Not Everyone’s Gunna Like You

[cmocarroll]

Recently, I saw a patient for his third follow-up visit. At the initial eval, I discovered that this patient had been through all kinds of treatment with essentially little relief of back pain that he’s had for the last 40 years (since he was 20). The patient described new symptoms that were not his familiar back pain and I could not reproduce them during the initial encounter. I ended up giving the pt general advice, explaining my minimal findings and saying that I did not want to give him just any exercises without having a good reason since he has been through so much. He shook my hand on the way out and thanked me. Because of this, I was feeling like we established some good rapport. I was also thinking that this may just be a chronic pain situation, but I was still interested in his new symptoms.

At the second visit, I did some additional testing and was able to reproduce the pt’s pain which he states had flared after the eval and appeared to be originating from a different area than he first thought. The symptoms appeared to be nerve related with a positive slump so we worked on neurodynamics, mobility and glute strength. I did not think much of this visit and figured we would continue on this route at the next visit.

At the next visit the pt came in stating that he was in increased pain for the last few days. I had him sit down to inquire further about what had happened since the pain increased and he could not give me a straight answer. Wondering what was going through his mind, I started a line of questions aimed at what the patient thought was going on and what he thought might be helpful to try. This backfired immensely. Fairly quickly, the patient became extremely angry stating that he felt as if I was asking him to diagnose and treat himself, comparing my treatment to other therapy and stating that he was about to get up and leave because “all my treatment consisted of was talking and we could do that over the phone”. In short, I was able to bring the patient back in by consoling him and stating what I felt I could offer him. The visit ended well with an additional 4 exercises for the patient to try at home.

I have reflected on this encounter for the last few days because it is the first and likely not the last time that someone did not understand or like my style of treatment. I’ve realized that I should have picked up on his agitation sooner and may have avoided so much aggravation. I also think I could have worded my questions in a better way so that the patient could have clearly understood my intentions. I really think this encounter was important because it brought me back down to reality that not everyone is going to like me and that I’m going to have patients that are difficult communicators, hard to read and I’m going to have patients that I don’t get along with or who are not nice. I also recognize that this patient has been in pain for 40 years, has had little relief, and may have a different agenda than mine as well as not understanding that his pain is going to take a long time to diminish and likely will not fully dissipate. These are expectations that I was planning to eventually work into treatment, but I know now that this will be quite a difficult route. In the future, I think I will choose my words more wisely, try to read the patient better and likely will have more of these encounters until I have the experience to read these situations better.

[AJ Lievre]

Clare
Really enjoyed reading your reflection. Do you think your patient’s response to your “style” was based on him expecting to “fix” him? Did you have a conversation about this being a collaborative effort where his input is helpful in making decisions about plan of care? I wonder if this was the first experience he had with a provider that wanted so much information from him, that he took this as you not knowing how to approach his care.
I think it is important to make it clear early on that it will be the 2 of you working together to find the best treatment approach. Especially when the patient has been dealing with pain for 40+ years.
Thoughts?

[cmocarroll]

Hi AJ,

Thanks for the response! I definitely think that this patient wanted me to “fix” him and he took my questioning as me not knowing how to approach his care. I’ve been pondering about his experiences at other PT clinics because of this. I think that this visit was a reality check for me because I typically think that my approach comes across as collaborative even if I don’t explicitly use that word. I tend to tell patients that “I like to have their input and thoughts” and that “I can’t feel what they feel so they have to let me know”. I feel like I use the term “working together” frequently, but now I’m wondering if that’s just how I perceive it.

As an update, I saw this patient again today and it was almost a complete 180. I did not prompt him to sit down and talk to me, but he explained in detail his symptoms over the last two days, what he did to try and alleviate it as well as what he thought was helpful. (all of which is what I had asked him 2 days ago) It was most interesting to me because one of the things he described in regard to his symptoms and what felt helpful was that he felt like he need to “pull” or “stretch out his back because something seems pinched” so he would find a door way to try and hang in. He went farther to describe that his hip joint felt almost jammed up too which obviously prompted me to try hip distraction which the patient felt was greatly helpful and stretched out his low back as well as his hip. This is an easy exercise to replicate at home so I was able to give him the self-mob to add in the HEP.

I wonder if the patient did some reflecting and realized what I had been trying to ask or if this was all coincidental. That being said, I do think I need to be more direct about the collaborative effort in order to avoid this situation altogether in the future.

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