Meeting patients where they are at: Are we on the same page?

I’m writing about Joyce again today. Usually my Stories from the Clinic episodes are at least 2 weeks apart, but I felt I needed to write this today.

For those of you who missed Joyce’s story, you can find it here.

I saw Joyce in clinic again today. I had spent the last couple days planning what I would do with her for today’s session. I felt ill-prepared to handle her case, because her company denied my request to have a mental health professional added to our team. Joyce needed a lot of counselling to reframe her beliefs and thoughts, to process her feelings, and to start charting an empowered way forward. I felt that I did not have the skills to help her much with this, so I was feeling very low on self-esteem and very frustrated. I felt as if I was thrashing around in rough seas, trying to stay afloat.

So I tried to plan as best I could for the session today. I planned to help Joyce mind map her situation and then use the vector diagram from dispositionalism theory which was effectively used with patients in persistent pain by physio Matthew Low who wrote about it here. This was my last hope, and I entered the clinical encounter with Joyce with much trepidation.

As I began to present the mind map based on things Joyce already told me about herself, it was as if those rough seas suddenly calmed to a crystal clear, peaceful lake and I miraculously felt like I was actually swimming instead of thrashing. Joyce opened up. And she talked and talked and talked. She talked about how she felt about her surgery, what the surgeon told her, her experiences with the healthcare system, what others have said about the healthcare system. She felt harmed, violated, betrayed. As I listened, I subtly filled in the mind map as she spilled her thoughts, uninhibited. We did no physical exercise today; no "typical" physical therapy.

She said many things to me that stuck out, but there is one that I’d like to focus on in this post today. She described her encounters with her surgeon.

He would forget who she was, and relied on her file to see what surgery he did at every session. He told her he does hundreds of these surgeries. Fair enough. But she said she felt like a spine and not a person.

“Which spine did I operate on here?” She felt as if she was just another spine.

This attitude was not isolated to her surgeon, but to her other health providers as well.

Her surgeon would take a phone call in the middle of their appointment, and then he would forget what they were talking about.

She confided that she only opted to do the surgery because he promised her an 80% chance of recovery. This did not happen. Rather, her pain worsened. She told him this and asked him to explain the reason. He hardly looked at her, but focused on her file instead. His response was that he had fixed the compression on the nerve; in his mind he had fixed the problem. So he did not understand why she had all this pain and could no longer help her. Her response to him was that, you did not fix my problem. My problem WAS and IS my pain.

WOW!

The session with Joyce blew me away for many reasons and I learnt so much from just that 1 hour with her. Here are some thoughts:

• 1. Do your due diligence and prepare for your patient. It is ethical practice. It is person-centered practice. Even in the depths of despair, you never know where it may lead. Just by presenting a mind map, Joyce seemed to have had a breakthrough moment. Research your patient problems to come up with options and solutions.

• 2. Try to understand your patient as a person. In reflecting on today, I feel that Joyce opened up so much because I think the realised that I was trying to understand her and to get her to understand herself and her situation. The mind map was a vehicle through which that could happen. I guess that respect of her personhood maybe made her feel safe enough to open up the flood gates.

• 3. Concordance of goals and being on the same page with your patient is indescribably important, especially when considering something as risky and invasive as surgery. Communication is crucial, and there was catastrophic breakdown of this communication between Joyce and her surgeon both prior to and after surgery. More discussion should have occurred around the expectations of surgery. Was the surgeon absolutely sure that her pain was related to the “nerve compression” per MRI? This certainty seemed to be conveyed to the patient which is why she opted to do the surgery. But when a patient’s goal is pain relief, yet a surgeon’s goal is to “fix nerve compression,” I think there is a lot of room for misunderstanding and unreaslistic expectations. Maybe the surgeon was not versed at recognising the psychosocial contributors to her pain? If he had recognised these factors, would he have operated? Maybe this strict biomedial approach is a failure of our medical education. Would Joyce have benefitted from a mental health professional prior to surgery? I bet she would have, but I doubt the company would have agreed to it if they don’t even support it now.

This is a failure of the entire health system on multiple levels, not only on the part of the surgeon. It is no wonder that Joyce felt betrayed and violated.

I may continue to explore Joyce's case more in Stories from the Clinic, so subscribe and stay tuned. I never know what stories and lessons I may experience in the clinic, but I look forward to sharing them! Everyday is an exciting opportunity to learn from our patients!

I’d appreciate your comments and thoughts on this situation, so feel free to type in the box below!

I also have a long form blog on person-centered care which you can access here. Follow me on the socials as well if you’d like to reach out:

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