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Tuesday May 29, 2018

What a Patient Taught Me About Subtleties of Communication

As I sat and waited for Stephanie to arrive, I contemplated what our day together would look like. I had spent a lot of time during the last two years of medical school with patients, but this was a whole new experience.

[lessons learned concept on green blackboard]

I was scheduled to follow Stephanie that day as she saw various health care practitioners for her chronic hip, knee and back pain through a pain management program at the Department of Veterans Affairs.

Stephanie is only 28, but an injury suffered during basic training has caused her pain for the past four years. No medications or treatments have allowed her to reach a functional lifestyle.

When I met her in the lobby, she appeared youthful and energetic, as you would expect of someone in her late twenties. We said our pleasantries, and had I not known she was there for a chronic pain clinic, I would have guessed she was in for an annual physical. I first noticed evidence of her disease when we got up to attend her physical therapy appointment. Her partner passed her a cane. Then she stooped forward in her chair and used maximal effort to lift herself to a standing position.

We shuffled to the first appointment, taking a couple of breaks during the 40-foot journey as she constantly swayed and leaned to find a comfortable walking position.

During her first visit, she was asked the standard pain questions, had an assessment performed and discussed her care plan. We then moved to the next office. The same set of questions followed with a different physical exam. Again, we moved to another office, and the cycle repeated.

However, I noticed Stephanie's answers were not consistent for each practitioner. In one visit she emphasized her knee pain more than her back pain. She gave more detail about how debilitating her pain was to the therapist, but she joked about the pain with the chiropractor. I could see the wheels churning in each of the practitioners' heads as they tried to figure out the root cause of her pain and the best treatment options based on her story.

Her inconsistencies from one visit to the next bothered me. I had never had the opportunity to see a patient explain her disease so many times in such quick succession. In my mind, her story should have been the same every time so that she could get the most accurate and best treatment.

Naturally, I wanted to know what she was thinking, so I asked Stephanie about her answers. She replied that she tailored her answers based on what she believed the practitioner wanted to hear. I asked her to clarify that she was not lying to the people taking care of her, and she explained that she was just answering the questions as she had them presented to her. If she was quickly asked a series of three questions, then she would give three quick responses. Likewise, she would elaborate on answers if there were pauses in a barrage of questions.

Having inconsistencies in a patient's story was not surprising. As a medical student, I experienced patients telling me one story about their illness and then heard completely different stories from the same patients when my attending entered the room.

My revelation with Stephanie was that I could see the direct impact of body language, pace of questioning and prosody of voice. I had been taught the importance of the clinician's body language and being conversational through standardized patient encounters, but I always assume that I am doing well and never get feedback on these interpersonal skills.

I now better understand how to be conscientious during patient interactions, but I still wonder what the best way is to have my interpersonal skills evaluated. How can I know that I am doing best by my patient? These are questions that I need to continue to explore through residency, especially for patients who suffer from diseases that are difficult to diagnose, because perfecting these skills will make me a better doctor to my patients and a better steward of our health care resources.

John Heafner, M.D., M.P.H., is the student member of the AAFP Board of Directors.

Posted at 08:42AM May 29, 2018 by John Heafner, M.P.H.

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