Updated: Apr 10, 2020
We need to communicate better with people in pain, now more than ever. As we adapt to a changing health landscape, musculoskeletal pain management services must rapidly innovate and use telehealth as a primary means of assessment and treatment. We are forced to let go of some elements of practice and to rely on other ‘soft skills’. Except now these skills are neither soft nor optional, they are the centrepiece of the clinical interaction and are sharply in focus. For many therapists, and patients, this time will be uncomfortable, but potentially transformative. This blog is directed at clinicians, but may also be useful for patients, who are now having conversations about pain in very different environments. In this time of COVID19, everything has changed, and I aim to provide some simple tips to help us have better conversations about pain. This is science-based, but is not a script or recipe; it is up to you to apply, practice and change the way we all communicate about pain.
Think about your role
When two people interact, we each have a role to play (Ref). A well established psychological construct is the sense of self (Ref). Ervine Goffman proposed that we present this ‘self’ in a way that is congruent with our ideas on what the situation requires (Ref). The typical ‘patient’ or ‘clinician’ roles represent a power imbalance that may not be helpful (Ref). Each will bring their own background and past experiences with them (Ref). And although we aren’t able to change this ‘baggage’, we can do something about the conversation we are about to have. We can think carefully about the roles we want to play in this scenario. These roles should be based on a new partnership and look forward to a new outcome.
Create a safe space
When we communicate about pain, context is king and our conversations occupy a separate ‘space’ (Ref). Pain conversations are co-produced scenarios that take place in specific contexts. We need to be mindful of the context surrounding the conversation but we can also work together to mould this separate space. Having a safe ‘space’ for this conversation refers to an environment of understanding and authenticity, one where both parties feel they can embark on this partnership with confidence.
Aim for understanding first and treatment second
Pain is a potent driver for change and this may drive both parties to aim for change first, leaving understanding in the wings. This can often mean decisions about treatments will be centre stage for both patient and clinician. An important evolution in healthcare is giving patients a seat at the table for decisions about treatment. Shared decision making is a worthwhile endeavour, because patients definitely want to be involved (Ref). But it’s a complex process, and rushing to treatment may be putting act 2 before act 1. If change is the ultimate goal, we need time to build a shared stage for knowledge exchange and aim for understanding first.
Time is the highest value asset
It takes on average 92 seconds for someone to tell their story, but on average 11 seconds for a clinician to interrupt (Ref, Ref). This is a disturbing trend in healthcare that is easy to change. Validating feelings, problems and expectations is known to promote better outcomes (Ref). Validation is hard to achieve if patients aren’t even heard. For health professionals a solution to this is to talk less and listen more. For patients; demand to be heard.
Value feelings over symptoms
Pain is a subjective experience and we wouldn’t describe any other experience without explaining how it makes us feel. William Shaw and others reported, in a 2009 study, that patients presenting with more disabling low back pain were more likely to talk about biomedical ‘symptoms’ over psychosocial ‘feelings’, subsequently occupational physicians asked 4-5 biomedical questions for every one psychosocial question (Ref). In an analysis of over 300 consultations spanning 20 years (from 1989 to 2008), conversations between patients with low back pain and general practitioners were recorded; patients were more likely to express worry and concern, while clinicians were more likely to provide counselling on biomedical factors (Ref). Although symptoms are important and intimately linked to our feelings about them, this trend in medicine is a consistent failure to appreciate the rich tapestry of a pain experience. If we flipped the script, we can have more meaningful conversations about pain.
Share the story
Narratives are incredibly important for people in pain to help make sense of the uncertain, confusing and frustrating experience (Ref). A consistent failure to validate the patient’s ‘sense-making’ story is yet another worrying aspect of healthcare (Ref). Narrative medicine is an evolving science but may prove to be a very important addition to pain management. And simply listening may not be enough, sharing a patient’s narrative has some strong theoretical basis (Ref). This must start by both parties placing more importance on the story that has been, and sharing the story that has yet to unfold.
Values may add weight to goals
Pain causes people to avoid activities and health professionals provide a way to return to these. Setting goals is one way this is achieved; goals are easy to set but harder to achieve. When people have pain, goals commonly involve getting rid of that pain. Although there is nothing wrong with this, there is data that pain-focused goals can lead to less satisfaction in comparison to goals that don’t involve pain reduction (Ref). Human behaviour is dependent on context and competing demands (Ref). In fact, much of our behaviour is out of our conscious control - as habit loops (Ref). Goals to help us change this behaviour can be useful, but it may be more useful to first understand why we create them. Values can guide us to understand why we behave in certain ways, and may add much needed weight to the goals we set.
Focus on a strong ending
Most fields value the act of closing the communication loop to ensure all parties have understood and can act on the details of the conversation. But this simple act is rarely performed in pain management (Ref). ‘Closing the loop’ can take the form of a review. There is good evidence to show this is effective in improving health outcomes (Ref). As is implementing a plan and sticking to it (Ref). A strong ending doesn’t need to drag out, it just needs to be concise and avoid ambiguity.
Communication is important, and it is an interactive joint venture. It is something we rarely focus on like other ‘treatments’; a lack of literature rigorously analysing this area unfortunately reflects this. We need to think more about communication and bring it to centre stage; it is important - in fact it may be the most important thing we do.