Words Matter, The Subjective Matters

[ebusch19]

I had an initial evaluation with a patient about two weeks ago who had a referral for both cervical and lumbar pain. These evals are always a little harder for me and usually I’ll split up the eval and focus on one area for the first visit that is usually aggravating the patient more and then finish the rest of the objective at the following visit. I started off the subjective with my usual opener asking what brought the patient into the clinic. Fifty minutes later the subjective was over and I was scrambling to get some objective information since I had a patient coming in right after. I think I wrote an essay for his subjective since he had so much to say about what was going on and Clare can attest to that. I probably wrote too much looking back, but in my head at the time it was all good information. The patient had been through a lot and seen a lot of different providers for his pain who told him all sorts of things. His chief complaints were primarily low back pain that he has had since 1996, mid back pain and R shoulder blade pain. To keep it short he was seen by his doctor previously who told him that he has arthritis in his low back that has worsened over the past few years, lumbar instability, and that he has problems with his neck (decreased curvature) and noticed weakness in his L UE. I asked the patient if he was currently having neck pain or symptoms down his arm since he didn’t mark it on the body chart and he said no, he mainly has low back and mid back pain so I was very confused why the doctor told him that. He has also worked with a chiropractor who has tried e-stim and softwave therapy that ended up causing muscle spasms in his back, and was also told that he has a leg length discrepancy so his chiropractor is working to improve that. He tried an orthotic to help with the leg length discrepancy which ended up causing increased foot pain so stopped wearing it. He also had PT previously which helped with the pain at the time, but has not been keeping up with his exercises. Right off the bat I was overwhelmed with all the information he was providing me. I was shocked with everything he has been told previously by providers he saw. He also had some unfortunate events happen over the summer with his Father passing away and having to move stuff out of his father’s house. So there’s definitely a psychosocial component to the case that’s involved with the patient’s pain.

Looking back at the initial visit, I feel like the patient needed that time to just explain his story and everything that has been going on especially over the past year. I know in the course and in school we talked about how important the subjective can just be, as shown previously in the 2021 article that was shared with us called “Evaluation is treatment for low back pain” by Louw et al.1. I think it was important to allow the patient to just talk and not interrupt although it did almost end up taking the entire session. The hard part was being able to organize my thoughts at the end thinking of my differentials and determining what was most important to examine within the time we had left and make sure I had at least 2 things for him to do at home before the following visit. I also wanted to make sure I provided some education to the patient based on the things he told me with prior experiences and imaging findings. I was so focused on that I barely had time to explain to him what I thought was going on with his pain and kind of struggled with wording. A CI previously told me to just step out for a moment to help organize thoughts so that I am able to provide a better explanation to the patient. I think that would have been really helpful in the moment since the patient was looking for an answer of what is contributing to his pain.

I definitely learned a lot from this eval and would love to hear if people have had similar encounters and how that went/advice on what worked for them in situations like this.

1.Louw A, Goldrick S, Bernstetter A, et al. Evaluation is treatment for low back pain. J Man Manip Ther. 2021;29(1):4-13. doi:10.1080/10669817.2020.1730056

[iwhitney]

Hey Emily,

I thought this was a really good post, and definitely highlights some difficult aspects of patient care. I think you’re right, sometimes it is important in the beginning to just let the patient talk and get their story out in order to build rapport and get the full picture, as long as the information they are mentioning seems relevant. I think it was definitely important to get the full picture with this patient because of the journey he’s had seeing so many other providers and how that’s impacting his pain experience, not to mention his environmental factors. I’ve definitely had some similar evaluations myself where it can be difficult to get any words in at all because the patient has a lot to say. It can be difficult to know when to budge in without seeming rude or just letting them talk so you can gather more information.
Something I’ve been told when encountering situations like this is that you don’t have to do everything objectively in that first visit. I think that rings true for this particular encounter as well. It was important for you to let the patient get their story out so you could see the whole picture, and you’ll have plenty of time in subsequent visits to gather more objective information. Time management can be super difficult at times and in order to ensure that the entire session isn’t spent talking, I personally find it easier to just move on after they finish a sentence and then refer back to that statement while in the middle of performing an assessment or treatment technique so that they know I was listening and acknowledge their statements. When crunched on time, I’ll usually wait to explain to the patient what I think is going on until after I put together an HEP. This also usually allows me the time to get my next patient started with a warm-up in the meantime so they aren’t waiting for me to finish. It sounds to me like you were able to establish a good rapport with this patient just by simply letting him talk, so hopefully the trust is there which will help with future visits. Let me know how it goes in future visits, I’d be curious to hear what other objective information you’re able to find!

[ebusch19]

Hi Ian, thanks for the response! Incorporating the subjective while doing an assessment is something I have thought about doing in situations like that. The second visit was similar, where we talked a lot and I tried to assess what I couldn’t in the previous visit and do treatment as well. He is now on Clare’s schedule due to a scheduling conflict so her and I have been keeping in touch with how his visits have been going. He is definitely an interesting case, and I think there are definitely a lot of things that can be addressed with him both with treatments and with education.

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