- Hey guys, welcome to another episode
of the Wednesday Checkup.
Today's episode is gonna be about a difficult
patient conversation.
I have those all the time.
Whether I'm talking about vaccines,
a cancer diagnosis, or even end-of-life care.
But today's patient conversation was very difficult,
and it reminded me of a book I just listened to
that I wanna tell you about.
Let's get started, bee-woop!
(upbeat music)
The audiobook that I'm talking about
is called "How to Have Impossible Conversations"
by Peter Boghossian and James Lindsay.
This book teaches you how to communicate with others,
understand their point of view,
how to present your point of view
so that people will actually care.
And in these polarizing times,
it's an incredibly important audiobook to listen to.
How do I use it?
Well, as a physician,
I have difficult conversations all the time.
I use it in my day-to-day life
with my friends, family, and loved ones as well.
I definitely recommend you check it out.
If you're going to, do it on Audible.
I have a special offer for you today.
You can sign up right now for a limited time
for three months at 6.95 a month,
where you're gonna get one Audible book,
and two Audible originals each month.
All you have to do is visit audible.com/doctormike.
Remember, doctor is spelled out.
And if you live in the U.S.,
you could text to number 500500 "doctormike" as well.
Remember, D-O-C-T-O-R M-I-K-E.
All right, we talked about the book.
Now let's get to the difficult patient encounter
that I've been meaning to tell you about.
And huge reminder here.
All of the details in these patient encounters
are changed drastically
so that we maintain the patient's privacy,
we don't make anyone feel bad.
But we still maintain the learning point
from the encounter.
I think that's the way doctors learn.
I think that's the way humans learn.
So to talk about these openly
without making anyone feel bad,
that's the goal of this chat.
It's a busy day for me in the out-patient center,
and I come across a patient who's a 42-year-old female
coming in with a complaint of left knee pain.
I walk into the room,
and I really wanna get right to the point.
I introduce myself, ask the patient how they're doing,
and she right away tells me:
So, I have this knee pain.
It's been going on for 20 years.
Right now, it's a four out of 10.
Sometimes, it gets to be a nine out of 10.
And it's getting progressively worse.
So right away, I jump into my doctor mode,
and I start asking these questions,
"Have you ever had surgery on the knee?
"Was there ever an injury?"
And she interrupts and says that she has had surgery
about 15, 20 years ago.
The surgery did help out a lot.
And for the last 15 years,
she's been pain-free the majority of the time.
I ask if there's been any trauma or injuries.
She denies all of that.
I ask if she's been taking any medications.
She says she doesn't really take anything.
Occasionally, an over-the-counter medicine
if it's really bad.
Her main issue is that she has a desk job.
And when she sits for a few hours at a time,
and then has to stand up,
the knee almost locks up for her because it's so painful,
and she needs to wait a few minutes
before starting to walk, and that's problematic for her,
and I totally understood that.
There wasn't anything else medically contributory
from her history except the fact that she is morbidly obese.
Her BMI was over 40,
and that can contribute alone
to having some sort of arthritis.
Let's do a physical exam.
I go, and I start trying to look at her knee.
She's wearing jeans,
and I could feel underneath the jeans,
she has a hinged knee brace.
So I ask if she would feel comfortable
changing into a gown
so I could actually see the knee,
we can take the brace off and I can do a proper exam.
She says, "No, I'm not interested.
"I don't wanna take it out, it's too much of a problem."
I explain that unless I get to properly examine the knee,
it's gonna be very difficult for me to make a diagnosis,
near impossible.
She sort of brushes that off.
And I explained sort of the options that we have
when a patient comes in with knee pain.
Just to see if that would sort of
ease up the conversation some what.
As I'm mentioning all of these possible treatments,
not even saying that these are the right treatments
for this condition, she just says no to all of them:
No, no, no.
One of my girlfriends has had one of those,
and she had horrible pain afterwards.
I'm never getting an injection.
Nope, no physical therapy for me.
I've tried exercises at home, I don't wanna do it.
I need this knee pain gone now.
I ask an open-ended question:
What is it you'd hoped to achieve today
by coming to see me?
What can I do to help you with your knee pain?
'Cause it seems like the things that I'm offering,
even though I'm not saying they're the right treatments,
you don't seem to wanna do.
And then she goes and starts giving me a lot of information
rather quickly.
She knows her weight is contributing to her knee.
She starts telling me her entire history.
