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14 Articles in Volume 18, Issue #9
Assessing Arthralgia in Children
Children, Opioids, and Pain: The Stats & Clinical Guidelines
How to Fit into a New Practice
How to Talk to Your Chronic Pain Patients
How to Treat Opioid Use Disorder in Pregnant Women
Intranasal Ketamine for Acute Pain in Children
Medication Selection for Comorbid Pain Management (Part 3)
MR Neurography: Using Peripheral Nerve Imaging as a Pain Diagnostic
Naloxone in Schools; Buprenorphine Conversions; OUD Management
Opioid Conversion Calculations and Changes
Pes Anserine Tendino-Bursitis as Primary Cause of Knee Pain in Overweight Women
Self-Management of Chronic Pain in Primary Care
The Homebound Adolescent: Managing Chronic Pain Conditions in the Pediatric Population
The Opioid Band-Aid: The State of Pain Pills, Congressional Bills, and Healthcare in the US

How to Talk to Your Chronic Pain Patients

A clinician's two-prong strategy for patient communication before diagnosis.
Pages 57-58

The world of chronic pain is filled with excessive testing, medication trials and side effect management, repeated interventions, and perhaps most devastating, a sense of hopelessness and frustration that can often get in the way of finding optimal health and function. The very first interaction with any patient in chronic pain is therefore a very powerful moment. Over the course of my 30-year clinical career in physical medicine and rehabilitation, I have evolved a two-part strategy that I believe helps to set the stage for a realistic provider-patient dialogue and smart decision-making.

Bring the Whole Patient into the Exam Room

First, I make sure the patient’s whole self is part of the initial interview and assessment. In a study completed several years ago at the University of Vermont involving employees with back injuries, I codified a way to make this possible.1 When greeting the patient, I ask two questions:

  1. Where are you from? (In other words, where did you grow up, not just where do you live now?)
  2. What did you like to do for fun before your pain?

I then ask follow-up questions based on whichever of the two answers seemed more animated, drilling down until the patient’s body language changes to show they are truly interested in the topic and starting to relax. Here’s an example:

Physician: What do you like to do for fun?

Patient: Fish.

Physician: Where do you go fishing?

Patient: Oh, on the Huron River.

Physician: Really? Got a favorite spot? (the patient makes eye contact now)

Patient: Well, actually, there’s this spot just downriver from the Barton dam. Just last week I almost caught a huge walleye!

With that shift in the patient’s tone and body language, I know the whole patient is in the room with me. It sets the stage for him to expect that we will be looking at his problem in more dimensions than pain or even work. Too often, especially with work-related injuries, patients feel that their role is as victim of their workplace, and doctors may only seem to care about returning them to the place that injured them. This upfront interaction, however, places the patient on a more level playing field with the physician.

In this hypothetical case, I may focus the patient’s treatment goals on returning to fishing rather than returning to work. As a result, the patient may feel more free to ask questions and to use his own judgment. Moreover, the patient becomes involved in thinking about choices for managing his pain before even I know what the right choices might be.

In some cases, a patient may not be able to think of anything fun that they used to do or may insist that we focus on the medical business at hand. In these instances, my antenna is up for depression, alcohol and substance abuse problems, legal motivations, or other reasons they may be guarding themselves.

In the Vermont study, the protocol used led to a drastic decrease in missed workdays as well as increased patient satisfaction.1 Today, this type of questioning has become part of my routine. When I use this tool, the day seems to go better for me, too. I often get some good stories out of my interactions with patients and come to truly respect them and their values moreso than I might if I dove right into the MRI findings.

Efficient interactions with patients before diagnosis are key to treatment acceptance and additional communication. (Source: 123RF)

Engage the Patient as a Service Purchaser

The second part of my strategy is to treat the patient as a consumer, or a purchaser of services, before I consider what types of services (eg, treatment) they may need. This approach is especially useful in managing complex conditions. After obtaining the patient’s medical history, but before the physical exam, I stop the information-gathering and transition to this type of dialogue:

“Mrs. Smith, I haven’t examined you yet, so I don’t know what treatments we might discuss. You’re the expert on how much this bothers you and also in charge of deciding what treatments you are willing to try. So before we begin, I want to understand what you think of treatment options.” Then, I hold up an open hand.

