Communicating non- specific aetiology in LBP
Epistemic uncertainty
Some of you have asked me how to communicate non- specific nature of etiopathology of low back pain (LBP). Basically how will i tell my patient we are not sure what’s the reason for LBP. So this is what i do.
Disclaimer: The following ideas are not evidence-based, as their effectiveness has not been tested. They stem from research in psychology, communications, and personal experiences, including hallucinations. Communicating uncertainty and presenting contrarian views to your referring surgeon or physician can be challenging. It necessitates skill and training, both of which I possess in limited quantities. Please proceed with this understanding. If you're still interested, feel free to continue reading.
The basic principles:
Please note in case of LBP we are in a state of Epistemic uncertainty, ie we have inadequate scientific knowledge to know the reason for LBP. to communicate this i think we need to follow some basic principles.
Therapeutic alliance:. basically it means building mutual respect, trust, and empathy between you and your patient. Remember back in PT college when they stressed the importance of gaining the patient's confidence? That's a crucial first step, though sadly, we often weren't taught how to do it effectively.
keep it simple: When conveying information to your patient, use straightforward language. Medical terms often sound like they're designed to confuse (they're mostly Latin and Greek!), so simplicity is key. It's believed that bombarding patients with too much information can overwhelm and confuse them. For example, using terms like "wear and tear" (தேய்மானம்) might seem easy to grasp, but it's actually an example of what not to do.
Be patient centric: I know it sounds cliché, but it's crucial to prioritize the patient. Provide information based on their needs and expectations. Remember, the interaction should feel like a conversation, not a lecture, to prevent cognitive overload.
Tell stories: Daniel kahneman always emphasis to tell stories to make a point rather than numbers and hard facts.
I think Dr. Mathrubootham did use these principle effectively to teach a generation about sex.
So let’s see how I try to use these and say to my patient- I don’t know!
Step I gaining the confidence:
Forming a therapeutic alliance is often smoother when we know the patient, especially if they've sought treatment from us before. However, for new patients arriving with overwhelming concerns, I typically initiate by asking, "Please tell me about your back pain." Some patients begin narrating their experiences, which aids in building a stronger alliance. As the great Maitland advised, I adhere to the principle of listening to the patient without interruptions, except for seeking clarification.
Occasionally, patients might start by mentioning a specific diagnosis like "I have a disc problem" or "I have issues with L4-L5." In such cases, I gently redirect them by saying, "That's okay—please share your experiences and the problems you're facing." I've learned from past mistakes where I would immediately discredit their assertions or launch into a tirade against the reliability of MRI scans. Now, I understand this approach isn't effective. Typically, patients become more receptive after experiencing some pain relief from my treatment. I believe that mutual trust improves slightly once they've felt relief, making them more open to discussions about the underlying causes and pathology of their condition.
listen to your patients experience with empathy
Step II- what’s the patient bias?
There are various approaches I take to reach step II. Sometimes, I start with a simple question: "What do you think causes your back pain?" Responses I commonly receive include, "I was shown in the scan," "My doctor or therapist told me," or "Instagram said."
Gradually, I weave stories about the implications of these diagnoses. Instead of simply dismissing them as incidental findings, which might not resonate with the patient, I employ Tamil sayings to emphasize the idea of not always trusting what we see. I typically have two or four stories ready, depending on what I think might engage the patient.
These stories revolve around the notion that seeing alone isn't always believing. For instance, I might show the patient a phone with a heavily scratched screen and ask, "Is this a good phone?" The ensuing conversation depends on their response.
If they say, "Yeah, it might be," I gently guide them to consider other factors by asking, "Right, how do you say that?" Eventually, I lead them to realize that a phone's value isn't solely determined by its appearance, but rather its functionality. I then draw parallels to their back, emphasizing that its condition isn't solely defined by what they see on scans, but rather by its capabilities.
It's important to note that these conversations occur after the patient has undergone some assessment and treatment, during which they've engaged in various movements and exercises.
I recall an incident when my schoolmate invited us to her daughter's wedding. During one of the rituals where the groom had to be lifted, she asked if we could participate. "I have an L4-L5 problem," was the common response. Therefore, I take measures to help my patients understand that back pain isn't like diabetes or hypertension—it doesn't always persist.
To prompt a change in mindset, it's essential for the answer to come from the patient themselves. I often begin by asking, "Do you always have pain?" If they respond affirmatively, I acknowledge it but then inquire further, "Does your pain come and go, or is it constant?" Some patients give me an irate look and admit, "Well, it comes and goes." I then proceed by asking them to recall when their current episode of pain increased or began. Through gentle nudging, I guide them towards the realization, even if temporary, that their pain is episodic.
Please note- these does not mean all my patients have changed their mind- just that they are slightly receptive to newer ideas
The second step involves understanding your patient's biases—identifying where they originate from and helping the patient recognize that they may not present the complete or accurate picture.
Step III- what’s the reason for my back pain
After dispelling some misconceptions, patients may inquire, "Okay, then why do I get back pain?" My response typically begins with, "Well, we don't know." This often elicits a quizzical look from the patient. While some may question my knowledge, it's a deliberate starting point before I delve into my next narrative explaining why uncertainty is acceptable.
நோய்நாடி நோய்முதல் நாடி அதுதணிக்கும்
வாய்நாடி வாய்ப்பச் செயல்.
well, ideally we should know the reason, but we don’t know, but we know how to treat it effectively. I usually start with my story about headache.
Do you get headaches? of course i do.
but we don’t know why we get headache isn’t it? a sheepish grin
Well, we don’t know, but we don’t care for 2 reasons.
it will go away after sometime- so no big deal
I pop a pill, drink a proper coffee , go for a walk- i know how to manage it so i don’t care
So the story her should be about even if we don’t know the reason, we can treat them well, You can add many instances of you don’t know but we can treat well, depending on what you think will resonate well with your patients.
what do my patients really want?
Please note, there's an innate evolutionary drive for us to understand the reasons behind things, as it helps us avoid similar situations in the future. People avoid ice water, for instance, fearing it might lead to a common cold. Therefore, when patients ask about the cause of their back pain, it's not for writing an exam, but because they want to know how to prevent future episodes.
Our focus should be on providing solid information about good practices to avoid future episodes, rather than fixating on pinpointing the exact cause. My advice typically includes encouraging patients to move more, pace themselves, and find distractions when experiencing pain. (i am expanding how i have a conversation about those here)
However, it's important to note that not all patients will immediately change their mindset. Many patients maintain a strong allegiance to larger authority figures such as physicians, surgeons, family members, or social media influencers. Unfortunately, I don't have the means to change their perspectives, so we must accept this reality and focus on what we can control.