Reading Between The Lines
Two hours before our scheduled 1st appointment I got a message to call this lady as she felt that she was in “too much pain” to attend for assessment. There was a time in my NHS service days of 20 min appointments and 25 cases/day that I would have been glad of such a reprieve but not now. My initial disgruntlement at the short notice cancellation was compounded by the knowledge that the appointment was only booked the previous day following a consultation (on the same day) with her Orofacial Pain Specialist. This raised a few alarm bells and I felt compelled to call her both to ascertain the extent of her flare-up, what her thought process was with regards to her expectation of Physiotherapy and to outline our 24 hour cancellation policy.
From there we began an interesting half hour telephone conversation. By way of background I should add that I work very closely with the Orofacial Pain Specialist who referred her and on that basis knew that there had been some degree of “priming”.
Our conversation went along these lines.
Good afternoon Mrs. Smith I believe you wanted to have a word with me regarding your scheduled appointment this afternoon?
Yes I won’t be able to make it, I am in too much pain
Oh you are calling to cancel the appointment? The message I had received was that you wanted to discuss whether it would be appropriate for you to proceed with assessment?
Oh no I am in too much pain. I couldn’t possibly make it. Can I reschedule next week?
What do you think would be different next week?
Oh it should settle down by then. I have been prescribed some new medication, which I am hoping will be effective.
Have you had a lot of medication in the past?
Yes I have tried them all. The last doctor didn’t tell me that I had to take the “nerve tablets” for weeks so they did nothing for me when I took them occasionally. I have had this problem since my husband died six years ago; I have seen three Rheumatologists and two Pain Specialists and none of them can do anything for me. Have you ever heard of Fibromyalgia? And none of them can do anything for me. Do you treat patients with this type of problem? Do you think you can help? What kind of treatment do you do?
Well undoubtedly you have a complex problem, which many skilled practitioners have failed to resolve. I wouldn’t do you the disservice of flippantly saying on the telephone that I could help you when so many others have obviously failed. Why do you think treatment hasn’t helped?
Well I have been a bit depressed since my husband died six years ago and I have tried every kind of treatment – Osteopathy, Chiropractic, Massage, Physiotherapy, Hot Stones. So I have tried everything I could and nothing seems to work. I also suffer from depression and that doesn’t help. But the doctor has given me new tablets so maybe that will improve things. Can I book an appointment to see you tomorrow?
Oh so you don’t want to see me?
No I didn’t say that. I said we couldn’t schedule an appointment for tomorrow. Do you feel the severe incapacitating pain that you have today will resolve sufficiently by tomorrow?
I don’t know.
How long do flare-ups usually last?
Oh can be a few days.
Well my suggestion is that you try at least one week with the new medication (Neurontin) that has been prescribed so you can judge the effect of that medication.
Well it’s just another tablet. I really don’t think it is going to help very much.
But a few minutes ago you suggested that you thought it was going to be a great help
Yeah I suppose so. Maybe it will. But I have tried so many I don’t have much confidence anymore. What do you think?
I think you need to try the medication for a week and see if it makes much difference to your symptoms.
Do you think it would help?
I am not going to predict if it’s going to help or not. I think you need to see whether it’s of any benefit and make a judgement.
But the doctor says it would take 6 weeks to work.
Yes indeed there can be a whole series of progressions on the drugs that you are on and it can take a 6 week period to work through. However, I think you will have a good indication in one week whether things are improving or not.
If you call me in one week then we can talk about whether you’re ready to commence Physiotherapy, what you’re expectations are and what you’re commitment to the rehabilitation process is? You tell me that you get great benefit from Chiropractic Manipulation so I would take it as a good indication that physical treatments have some role to play in your management. However it is clear that they are not the full solution and we need to address other issues, which may involve posture, muscle conditioning, ergonomics, pain management etc, etc.
Why do you not continue with chiropractic if it has been helpful?
Oh you seem to understand my problem so well. Can I not come and see you tomorrow?
I need to make this absolutely clear that no individual clinician is going to wave a magic wand and solve the symptoms that you have been experiencing. It is likely going to take multiple specialists in different areas to assist and also a significant change in your strategy of seeking a solution from what you have described so far. I would do you no favours by seeing you tomorrow, simply adding another opinion to the long list of opinions that you have sought and in all likelihood not living up to your expectations of miraculous improvements.
Oh, yes, I see. So do you not want to treat me? I can’t go on like this.
I don’t want you to feel that I am refusing to treat you. What I am trying to do is ensure that you are in a good place to respond to treatment. As we have discussed, you obviously have a complex problem and there is obviously no point in repeating speculative treatments, which have been tried in the past and failed.
I am very willing to try to help you but I think we need to clarify each of our respective roles in order to increase the likelihood of a positive outcome. So I will put the ball in your court and wait for a phone call from you next week to discuss the plan to move forward. Talk to you then.
This conversation struck a chord with me as I reflected on the thought processes of both parties and the strategies used in response to the conversation. I tried to adopt a style, which was challenging but not too confronting whilst at the same time recognising some fundamental belief system changes I felt were required.
The fact that I deferred arranging for a new appointment was partly to address the trial medication issues as discussed above (incidentally, my expectation is that there won’t be a significant change with the medications or the side effects will be to unacceptable) and secondly so that there can be no misconception that scheduling an appointment was purely for the purposes of me seeking financial gain (as I work in a Private Practice setting and hence my desire to be separated from the long list of other money grabbing failed clinicians). So I ask myself these questions:
Will she call in one week?
Is she likely to comply with a treatment regime?
How far can I go with challenging her distorted belief systems?
Is she likely to comply with a long-term management regime?
Is her depression likely to be an insurmountable compounding variable, which ultimately forms a roadblock?
How do you think I handled this situation?
What would you have done differently?
Let us know your thoughts.
Enjoy the clinical challenge.
DavidGHTime Code(s): nc nc