First Encounter; LBP: The clinician must consider the patient’s values, and ideas about the pain and what it means to them. Maybe the problem is the failure to consider the entire patient. This requires more attention, but at the end of the day, clinicians are building the best possible relationship with their patients and practice, and setting an example of excellence for their colleagues.
When you ask a patient how they feel, they commonly respond with a physical description like, “My back feels stiff and achy”, and they may point to the area of concern. They may elaborate a bit more on their own, or if the doctor inquires further, “My back hurst when I play tennis.” In my experience, patients that are the most frustrated and feel like their injury is causing them the greatest annoyance will automatically spell it out, “My back hurts on the inside, right here (pointing exactly) after a few forehand strokes, so I have given up on playing all together.”
Pain is an entire experience, not just discomfort, “ouch!” The entire experience may include anger, sadness, lifestyle inconvenience, loss of court time with friends, worry, assigning self-blame, for example. When you ask the patient, “How does the pain make you feel?” they will respond with an emotional description instead of a forensic description, “Doctor I am so frustrated, I just started playing tennis… I am not a sporty person and this is my first try at sports… I already feel like a failure.” What is the importance between the two questions? Firstly, asking both questions demonstrates that you are a caring clinician, and that you want to understand how the patient interprets the pain. Secondly, asking both questions demonstrates that you do not manage your practice by isolating your case management to an area of the isolated complaint, but rather that you respect how the complaint is interfering with their lifestyle expectations, and that the patient is an entire person. Asking both questions provides the clinician a huge advantage in diagnosing and case management since everything they need to know is embedded in those two question-answers: “Where does it hurt, and how does it make you feel?”
Case management is not just a diagnosis and execution of a Course of Care (sometimes mistakenly called a ‘treatment plan’, or worse, a ‘treatment’.) Case management implies that the patient, the entire patient, will receive professionally supervised care, and that the patient will be directed to care that is efficient (least time and cost) and effective (best outcomes, least risk; side effects, delays) towards a return to normal daily activities (ADLs) and a return to athletic activities (RTP.) The highest priority is to respect the patients’ values… if you even bothered to ask. Medical doctors commonly practice only [between the brackets]; however, consider all four for best practices:
Mechanism of injury + [diagnostic features + symptoms] + patient values
In my office, after cordially greeting the patient and settling them in comfortably in the exam room, I say something like:
“Thank you for coming into my office today, I am grateful that you have chosen to entrust me with your care, I understand from your chart notes that you have back pain the past few days since you were playing tennis, mostly when your swing your racquet…
Can you tell me a bit more about the problem…?”
In my office, I immediately demonstrate my willingness to recognize the patient as an entire patient, not just back pain residing inertly. Then I ask: “Can you tell me how the pain makes you feel?”
“The intensity and suffering is largely determined by what the pain means to the patient… the person’s beliefs about the cause of the pain may be right or wrong. The location of the cause of the pain must be distinguished from the location of the pain itself.” (Brodal, 2017)
Isn’t it commonplace for the clinician to stare at the site of the complaint, and isolate this area from the rest of the patient’s body? What are the automatic questions that you use to determine the cause, source and explanation for patient pain? What are the automatic actions that you perform to determine the cause, source, and explanation for the patient’s pain? Did you reflexively prescribe muscle relaxers, pain killers, anti-inflammatories, refer to physical therapy or epidural? Brodal’s statements steer the physician’s understanding (diagnosis and Course of Care) towards a personalized approach, a sensitive, entire approach.
Then I ask, “What are your expectations of me today?”
Usually, the patient has no idea how to respond, so I prompt them, “I am here to advocate for you, to help you get better as quickly as possible and to meet your personal values regarding your preferences in care… this is your opportunity to give me my marching orders… how may I help you today?”
What are ‘patient preferences in care’? Different patients have different ideas about how they want to receive care. Do not assume that every patient is okay with prescription or OTC drugs, or surgery. Remember, patients believe that every doctor knows everything there is to know about medicine; doctors only prescribes the absolute best care that works 100% of the time… though doctors do not, and can’t.
LBP is evil, elusive, and very difficult to diagnose, since there are more than 200 possible contributors to be considered in isolation (the majority of which cannot be seen on imaging) according to my research, potentially giving clinicians x10114 combinations to consider. Why is it important for the clinician to order imaging, do labs, refer to neurologists, repeat imaging, and delay diagnosis when a sufficient Course of Care (without drugs) can begin today? Isn’t it possible to address the patient’s complaint from an ‘entire patient’ platform? I call this platform the ‘whole patient approach’; the polar opposite of attempting to zero in on grams of tissue, pointing a pencil eraser at a disc herniation, and proclaiming a singular cause. And in truth, the disc did not herniate for no reason… so why diagnose the cause as herniation, considering that there is an entire patient? Why not ask the patient what they are doing when their pain occurs… mopping? sitting? reaching? pulling luggage???
‘Pain is not the only problem.’ The clinician must consider the patient’s values, and ideas about the pain and what it means to them. Maybe the problem is the failure to consider the entire patient. This requires more attention, but at the end of the day, clinicians are building the best possible relationship with their patients and practice, and setting an example of excellence for their colleagues.
LBP Blog General information
These articles intend to (1) re-evaluate the prevailing clinical practices thought to manage low back ‘pain’, (2) submit and debate novel low back ‘pain’ contributors and mechanisms, (3) meet patient expectations & satisfaction and clinically meaningful results, (4) recommend a conservative non-surgical course of care to over-ride ‘pain’ instantly, and (5) restore ADLs and patient confidence on the first visit at low cost. This article has a companion podcast.
Dr. Dean Bio
Forester Dean is a chiropractic and physiotherapy sports medicine doctor practicing in Los Angeles, California. Dr. Dean is a lifetime athlete, and currently teaches tennis, track, boxing, yoga. The Core X System™ Campus flagship location was opened by Dr. Dean in 2020. www.preformancecxs.org
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