The patient that AJ and I discussed today is a bit of a unique situation. He is roughly 4 visits away from his hard medicare cap due to a THA in February. His wife is telling me one thing (that he still has pain/limitations following the THA as well as him having some mild cognitive decline), however when the wife isn’t there, he’s telling me that he does not want to be in therapy because he denies any pain/limitations. He states that he is doing his exercises every day, however when he demonstrated them to me, he performed them extremely quickly and is unable/unwilling to perform them slower and with correct technique stating that “its harder that way”. AJ and I were discussing possible methods for getting this patient to recognize his limitations and “connect the dots” between proper exercise technique and improvements in condition. One method we discussed was presenting him with the status quo, i.e. “you’ve been doing these exercises for months now and are still having trouble” and presenting him with an alternative: “what if we tried them this way to see if there was any change in your symptoms?” I think that this is going to be a hard sell to this patient while he is denying limitations due to his hip symptoms.

I think what I took out of this article (and today’s discussion with AJ) is that I need to have a more in-depth conversation with this patient regarding his limitations, expectations of exercise, opinions about how exercise relates to his condition/sx and his perception of limitations as they relate to functional goals. I also think asking him questions like “why don’t you do the exercises like this?”, “why do you think they are harder to do this way?”, etc. might help him realize the relevance of performing them correctly. I think once he and I have a better understanding between the two of us of what he would like to get (or not get) out of our time together, I will be better able to develop an appropriate plan of care for him.

I have definitely been in similar situations. I recently evaluated a patient with shoulder pain and one of her first comments to me was that she has always been reluctant to go to the doctor. She had put up with her pain for 3 years before going to the MD and was very fearful of exercise and movement. I think this idea of behavior change and motivational interviewing is something that will be important to apply in her case, as she is lacking intrinsic motivation and is fearful of exacerbating her condition. I have thought about this in some of my self reflections as well. It can be difficult to find the right wording in the moment and I have been guilty of giving unsolicited advice, when the patient may have not yet been ready or willing to hear it yet. I like the strategies this article suggests for giving advice, providing information “in a neutral way that leaves the personal interpretation to the patient”.

As someone who is definitely guilty of giving unsolicited advice and summarizing research to patients who probably could not care less, this article provided me with some good tools to improve my rapport with patients. I particularly liked the idea of asking patients to describe what the best possible outcome would be if they made a change and then to ask them what they think would happen if they made no change at all. This gives us an opportunity to encourage our patients rather than to merely give advice. One component to the difficulty with the traditional model of motivating others is that we are often unsure of how much of what we are teaching resonates with our patients. I often find myself explaining concepts to patients in convoluted ways that probably do not make sense. By shutting my mouth and giving them the opportunity to express their concerns, I can serve them better. I will definitely try to incorporate more of this verbal judo in my future interactions with patients.