Critical Thinking

Can you stop short?

I want to start with a simple question, as a therapist are you prepared to stop mid-intervention to listen to the patient?

If not I don’t think you’re ready to treat pain seriously. 

That’s a bit blunt you say. Right, well I think this important.  The question is how I got to the point of making this judgment.  Well it starts with something I have noticed in clinicians throughout the years, which is their disdain for the communicative moments in therapy, especially sessions where the patient is doing most of the talking.  After such sessions, the therapist returns to the confines of the office exasperated. “The patient just won’t stop talking about all their problems”  It is my opinion, that the hallmark of exemplary clinical reasoning of pain is the therapist’s  ability to react instantaneously to a perceived need by the patient to express themselves and to listen attentively.

Let’s start with the fact that we as physical therapist are not groomed with skills of communication.  Some of us who are attracted to the profession are good communicators–especially those that stick around for a while.  Some of us might be highly relatable within the niches of clientele we have crafted for ourselves.   However, communication skills are not requisite and definitely not universal, even if you are relatable.  Our schooling reflects doing unto others, rarely it considers listening to others.  It is fixated on creating patient centered goals but leaves emotions, beliefs and cognitions conspicuously out of the picture.

The late Patrick Wall states: “If the sequence (of pain) is frustrated at any stage, the sensation and posture remain.” (1)

There is potential for frustration, at the point when the patient may be wishing to express the most important aspects of themself or their pain but our own discomfort with situation causes us to shut it down, divert or distract.  Oh! The patient seems uncomfortable and distressed well I must cheer the patient up so we can keep on going, or that is just a psychological problem, not in my wheelhouse–are both potential common excuses of the treating therapist

The expression of pain is both the verbal and non-verbal communication of pain to another person.  It is a type of pain behavior that carries emotional valence and demands the attention of the listener.  If we take a person’s emotions, beliefs, and thoughts as part of that expression and we choose to ignore it or explain it away, there is a problem.  We may be potentially thwarting the patient’s expression and thus frustrating the natural sequence and process of pain resolution.  Unfortunately, a patient’s complaint is not going to come in a neat little package: a numerical rating or a common adjective.   Understanding it as such might cause the patient to feel that their expression fell on deaf ears.   The expression of distress and pain is messy and sometimes tied up with other aspects of the persons being.  The more comfortable we are with ourselves and the patient, the better listeners we can become.

So to return to the original question, if you answered yes and are prepared to stop, what do you do during those moments?  What occurs during the patient’s expression that contributes to your clinical reasoning and processes?  How does your reaction to their expression affect their presentation? Do you know techniques of listening that facilitate the patient feeling supported and cared for?

Before I conclude this post I want to give you two example interviews conducted by Peter O’ Sullivan.  He is an Aussie who is developing a clinical reasoning model called cognitive functional therapy.  Just as we know there is more to passive movement than meets the eye; there is more to listening than just being talked to.  Peter demonstrates this.  Can you spot the tricks that he uses?


To be continued…#stopshort ;)

Eric Kruger @Kintegrate

Post Script:

The term stop short in  the urban dictionary implies a certain interpersonal gesture as depicted in this Seinfeld episode it more commonly means to stop (or cause to stop) suddenly or abruptly.

References:

1.  Wall, P. D. (Ed.). (2000). Pain: the science of suffering. Columbia University Press.

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5 replies »

  1. I work in a multidisciplinary chronic pain rehabilitation program. “Stopping short” is a part of my everyday life. In general, I try to maintain eye contact with the patient and then reiterate what they have just told me in an effort to make sure I have understood them. Most of my sessions start with a plan of what I want to accomplish but I frequently go off on tangents depending on some concern the patient has expressed. I want to the patient to know that 1) our goal is a positive outcome, 2) there is a plan to get to that outcome and 3) I’m willing to change the plan if it does not address everything that is a concern for them.

  2. The patient should always have the opportunity to “tell their story,” no matter how long it takes; and this is something I try really hard to teach my students as well. If you let the patient talk, they’ll usually tell you almost everything you need to know for history. Also it’s incredibly important as we are probably the first health care practitioner to listen to the patient (hopefully). Survey/study show most physicians don’t let you get a word in edge wise and often steer the conversation away from what the patient would like to talk about. It’s not uncommon for evals of mine to have very few objective measurements with more talking and education, as I think this yields way more value.

  3. Eric, I like a lot of your ideas, but you really hit the nail on the head with this one. I think the key is: being willing to stop at any part of the treatment, ESPECIALLY during a manual therapy technique.

    There’s a lot of stuff P.T.s need to hear – you might have just come up with something that many will be WILLING to hear. Let’s hope.

  4. Excellent topic and comments. Comments received from my patients,”Where did you train. You are different to the others, you listen.”; “You are as much a counsellor as you are a Physio.”; “It’s so different and such a relief to have someone take time to see me as human.”
    Such comments tell me that 1. I have made a communication connection 2. Gained trust 3. Am on the right track to target whatever the patient wants me to focus upon.

    At a first visit, start off by asking a patient, “How can I assist you today?” or words to that effect.

    Gaining trust and targeting and maintaining focus with a patients requirements should carry over from one session to another. Treatment notes should include memory joggers for the therapist assisting personalisation of interaction, e.g. “Was your dog better after the vet visit?’ Humanise interactions.

    It is very true that we must be prepared to change tack mid consultation. Such a change should not be viewed as a logic derailment, simply viewed as an alternative track diversion to a better destination or even a more valuable scenic enlightenment to the same eventual destination.

    I actually set up rules of engagement with my patients by giving them permission to talk to me as much as they wish. They are told that in my rooms, they are just as important in the relationship as the therapist, because two way communication is better than a one sided lecture. The two way component is necessary – as it reminds me to hold my tongue and listen, but also lets the patient know that they are not to lecture either.

    Patients are often nervous at consultations. Some demonstrate anxiety by not talking and others are garrulous. Sensitivity to draw one out or allow another to vent is necessary. Eventually a balance is achieved. I also state to patients that if I appear to be misinterpreting what they are telling me, they have permission to say,”No Mark, you are an idiot, that is not what I meant.” Such a statement reduces any ability for the patient to think, that I think, I am on a higher level than them. Most feedback positively to this scenario.

    It is true that I am in Australia and we are known as being more laid back, but additionally I am in a semi country area, magnifying the effect somewhat. The principle remains the same and can be tailored to various cultural etc requirements.

    It is agreed that this topic is very important in relation to assessment and treatment of patients of all types, not only those with chronic pain. Remembering that not only can we educate patients, they are our best form of education – if we are flexible and open to allow such education.
    Cheers,
    Mark Quittner MrPhysio+ Healesville Australia

    • Thanks for all the replies everyone.

      Mark I really like you ideas about setting up rules for engagement. This is something I am trying to a better job of each day. Leveling the playing field of communication is huge. I think we have tried to pattern much of what we do as therapists after physician engagement, diagnosis, and management of conditions. In retrospect I think it is pretty clear to wonder if this was the best course. Now that the science is catching up and describing things like the social modulation of pain, placebo, and the importance of the therapeutic alliance. Perhaps it means we should be modeling a more psychologically therapeutic approach. Joe has talked about Self Determination Theory. I have been influenced strongly by reading about humanistic psychology which Self Determination Theory was borne out of. I think this is conceptually very difficult for many practitioners to understand. It seems that Pete is making a solid go at it. What do you guys think?

      Eric

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