Difficult Conversations With Patients

During my early years of practice, I treated a 93-year-old gentleman who had an interesting chiropractic story. He and a college classmate spent their summer break traveling the country to promote chiropractic. Two of his uncles, both chiropractors, sponsored the venture.

My patient, whom I will call Coach, and his friend traveled the U.S. in a 1923 automobile adorned with chiropractic signs. They were spreading the word. The young advocates were well-suited for the assignment, as they were college athletes and had made great use of their sponsors’ chiropractic services.

Coach told me that during his college years, when he was in top form, it only took one or two adjustments to get him back into shape. Unfortunately, he thought the same situation should exist at 93. I had already treated him three or four times, and he was obviously impatient with me. The speed of his recovery came up during each visit.

Each time the topic came up, I pointed out that the rates and quality of healing are much slower and less efficient at 93. Coach did not respond to my explanations initially, but one day he looked at me very sternly and asked, “Are you saying I am old?”

By that time, I was as frustrated with him as he was with me, and I replied, “Life expectancy is currently 72 years of age. At 93 you are 21 years past dead. You’re old.” We parted ways.

Five Difficult Conversations (and the Best Way to Approach Them)

Difficult conversations with patients – awkward, uncomfortable, upsetting, unpleasant, embarrassing, or painful could be used as alternatives to the word difficult in this context. In my 38 years of practice, I have found five particular conversations to be the most difficult: the ill effects of advancing age, the need to stop driving, excess body weight, smoking, and psychological issues.

#1: Age

As we age, our tissues change. Cartilage deteriorates and joints begin to show arthritic changes. Hearing, sight, smell, and taste diminish; the skin wrinkles and hair grays.

Some patients make it easy and acknowledge age as a factor before you bring it up. Unfortunately, this is the exception, not the rule, and it isn’t long into a conversation about age before the patient knows where the discussion is heading.

Two common statements I hear from aging patients are, like Coach, “Are you saying I’m old?” and “It has never been this way before.”

I have developed a more diplomatic response to the first question than I had for Coach: I ask, “What age do you think is old?” They never choose an age close to their own. However, it causes them to realize that it is unreasonable to say, for example, that a 67-year-old person on Medicare with multiple grandchildren isn’t advancing in age.

I use filling a bathtub as the foundation for my answer to the second question. Bathtubs have limits on the amount of water they can hold before overflowing. The body has limits on the degree of aging that can occur before it “overflows” and health issues begin to appear.

Clever analogies like this are helpful, but the tool that is the most effective in these situations is imaging. Showing the patient images of their degenerative disc disease, posterior joint arthrosis, etc., is proof over opinion.

Patients may protest further by saying, “You’re as old as you feel.” Great, but they are in a doctor’s office, so something isn’t right. Time and physiology march on.

#2: Driving

Convincing a patient to stop driving is a difficult conversation. This conversation can be horrible, as driving represents one of the last forms of independence for many elderly patients.

A patient’s family usually initiates the need for the conversation. They want you to begin the discussion with their loved one. They say it will be more authoritative. As I doctor, you do provide more authority, but I refuse to have this conversation unless family members participate.

The burden of proof for ceasing to drive begins with identifying existing dents and dings in the patient’s car, as well as any accidents or the patient’s decision to avoid driving under certain circumstances, such as nighttime driving. Significant losses in eyesight, hearing and reaction time are also essential considerations.

This information is obtained from family members, which supports the need for them to be present during the conversation. Do not allow the family to place the entire weight of the conversation on you.

#3: Body Weight

Discussing excess body weight can be a tough conversation. It is another conversation that patients quickly know where the discussion is heading.

Patients may make things easy on the doctor and acknowledge their weight as a factor in their onset and recovery. Otherwise, they may be defensive; and in some situations, emotional. Emotional reactions originate from years of struggle with their weight.

“I have always been heavy, so don’t tell me this is because of my weight. If it is my weight, how come it didn’t hurt until now?” is the most common comment I hear from overweight and obese patients. I also use the bathtub analogy in this situation. The patient’s frame has held up to a point, but is now overwhelmed and overflowing.

The key to this conversation is having a plan for the patient after you bring up the topic. You cannot bring up their weight and move on. You should have access to a dietitian, a bariatric center or another weight-loss method, and utilize them.

#4: Smoking

There isn’t a patient on the planet who is not aware that smoking isn’t good for them. The essential factor lies in the difference between decision and addiction. Starting to smoke is a decision. Continuing to smoke is an addiction.

Again, you cannot bring up these topics and move on. You have to have smoking cessation methods and psychological help available for these patients.

Patients are always anxious to feel better and have their treatment end. With this in mind, I inform smokers that many joint conditions heal five times more slowly in smokers. Making this point won’t cause the patient to stop smoking immediately. However, it often push him/her to seek help.

#5: Pain Behavior

Pain behavior is frequent among patients with long-term neuromusculoskeletal conditions. Their pain becomes a constant irritation that affects physical function, occupational capabilities, household duties, relationships, and eventually their mood and mental health.

Many patients have already consulted other providers by the time they seek chiropractic care. This situation suggests the patient may have been told at some point that their symptoms are all in their head, stemming from psychological origins.

To be able to address psychological issues, we need to understand the difference between pain behavior, symptoms of psychological origin, and malingering.

Pain behavior originates with an actual injury / condition, which eventually leads to psychological symptoms. The symptoms begin in the tissues below the foramen magnum and progress cephalically.

Psychological and malingering symptoms originate above the foramen magnum and progress caudally. Since the origins of these onsets are similar, differentiation is necessary.

The key to differentiation lies in the patient’s intention. Symptoms of psychological origin are not intentional (unconscious origin). Symptoms related to malingering are intentional (conscious origin)

I begin the discussions related to pain behavior and psychological origins in the same manner. I bring both situations up and define the difference between them.

Patients with pain behavior feel relieved when you tell them they have pain behavior, not pain of psychological origin. They feel like you understand and are on their side. Pain behavior patients are a little easier to manage from that point.

Patients who are told they have symptoms of psychological origin often become angry and will discontinue care. You should document this situation and provide recommendations or referrals for the patient. The only aspect of this situation that is a win for you, the doctor, is maintaining appropriate clinical standards.

I approach the conversation with patients I suspect of malingering as though they have unconscious psychological symptoms, giving them the benefit of the doubt. I avoid the term malingering because it is an indictment. Saying the patient is malingering without proof can lead to legal repercussions for the doctor.

Be Prepared

You will likely have one or more of these difficult conversations soon. When it happens, I hope this discussion proves helpful. If you need additional help, ask yourself the following questions to gather the necessary information to succeed:

• Which party usually initiates the conversation, and why?
• Do I have a simple explanation for the topic of discussion?
• Do I possess the resources to equip the patient with the necessary tools to succeed?
• How will the patient react?
• How will I handle the patient’s reaction?
• Are there other parties who should be involved in the conversation?