Blunt Conversations: Setting Realistic Patient Expectations for Pain
At APTA's recent "Beyond Opioids" panel, Sarah Wenger, PT, DPT, observed that clinicians need to give patients realistic expectations for pain and pain relief. But how do we have these difficult—yet important—conversations? In this Q & A, Wenger dives deeper into the topic.
Wenger is a board-certified orthopaedic clinical specialist and associate clinical professor at Drexel University's College of Nursing and Health Professions. She co-authored "Reducing Opioid Use for Patients With Chronic Pain: An Evidence-Based Perspective" in the May PTJ special issue on nonpharmacological management of pain.
#PTTRANSFORMS: During the panel discussion, you stated that a "goal of zero pain is not realistic for anyone." Managing patient expectations also was a theme in your Perspective article. How do you convince a patient who is experiencing debilitating pain that some pain is okay?
SW: People in pain often cling to the idea of a cure but are usually realistic about their current scenario. Being truly blunt here is helpful. I tell patients that I can’t get rid of all their pain and that most adults have some pain, but I can help limit how much that pain interferes with life. I say things like: "You told me your pain stops you from walking more than 2 blocks. What if I could get you walking 4 blocks before the same pain stopped you? Most people with chronic pain notice that once they are doing more their pain doesn’t bother them as much. Whether or not your pain changes, at least you will be able to do more of the things that are important to you, and I think that is worth working on—how do you feel about that?"
Build-up patient buy-in and establish caring and respectful rapport. Be honest and realistic about prognosis.
#PTTRANSFORMS: How can physical therapists and physical therapist assistants build trust and credibility with patients with chronic pain?
SW: Be transparent. Demystify your clinical reasoning and decision making, so your patients can understand your assessments and how you used the information you collected from them. Tell them exactly what you want them to do and why. Research has found that empathy, respect, genuineness, acceptance, encouragement, communication, and warmth are associated with positive provider¬-patient relationships.
#PTTRANSFORMS: You also mentioned focusing on "small-step goals" of participating in activities of daily living. Can you elaborate?
SW: Helping patients focus on doable goals can keep them from being overwhelmed by the enormity of processing the whole biopsychosocial pain experience all at once. Invite patients to appreciate their progress. Of course, we want to strive for full function and no pain, but we need to acknowledge that any progress in that direction is helpful. Better is better, even if it isn’t ideal. Small wins help build the foundation of confidence and hope needed to tackle larger goals.
#PTTRANSFORMS: Patients with chronic pain often feel that their health care providers don’t hear them. What are some tactics for clinicians to make sure (1) they hear their patients accurately and (2) their patients have confidence they’ve been heard?
SW: Repeat your understanding of the patient’s story and ask them to verify and fill in gaps. Explain why you want to know the information you are asking for. If patients understand how you are thinking, they can better choose the most important things to share.
Include what you perceive the important details to be and tell it like a story; in other words, don’t verify facts without verifying the narrative. Patients feel heard when they think you "get it"—not when you separate their story into a collection of facts.
Also understand your own perspective and the difference between pattern recognition and bias. We all use pattern recognition to help us diagnose and treat. We need to assess if the patterns we identify are accurate or if they have been influenced by our perspective or beliefs. An example of this a patient who is injured in a worker’s comp case and displays fear-avoidant behavior. We tend to assume that the employee is trying to get something over on the employer without ever considering how fairly the employer is treating the employee. The employee could be fearful because they are being mistreated and disrespected at work and is legitimately concerned that their injury will be ignored or worsened by the employer’s practices. I like to tell my students, "use your judgement, but don’t be judgmental."
#PTTRANSFORMS: Your PTJ article mentions the importance of monitoring patient learning and employing "high-quality teaching and mentoring skills." Is the profession "there yet" in terms of possessing these skills?
SW: I don’t think health care is "there yet" in teaching and mentoring, and we should absolutely devote more attention to this essential aspect of health. We should assess how each patient understands their health and tailor education based on that individual’s knowledge and beliefs.
A basic education process might follow these steps:
- Assess knowledge and beliefs.
- Design a curriculum tailored to each individual that addresses what you believe is important and what the patient is interested in and open to.
- Build salience; adults learn best when the material is salient to their perceived needs and circumstances.
- Use a range of individualized instructional methods.
- Mentor for knowledge translation; help the patient apply learned information to their day-to-day lives.
- Assess barriers and partner with the patient in problem solving.
- Reinforce and encourage.
#PTTRANSFORMS: For PTs who don't work in a multidisciplinary environment, do you have suggestions for growing a professional referral network to make sure the patient is receiving supportive care in all the areas they need?
SW: There are 2 important ways you can tap into the effectiveness of interdisciplinary care without formalized access to it. First, you can broaden your perspective by reading literature from a wide range of professions and learning from your colleagues in other occupations. Second, you can be a skilled and tenacious communicator. Initiate contact and make yourself available. Create front desk practices, websites, etc, that facilitate communication. Build relationships with other providers by coordinating, reinforcing, and supporting each other’s plans of care. Be verbally efficient; time is hard to come by, so make sure your point is obvious and not lost in the details. Ensuring that communication is a positive experience will lead to more efficient and effective work flow for all parties.