i am currently shadowing at a clinic and we had a 20 year old patient come in with chief complaint being chronic pain, muscle spasms, non-specific low back pain, etc. Before the doc and I went in, she was telling me all about his slight scoliosis being a potential cause and wanting to probably refer for MRI. I couldn’t help but suggest to the doctor that maybe someonething psychological was going on here. She thought it was a good idea, the patient was after all on quite a high dose of Zoloft. After examining the patient, it was clear that something was going on with him psychologically. She still exclusively discussed physiological components of the complaint and didn’t investigate the psychosocial components.
My question is, in a setting like this, where the physician is limited to say 10 minutes or less with a patient, what are some good strategies for fitting in pain education where appropriate? In your most recent podcast on Philosophical Weightlifting, you mentioned that establishing a relationship with the client/patient can be crucial to understanding the patient’s/client’s beliefs, and reframing them if need be. How can this be done in a fast paced clinical setting?
I’ll start in on this but I will make sure Mike is aware of this as well. One of the biggest things is working to set expectations and reframe what the patient is experiencing. Never underestimate the power of “you’re going to be okay.” Many times when a patient arrives to clinic (especially at a tertiary provider) they have already been told a plethora of polysyllabic words that led them to Google, where they figured out they are going to die. We forget many times that the training we receive as healthcare providers teaches us to speak a language full of acronyms and archaic words that mean absolutely nothing to the patient sitting in front of you (rotary cup anyone?). Letting patients know that whatever huge word got assigned to their current condition is likely not life threatening and there is a high probability that they will get better is a step in the right direction. With the confounding factors that anxiety and depression can have on the experience of pain it is disadvantageous for any practitioner to give unwarranted advice that facilitates that. Even in a time crunch it is helpful to ask the patient to explain back to you what you have said to them as a means of seeing how they interpreted what you said. This exercise can be beneficial at pinpointing any misinterpretation in communication. If all the patient heard was mechanistic diagnoses then they likely missed the big picture of what is going on and the visit did nothing but reaffirm priors for their causative belief of their pain.
I would also say this is where have a GOOD (emphasis entirely added) rehab specialist downstream can be crucial. We are often the providers who have more time to discuss what is going on with patients (as has been shown, this can be a bad thing when some BS is being said) and we often get multiple shots. I typically see my second appointment with patients as equal in importance to the first as now I get to hear a patient’s reflection on what was said during the first visit.
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To add to what Derek said, there is often pressure to provide patient’s with a specific diagnosis. Saying “I’m not sure” comes off a lot better when paired with “but I’m confident it’s nothing serious and you are going to be ok”. In reality, with proper screening, this is an evidence-based answer to the majority of orthopedic based conditions. I like to follow that up with “I know that might not be the exact answer you want to hear, but I want to be transparent with you and not just give you some convoluted answer just for the sake of doing so”. There are a lot of prior beliefs and expectations the patient already has before they even meet you, so knowing when to elaborate more and when to back off is tricky particularly in a fast-paced clinical setting. Perhaps if you wanted to evaluate the psychosocial component more in a fast paced clinical setting you could provide patients with additional outcomes measures that they can fill out at their leisure (in this scenario, STarT Back Tool comes to mind). That could be my rehab bias though and I’m not sure how often physicians use measures like these. I’ll stop there as Derek and Mike have more expertise on this topic than me.
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For low back pain I am partial to the STarT as well as it does offer some guidance on questions you may want to ask. It also has shown some prognostic validity in discerning those who may be at an increased risk for continued pain down the road.
The use of STarT back screening tool to predict functional disability outcomes in patients receiving physical therapy for low back pain - PubMed
Great discussion. I don’t have too much to add other than this is an issue with our current healthcare system. If we are forced to remain within the current constructs of the paradigm then what Derek presented is likely the best option. My hope is in none emergency settings (when quick decisions are likely necessary) we can shift to a patient centered model beyond a profit based model (apologies if this sounds negative). I don’t know that is possible based on our current insurance model (in the US). This isn’t just a primary care issue but is similar in many rehab settings where daily patient visits are 20+. We also have clinics predicated on an assembly line model, which isn’t helping. Happy to discuss.
Edit: Profit will be a necessary part of the equation but does it need to be THE primary variable. I’m sure if we zoomed out a bit there are many influential factors such as cost of schooling for doctorate level status and the need to repay loans. This is a complex issue. Hopefully this didn’t detract from the goal of the thread. Also - in the physician’s defense, many remain unaware there is another model to frame healthcare through. This isn’t to completely remove blame from them but schooling is likely not up to par (I’m sure Austin and Jordan can speak to medical school).
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