- Hey guys, welcome to a new episode
of the Wednesday Checkup.
Today I'm going to be sharing a story with you
that happened a couple of weeks ago,
where unfortunately a patient filed a complaint against me.
That made me really emotional.
Let me tell you why.
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Before we start I want to let you know
I'm going to be changing some details about the patient.
Just so we maintain this person's privacy,
and we don't make anybody feel uncomfortable.
Because that is not the goal of this channel.
Our job is to stay happy, healthy, learn about ourselves.
Learn from our mistakes, and that's what we're going to do
with today's story.
Here we go, let's get started.
To set the scene,
I'm working in my outpatient family medicine office,
and I see a patient on my schedule.
I have the demographics that he's a male,
he's in his late 20's, and also the complaint
or reason why he made the appointment.
Patient would like MRI for low back pain.
Patient comes in, my nurse rooms the patient,
I go in and we start having a conversation.
The history of present illness goes as follows:
The patient is a late 20s male, works many hours
in his job as a department store salesman,
where he's on his feet.
He's been complaining of low back pain
for an extended period of time.
Worse sometimes, getting better sometimes.
Currently is not in a lot of pain,
somewhere like three to five out of 10.
It does get pretty bad at times,
going all the way up to an eight.
This patient has had prior back surgery.
We don't really have a clear understanding
as to what the surgery was
and what the indication for the surgery was.
But we know there was a back surgery performed.
And my first questions is,
because my goal is to help the patient
and answer the patient's question directly,
was, you told me, or at least you told my nurse,
that you would like an MRI,
what are you looking to find out with the MRI?
He wants an MRI, because he's worried that the activities
he's doing in his everyday life, could be causing
more damage to his low back,
and that perhaps there may be scar tissue
from the past surgery, or perhaps there's something
else going on within his lumbar, or his thoracic spine
that could be causing his symptoms.
I understood where he was coming from,
so I said, Okay, let's take that apart piece by piece
and we'll have a longer conversation
than we originally scheduled.
The visit was supposed to be 15 minutes,
which is normally what we get for an acute visit,
but I said, we'll spend extra time,
because I really want us to both be on the same page,
and especially because I've never seen you before,
I wanna create a little bit of a relationship
before giving any kind of advice or guidance.
One of my first questions, being sports medicine
and osteopathic medicine trained, was,
do you do any kind of physical activities
and how does your back pain affect that?
He told me that every morning,
or pretty much five days out of the week,
he does calisthenics in the morning
for about half an hour, and he's able to do those
pain free, and actually, he gets a lot of benefit
from doing this calisthenics and stretching.
Also, at least once a week
he goes on an eight/nine mile hike.
After the eighth or ninth mile he starts developing
low back pain that makes it uncomfortable for him
to continue and he has to cut his hike short.
What do I take, as a doctor, from that kind of information?
Well, first it shows me
that this patient is very functional,
that they're able to do stretches, they're able to do
complicated and compound movements.
They're not limited incredibly by this back pain.
That was a good sign for me, because as a doctor,
my job is always to get my patients moving,
especially when it comes to low back pain.
There was a misconception back in the day that,
if your low back hurts, you should rest it.
That's actually pretty inaccurate,
because, what we found is, the longer time you spend
in bed with low back pain, the worse it can actually get.
Now, this was my first time seeing the patient,
so I asked, what's going on in my patients life.
He described a very stressful life,
especially when it comes to work.
He's working many hours, 12 to 14 hours at times,
and the back pain gets worse after standing all day.
And, at times, the patient even became tearful,
because he was so upset about the stressors in his life,
of family, friends, there was a lot of things going on,
but I could see that stress was a major component,
and there was a big mental component of this pain.
So after getting the full history
and what was going on with his back pain,
I perform a physical exam.
Now, in the physical exam the patient had some muscle spams,
straight leg raise, which is a test that we do
to check for sciatica, was actually negative,
which is a good sign.
That means, that the sciatic nerve is not involved
in this type of pain.
I did some other provocative tests
and everything came up negative.
There were some tender points that I elicited,
but nothing that was really worrisome,
no bony tenderness, the reflexes were fine,
those are important things that we rule out
when we're looking at someones back pain.
So, once I conducted the proper history,
then I did the full physical.
I then decided to explain to the patient
what my thoughts are on whether or not he needs an MRI.
I told the patient that an MRI wouldn't benefit him,
because what we find on MRIs, doesn't always translate
to clinical symptoms, in fact,
it doesn't the majority of the time.
There have been studies done in the past, where we scanned
100 people who have no back pain,
and found that on MRIs, they had significant findings.
Arthritic changes, degenerative changes, bulging discs.
But these patients weren't having back pain.
So what does that tell us?
That tells us, that just because you have a finding
on the MRI, it doesn't mean
that it'll have a clinical significance.
