the therapeutic relationship. J Psychiatr Ment Health Nurs. 2004;11:575–582. doi: 10.1111/j.1365-2850.2004.00763.x [Crossref], [PubMed], [Google Scholar]]. Sacks et al. maintain that people take turns to talk by following a set of conventional rules that assign speaker time and direction, and any deviation could indicate a person's attempt to display power, status or influence [6Sacks H, Schegloff EA, Jefferson G. A simplest systematics for the organization of turn-taking for conversation. Language. 1974;50(4):696–735. doi: 10.1353/lan.1974.0010 [Crossref], [Web of Science ®], [Google Scholar]]. Interruptions may not simply be a reflection of status or dominance however, they may reflect a speaker's enthusiasm, interest or spontaneity [22Irish JT, Hall JA. Interruptive patterns in medical visits: the effects of role, status and gender. Soc Sci Med. 1995;41(6):873–881. doi: 10.1016/0277-9536(94)00399-E [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. Furthermore, it is important they are not interpreted as signs of power, control or dominance, rather they are indicative of interpersonal relationships, such as neutrality, power or rapport [39Goldberg JA. Interrupting the discourse on interruptions. J Pragmat. 1990;14:883–903. doi: 10.1016/0378-2166(90)90045-F [Crossref], [Google Scholar]], which is particularly pertinent to healthcare where power differentials prevail. This was seen in the current study, both in theme 3, and when the patient interjects with humour in the penultimate quote. Practical guides to clinical communication skills concur with Sacks’ model and the two most important skills have been identified as: the ability to allow the patient to speak without interruption; and the ability to truly hear what the patient is trying to say [40Jackson C. Shut up and listen. A brief guide to clinical communication skills. Dundee: Dundee University Press; 2006; p. 1. [Google Scholar]].

McAllister et al. highlighted the importance of the clinical consultation as a conversation, paced and directed by both participants [5McAllister M, Matarasso B, Dixon B, et al. Conversation starters: re-examining and reconstructing first encounters within the therapeutic relationship. J Psychiatr Ment Health Nurs. 2004;11:575–582. doi: 10.1111/j.1365-2850.2004.00763.x [Crossref], [PubMed], [Google Scholar]]. Sacks et al. maintain that people take turns to talk by following a set of conventional rules that assign speaker time and direction, and any deviation could indicate a person's attempt to display power, status or influence [6Sacks H, Schegloff EA, Jefferson G. A simplest systematics for the organization of turn-taking for conversation. Language. 1974;50(4):696–735. doi: 10.1353/lan.1974.0010 [Crossref], [Web of Science ®], [Google Scholar]]. Interruptions may not simply be a reflection of status or dominance however, they may reflect a speaker's enthusiasm, interest or spontaneity [22Irish JT, Hall JA. Interruptive patterns in medical visits: the effects of role, status and gender. Soc Sci Med. 1995;41(6):873–881. doi: 10.1016/0277-9536(94)00399-E [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. Furthermore, it is important they are not interpreted as signs of power, control or dominance, rather they are indicative of interpersonal relationships, such as neutrality, power or rapport [39Goldberg JA. Interrupting the discourse on interruptions. J Pragmat. 1990;14:883–903. doi: 10.1016/0378-2166(90)90045-F [Crossref], [Google Scholar]], which is particularly pertinent to healthcare where power differentials prevail. This was seen in the current study, both in theme 3, and when the patient interjects with humour in the penultimate quote. Practical guides to clinical communication skills concur with Sacks’ model and the two most important skills have been identified as: the ability to allow the patient to speak without interruption; and the ability to truly hear what the patient is trying to say [40Jackson C. Shut up and listen. A brief guide to clinical communication skills. Dundee: Dundee University Press; 2006; p. 1. [Google Scholar]].

Clinical implicationsTo the best of our knowledge, this is the first time the prevalence and nature of overlaps and interruptions have been reported in patients presenting with low back pain. This work has highlighted the complexity of evaluating the impact of communication during clinical encounters. Clinicians need to ensure that the pendulum of current clinical practice does not swing towards pathoanatomy and physiology, biomechanics and technological advances at the expense of treating the patient as a person and providing truly patient-centred care. Therefore, clinicians at the forefront of practice, whatever their profession, need to invest time evaluating and developing their own communication skills (for example by audio-recording consultations or engaging in peer observation, with patients’ consent) to optimize non-specific treatment effects and ultimately enhance patients’ experience and outcomes.

Whilst this study intended to explore participants’ perceptions of the impact of empathy on a clinical encounter, participants focused their discussion on how the attributes of both the clinician and patient, as well as external factors, could affect the delivery of empathy during a clinical encounter. Participants identified building rapport, active listening, verbal and non-verbal communication to be factors that could influence the patient-clinician relationship, which is supported in the literature, alongside empathy which has been shown to affect the patient-clinician relationship, improving clinical outcomes, diagnoses and adherence to therapy [3Hojat M, Mangione S, Kane G, et al. Relationships between scores of the Jefferson Scale of Physician Empathy (JSPE) and the Interpersonal Reactivity Index (IRI). Med Teach. 2005;27(7):625–628. doi: 10.1080/01421590500069744 [Taylor & Francis Online], [Web of Science ®], [Google Scholar],8–12Beck R, Daughtbridge R, Sloane P. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Med. 2002;15(1):25–38. [Google Scholar]Hojat M, Gonnella J, Nasca T, et al. Physician empathy: definition, components, measurement, and relationship to gender and specialty. Am J Psychiat. 2002;159(9):1563–1569. doi: 10.1176/appi.ajp.159.9.1563 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Shapiro J, Morrison E, Boker J. Teaching empathy to first year medical students: evaluation of an elective literature and medicine course. Educ Health: Change in Learn Practice. 2004;17(1):73–84. doi: 10.1080/13576280310001656196 [Crossref], [PubMed], [Google Scholar]Stepien K, Baernstein A. Educating for empathy. J Gen Intern Med. 2006;21(5):524–530. doi: 10.1111/j.1525-1497.2006.00443.x [Crossref], [PubMed], [Web of Science ®], [Google Scholar]Rakel D, Barrett B, Zhang Z, et al. Perception of empathy in the therapeutic encounter: effects on the common cold. Patient Educ Couns. 2011;85(3):390–397. doi: 10.1016/j.pec.2011.01.009 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]].

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Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]], the authors identified four possible reasons for this: negative experiences with clinical supervisors; a feeling of vulnerability as a student, resulting in reduced self-confidence; a lack of social support and increased workload combined with long clinical placement hours [24Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]]. The student physiotherapists in this study stated that there were multiple factors to focus on whilst on clinical placement, and that their focus was more on their personal development and academic grades rather than their focus being on empathising and communicating with patients. Students did however acknowledge the importance of empathic communication during clinical encounters, but deemed other aspects of their education to be a priority. Neumann et al. [24Neumann M, Edelhäuser F, Tauschel D, et al. Empathy decline and its reasons: a systematic review of studies with medical students and residents. Acad Med. 2011;86(8):996–1009. doi: 10.1097/ACM.0b013e318221e615 [Crossref], [PubMed], [Web of Science ®], [Google Scholar]] report similar findings, with medical students’ empathy levels showing a significant decline at the point that they enter clinical practice during their educational programme, due to their focus on academic work, improving clinical skills and lack of time to relax and de-stress.