How she started putting on the weight,
the horrible relationship
that she's in now with her husband,
who's dominating her, that's putting her down,
not listening to her.
And we sort of shift away the conversation
to talking about that.
But anytime I try to jump in
and offer either a reflective question,
or some feedback, or guidance,
the patient just wanted to continue on talking.
This went on for about 30, 40 minutes.
I respectfully said:
Look, I'd love to continue this conversation.
I have patients waiting,
and we've already gone over our assigned time limit.
Perhaps we can meet again
and discuss this at a later date,
or we can get you to one of these specialists
who can help you with these worries.
The patient reassured me quite confidently,
"This is all I needed.
"I just needed to vent, I just need to talk.
"I know now what to do."
I definitely let her vent,
which may have served some benefit.
I wanted to do more.
That's not to say that I could have done more.
That's not to say that I did a disservice to this patient.
I tried my best, and a lot of times in medicine,
you'll try your best, but based on the time limits,
and the patient's own personality,
and what they hope to achieve, the goals may not add up,
especially when you don't know the patient.
What I should have accomplished from that visit
was not to solve the knee pain.
It was to isolate what the patient's concern is.
I found three real takeaways
from listening to this audiobook
that I could have used in that visit
to become not only a better communicator,
but a better doctor.
The first one is to build a rapport
before starting a difficult conversation.
It sounds easy, like, duh, anyone should be doing it.
But a lot of times, we miss out on it,
and I did in that visit.
When I walked into the room,
I introduced myself, I was very professional.
I asked what the reason that the patient was there.
But instead, I could have come into the room,
since I was meeting the patient for the first time,
introduce myself,
ask them how long they've been a patient here.
Who's their doctor that they see normally?
What's the weather like when they came in today?
How did they get to the office?
And this little 30-second, 60-second commitment
to build a rapport
can really improve the following questions
when we talk about a more substantive issue.
The second learning point is called epistemology.
It's the study of knowledge.
And basically, when the patient was saying things
that I may have known to be incorrect,
I shouldn't have jumped in and said,
"Oh, those things are wrong."
I didn't do that, but that was what I wanted to do,
'cause I wanted to correct the patient
and give her the best information possible.
What you should do is understand
where their knowledge came from.
The book talks about these six reasons
that most people will find their knowledge from.
One is religion, two is personal experience,
three is definitions.
The example the author gives is,
having too much of broccoli is bad
because too much of anything is bad,
because it's bad by definition.
The next is culture, because everyone believes something.
Next is reason, that you think X,
so then therefore it must be Y.
And then the final one is evidence.
I, as a physician, usually go to evidence first,
and then maybe go to reason or another one
as my secondary source of knowledge for a given thought.
A lot of patients will come in
with religion, personal experience,
and cultural knowledge being their guide
for why they believe in something.
For example, like the thought the patient had
that eating a lot of rice and beans
would be very healthy for her,
and that she wouldn't gain weight if that was the case.
Perhaps there was something in her culture,
in her experience, that has led her to believe that,
that if I asked her why she believed that,
I can then address that,
as opposed to countering her fact.
You see how it could be less hostile, right?
And the third point is something that the author says
that we both shouldn't do nor have done to ourselves.
We shouldn't bully people into having conversations
they don't wanna have.
So for example, if this patient didn't wanna talk about
her weight loss, and I introduced it,
and you could see that she was pulling back,
perhaps this wasn't the best time to do it,
or at least I should figure out
why she was having reservations.
But in this case, I feel that I may have been bullied
into having this conversation
about things that didn't pertain to the issue at hand.
I feel because I let that happen,
I ultimately did a disservice to the patient
'cause we weren't able to set strict goals,
and set up an actionable plan for her to succeed.
What I'm doing here
is essentially being the Monday morning quarterback.
Now that I know the outcome,
I'm essentially saying I did something wrong.
Maybe in that situation, I was doing the right thing,
and now, I'm just trying to figure out,
if this happens in the future, what can I do differently?
Perhaps my original approach may have been the right one.
So it's important to not kick yourself,
and always feel bad about the outcome,
because maybe what you were doing was right,
you just couldn't have known all the information
at that given moment.
Speaking of difficult conversations, check out this video
where I hit the streets of New York City
to talk about vaccines,
or click this video to seen when a patient
filed a complaint against me.
Which one of these you gonna click?
I'm excited to see you in the next one.
Staying happy and healthy.
(light music)