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About a month ago I started working with a patient who was 2 months s/p R anterior hip replacement. Last week she came into the clinic and I asked her how she was doing and she had a down look on her face and said she was not doing well. I asked her why and she handed me a new prescription for her R shoulder which I was not expecting since she has never mentioned complications with her shoulder before. When she handed it to me, I asked her what it was for and she immediately said that her doctor told her it was “bone-on-bone” in her shoulder joint. I asked her if she had pain in her shoulder and she said no, it’s just “bone-on-bone” and is constantly making noises. Then she went off on how she is probably going to have to get surgery on her shoulder, most likely both, and have to get her other hip replaced as well.
To give a little background on the patient’s PMH, she was diagnosed with crohn’s disease when she was younger and has been living with it for about 20 years now. When I asked her how she was managing it, she told me she’s taking antioxidants like turmeric to help and is trying to avoid medications. I asked her why, and she told me she had bad side effects awhile back when she tried them and just gave up. So I talked to her about reaching out to her doctor and talking to him/her about that and how they can work with her to find a medication that works best. She even admitted she doesn’t think taking the natural ingredients is really helping and the past few years her symptoms seem to be gradually getting worse. She also has anxiety and depression and is taking medications to help manage both.
Going back to when the patient told me what her doctor said and seeing how that was the main thing she remembered from the visit, I was a little frustrated based on everything we have learned about how words really do matter. I was trying to think for a second on how to best manage the situation and say the right thing without calling out her doctor. I asked her more about what her thoughts were on what he said and that’s when she went into likely having to get more surgeries because of her crohn’s disease. I’m not sure if she asked him about surgery or if he first mentioned surgery to her, but he at least wants to wait a year before considering it. Great. He also talked to her about avoiding high impact exercises like planks and push-ups, which is hard for her to avoid since she is a fitness instructor at a local gym. Everything she was telling me was a lot to take in and I think we spent probably the first 10-15 minutes or so talking about this. I didn’t know where to start.
She told me how strengthening and moving feels better for her hip so I used that to an advantage and talked to her about that and how that applies to the shoulder as well. I briefly talked to her about activity modification and that she does not need to avoid movements, especially since she is not having any pain. It was tricky since she is in for her R hip and I wanted to make sure we had time to focus on that as well. I could tell when she came in today, she is still thinking about what the doctor told her and kept bringing up her shoulder and how it’s “grinding” while we were doing some of the exercises where she had to use her arms.
I need to talk to one of the workers at the clinic on how to best go about the situation, whether she needs to schedule a separate evaluation or if there is a way to incorporate it into her current case. I definitely want to get her in for an evaluation and provide more education to help her. It’s difficult since I don’t want her to think I am ignoring her shoulder, but also want to focus on her hip.
Has anyone else had a similar encounter? How did you talk to the patient about it/manage the situation?
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Emily,
I really enjoyed reading this post and actually relate to it quite a bit after a similar encounter I had with a patient this past week. My patient is a 41 y.o. male who is post-biceps tenodesis and his #1 goal is to get back to weightlifting. Last week, he had his 12 week f/u with his surgeon, who, for the second time, told this patient he should never lift weights again due to the amount of OA in his GH joint. He then proceeds to tell the patient that he’s too young to receive a TSA and should just give up on the idea that weightlifting is going to be possible. Needless to say, I was not happy to hear this and incredibly frustrated that the surgeon would say this. Even if there is some merit to the presence of OA in his GH joint, I feel that with the right amount and type of PT, he will certainly be able to get back to weightlifting at a reasonable amount of weight, especially if we can take the necessary steps to ensure stability in his shoulder.
When reading through your patient experience, I thought of my own patient and the long session we had discussing his presentation and prognosis. Of course, you never want to totally negate what the surgeon is saying. However, I think it is our responsibility to give these patients a positive perspective and outlook on their condition. How much research can we refer to that shows the impact of positive expectations with therapy on patient outcomes. I also think discussing the prevalence of OA is important when managing patients that present with a negative outlook on their condition. I have even pulled up the research showing the % of people over 30 y.o. living with arthritis despite being asymptomatic. This often hits home since most people coming into the clinic aren’t aware how common it is. I think it also makes sense to them when you frame it in the perspective of being a human being walking around on Earth for a certain amount of decades and fighting the effects of gravity. Empowering patients that show up with a negative perspective is in my opinion one of the hardest things to achieve, but I feel that if we can give them some form of reassurance that they have the ability to control their own outcomes and not be defined by their condition, then they can leave clinic feeling hope. -
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