“We offer 5 things for people with pain.” Touching each finger in order, I say, “surgery, injections, pills, therapies, or do nothing.” Then, I remind the patient that I am trying to get a sense of their interests. I make up a scenario for each finger. For example:

“I know you’ve had two back operations in the past. Let’s pretend that another operation would give you a 60% chance of cure and a 10% chance of making you worse. Would you take it?” I put my pinkie finger down.

“Injections can sometimes prove what’s wrong and sometimes provide months of relief. They typically do not cure pain in the long term. So if I offered you an injection that you’ve never had, and it would give you 80% pain relief for 3 months, but had a 1 in 20,000 chance of complication, would you take it?” Ring finger flexed.

“Pills are kind of dumb.” This is the middle finger, so the patient usually laughs. “At best, they get rid of 30 to 40% of chronic pain, and they all come with side effects.” Citing Chou’s review for the American College of Physicians,2 I say, “Let’s say I have another pill. You have to take it three times a day, maybe it makes your mouth dry, and it would get rid of one-third of your pain. Would you take it?”

Fourth finger raised: “Therapy includes things like exercise and chiropractic. Let’s say I have a new therapist, and if she worked with you 3 times a week for a month, you’d get rid of about half of your pain. Would you do it? The pain may come back if you don’t do a half-hour of her exercises every day. How long would you continue with that regimen?”

Now all the fingers are in a fist, and the thumb is sticking out. “OK, so here’s the hard one. You have to pretend that deep in your heart you know there is nothing medical professionals can do for your pain. Second opinions and doctor visits may not do anything. What if you’re just stuck with the pain?”

At this point, the patient often realizes that there is no sixth finger. To date, all of my patients have found a treatment that is represented by one of the five options. Often enough, they also realize that the first four options may be dead-ends. Some break into tears. It is a good opportunity to ask about depression or suicidal thoughts but also a time to build hope by acknowledging the ubiquitous mental health problems that accompany chronic pain, which are often successfully treated.

Move with the Patient into Acceptance and Rehabilitation

Most important, the above scenario creates a paradigm shift in which the patient stops vague thinking about miracle cures and instead begins to feel ready to cross the bridge into the realm of acceptance and rehabilitation. Often, I transition like this:

“Sometimes, it is a lot easier for my amputee patients to get on with life than it is for my patients who have chronic pain. The amputee knows that their leg is gone for good so they can just focus on quality of life despite their new disability. For you, it may be harder to focus on the quality of your life despite the pain. I will do my best to look for that missed diagnosis or new cure. But honestly, if we don’t find a quick fix, or if you don’t like the options, I know that rehabilitation despite pain can be super successful.”

Then we begin the exam. I pull out my open hand at the end of the visit to talk about specific diagnostics and treatment.

This five-finger approach advances the idea that a patient will have to make choices based on his or her personal experience of pain and disability as well as his or her own willingness to take medical, psychological, and financial risks. It establishes an expectation of self-efficacy before the serious questions arise. Self-efficacy, in fact, is increasingly being seen as one of the most important predictors of success for pain patients.3

At first, this backward approach of talking about lifestyle before therapy and of offering choices without a diagnosis may seem impractical or unnatural. That’s because, as students, healthcare professionals learn by getting the basic facts down. They must be sure that everything is plugged into a rational location. Chief complaint, history of present illness, past medical history, review of systems, physical examination, assessment, and treatment plan must all be noted in order. So they learn to ask questions in the order that they must record them.

Yet, after a few hundred or thousand cases, expertise theory says that clinicians will have “heard it all before.” They will pass from the neophyte stage to the competent stage, and on to the kind of thinking that experts engage in. They will be looking for exceptions rather than the usual. With the diagnostic and treatment plan running in the back of their head, clinicians at this stage can begin to view patient dialogue as primarily therapeutic. They will find that interaction is part of accomplishing the patient’s needs, above and beyond the need to make a diagnosis.4

Last updated on: April 12, 2019
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