And as a doctor, it's not my job to treat the MRI,
it's to treat my patient.
So I told the patient that based on how functional they are,
based on my physical exam, knowing that they're able
to do calisthenics everyday, hike for eight miles,
I can barely hike for eight miles,
their back pain seemed more tied to their stress levels
in their job.
Now, that's not to say my patient doesn't have a true
medical problem, they do,
and it's elicited by tender points.
They're describing pain, which is a subjective measure,
but they are describing it and they're saying
how uncomfortable they are.
So, it's my job to fix that.
So what I explained to the patient, is,
I thought that they could benefit from conservative
management, specifically physical therapy.
I also recommended some osteopathic manipulation
and I gave a recommendation of some reading material
about mind-body conditions, where based on our mental state,
some physical problems can arise, like low back pain.
As a primary care doctor, it's my job to delay the process
of risky procedures as much as I can,
as long as there's no pressing matters at hand.
I didn't view that an MRI was the correct next step.
But, I understand that some patients
may have reservations about that.
I understand that they can have anxieties
about their back pain, for example,
why is it there, I would like to get a better look.
So I explain that to the patient.
If you don't agree with my evaluation,
or you think that you still need
an MRI after this discussion,
I'll happily write you a prescription for an MRI,
and we can get the process started.
Or, I'd like to see you back the following week,
so we can continue this conversation.
You would have started physical therapy by now
and gotten a couple of sessions in,
and we could see what progress you're making.
And if, during that point,
you decide that you want an MRI,
I'll write you the MRI then.
I'll write you a referral to a specialist
if that's what you want,
and my patient, seemed to be very understanding.
"Doctor, I appreciate you spending the time.
"I see what you're saying.
"I don't want the MRI now, I hear you.
"I'll see you next week, I'll start physical therapy,
"and we'll go from there."
And I was really proud of myself.
As a doctor, it's not always easy to have a patient walk in
who wants something, and it's your job to convince them
for their own good, or at least from your medical opinion,
for their own good, that it's not ideal what they want
and that there's a better way.
And, for them to understand that and be on the same page,
that takes skill and sometimes it takes many years
for doctors to develop that skill.
I came back the following week to my hospital,
a patient called and left a complaint
with our office manager.
The complaint was basically as follows.
That, the doctor that I saw, did not help me at all
with my pain.
This doctor was overly spiritual and I'd like to see
a real doctor, who's willing to help me with my pain.
It was something along those lines, I'm paraphrasing.
The rest of the day I was left feeling like,
what could of I've done better?
What did I do wrong?
Where did the communication break down?
So I started replaying the situation
over and over in my head,
trying to figure out what I can do better,
how I can improve.
And, something that I do is, I ask people,
who have more experience than myself,
or people who are experts in other fields, for their advice.
So I went to go see one of our behavioral specialists
that work within our office,
and basically what he told me is,
there are some patients,
which is a small percentage of patients,
like, less than 10%, even less than 5% probably,
the more care you give them,
the more you time you spend with them,
the more effort you try and go through
in explaining something, the more that they take away
from that, something negative.
Why is this doctor trying to sell me on this?
What is the doctor?
Is he trying to get over me on this?
Especially if you're disagreeing
what they initially came in for.
And he said, "What's a good strategy for that,
"basically, going into the patients room,
"now that you know that their personality style and type,
"and just being very buttoned up.
"Well, you want an MRI,
"I don't think it's in your best interests to get an MRI.
"And say that, you know, if you don't agree with this,
"here's, I can give you a referral to see a specialist,
"another doctor, or the test
"that you actually want ordered."
What it taught me was that at certain times,
with certain personalities, it makes sense to be more brief,
and to be more succinct and just explain things clearly,
instead of trying to sell and influence that person,
'cause it can come off manipulative to some people.
You can't fault yourself for everything.
A situation could just happen because of an unfortunate
coincidence, if you will.
The fact that this patient never met me,
I never met the patient, I tried to be really nice,
the patient misinterpreted that, for whatever reason.
The patient filed the complaint,
but the people that know me and the nurses,
and other patients,
will understand that my intentions were good.
Intentions matter.
There's many times where we have great intentions,
but have bad outcomes.
We need to always look at the intentions
and then look at the outcomes.
If the intentions were bad, now we know that person
needs some work on that end of the spectrum.
If the intentions were good,
but the outcomes were bad, then we need to work on
the action and figure out what we need to improve
on that action.
I wanna keep learning as a doctor,
and I feel like, if we can learn together,
along on this unique journey of mine,
I think that's even more special and that's why
YouTube was created.
Speaking of good intentions and bad outcomes,
check out my mental health video right here.
Stay happy and healthy, and I'll see you in this video.
Click it, click it.
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