I’m doing something new with this post, and would love to hear your thoughts. In response to my Challenging Patient post earlier this year, Matt Parselle, a physical therapist, shared a story about a colleague’s encounter with a patient who might be considered challenging or difficult and asked for my thoughts. It led to a wonderful exchange.

I’m sharing that exchange here, with Matt’s permission (it’s on the comment thread of the original post as well). I value these conversations beyond measure as it is through dialogue that I learn the most. Through conversation I can think aloud and work through ideas while learning from the questions, thoughts, ideas, and insights of others. It is a glorious thing!

Here we go!

Is this a case of a challenging patient?

Hi Joletta, thanks for another great article, I always enjoy reading your blog!

It was very timely, as it made me think of a situation at work today (I work in a physio outpatients department). A colleague of mine had what some might call a ‘challenging’ or ‘difficult’ patient. The gentleman had recently received a course of passive treatment from another physio (ultrasound) and was very keen to buy his own ultrasound machine so he could self treat. He was very distressed and disabled by his pain. He also had a lot of other stress in his life, through a number of family issues. Understandably, he was also very angry about his situation.

My colleague is a very kind, sensitive and compassionate person but ended up feeling helpless because she could not seem to find a way to reach out to this patient and help him. She attempted to address some of the other factors in his life that might be contributing to his problem, but each time she was rebuffed with an angry retort. I agree with you that there is a great responsibility on us, as clinicians, to work with and collaborate with our patients to help them rebuild their lives, but I think this has to work both ways too. If a patient does not want, or does not appear ready to work with you, it makes any sort of collaborative relationship very difficult.

I would be very interested to hear any thoughts you may have about this.

Best wishes.

Or is it a challenging situation on both sides?

Hi Matt, thank you so much for your kind words and for sharing your thoughts and this story.

From my perspective, it seems the clinician may see this patient as challenging because he is not doing what she, the clinician, wants. The patient may also see the clinician as challenging because the clinician isn’t doing what he, the patient, wants. Both sides blame the other and both sides are frustrated as there is no moving forward.

So who is being challenging or difficult? Is it the patient? Is it the clinician? Is it useful to think in such terms? I would argue it is not. The situation itself is difficult, the circumstances are what is challenging.

From my experience, clinicians often feel helpless when they try to force conversations, like seeking out what else may be contributing to a person’s pain, rather than letting the patient lead the conversation. If the ultimate goal is to help the patient, then what is most relevant to the patient, what concerns the patient most, what the patient believes, should be the starting point. That’s where the narrative begins, and where the collaboration begins.

To change the narrative to one that might be more accurate or helpful it cannot just be imposed upon the patient. If it doesn’t make sense to him, within the framework of his own story and beliefs and values, it may very well be met with anger because he’s not feeling heard, not feeling his concerns are being addressed, or feeling as though his concerns are being trivialized.

Very well-meaning, kind, compassionate clinicians try to impose narratives rather than co-create them. They want what they believe is best to be the path forward and can be a bit dismissive, often unintentionally, of what the patient believes is best. But this is the patient’s life, not the clinician’s. If it is their life that is being rebuilt, they should be the architect.

Their knowledge and expertise in their pain, themselves, their goals, their lives is just as valuable as the clinicians knowledge and expertise about pain, rehabilitation, recovery. Too often the latter is the only voice that counts. That is the water we swim in, the culture we are all a part of, not any sort of individual failing.

The traditional view of Western health professions has been that the practitioner’s expert, monological voice is the only voice that counts, the only voice with authority.

In the dialogical position advocated here, allowing for multiple voices to be heard, there are other ways of looking at problems and interpreting them. If the problems are ever to be dealt with satisfactorily, it is important that these other voices are taken into account.

Stephen Loftus, Pain and It’s Metaphors: A Dialogical Approach

A wonderful resource on how to co-create narratives is Conversations Inviting Change, by John Launer. His book, Narrative-Based Practice in Health and Social Care, should be mandatory reading in health care in my opinion! Some articles I would recommend, too, are “My Story is Broken, Can You Help Me Fix It?”: Medical Ethics and the Joint Construction of Narrative by Howard Brody and The Nature of Suffering and the Goals of Medicine by Eric J Cassel.

Even with the best narrative and/or clinical skills, not every clinician is the right fit for every patient. Is that because the patient is challenging, or difficult? Or is it because the clinician is challenging, or difficult?

Again, I don’t think blaming either, or calling them challenging or difficult, is useful. It will always be a matter of perspective. Is the patient not ready, or is the clinician not willing to meet the patient where they are?

Taking a different perspective we might think it is the clinician who does not want, or does not appear ready, to work with the patient. After all, it could be argued that if the clinician isn’t ready to meet the patient where they’re at, that also makes any sort of collaborative relationship difficult!

For me it’s about widening our lens. Pain is complex, humans are complex, human interactions are complex, the cultures and environments we live and work within are complex. None of this comes down to individual faults or difficult people, in my opinion.

There are many difficult circumstances we are all trying to figure out, many challenging situations we are all trying to work through. We will only figure out the best ways forward when we lay aside blame and judgment and work together.

Thanks for asking for my thoughts. Hope something in there grabs your attention! If you have trouble accessing the papers I linked and are interested in reading them, I’m happy to email them to you. Would love to keep the discussion going, too!

An interesting and uncomfortable read

Wow, thank you Joletta for that extremely helpful and detailed response, it made for a very interesting, albeit uncomfortable read at times for me!

I tried to put myself in my colleague’s shoes and think about how I would have responded if I had had such a patient in front of me. I must admit, my first response was to think “Hold on, I am the expert here, you’ve come to me for my expert opinion, perhaps you should listen to me”, but after reading your response above, I think we (as physios) have almost certainly been guilty of trying to impose our knowledge and beliefs on patients, and this can lead to an escalation in anger with both the patient and the clinician becoming increasingly defensive, with neither party feeling like they are being listened to.

I would be very grateful if you could email me those articles you provided links to, as I was having difficulty accessing them.

Thanks again.

Closing thoughts

An email will be on its way shortly! Thank you for taking the time to reflect on my comments and see things through a different lens. One of the passages from Howard Brody’s paper includes the following:

“One important element of the joint construction of narrative is that the patient is fully involved throughout the process. The physician does not hand the new narrative…to the patient in the way that the traditional physician hands out a prescription at the end of the visit. There is an ongoing, partly nonverbal give-and-take as the physician listens carefully, throws out a few tentative comments, and modifies her approach depending upon how the patient responds to her initial offers of advice, explanation, and reassurance. If the patient indicates acceptance and relief, the physician moves quickly to complete her account of what is bothering the patient and what should be done about it. If any of these comments produce a raised eyebrow or other evidence of questioning or resistance, the physician will stop at that point and explore much more fully what the patient might be thinking. The involvement of the patient is critical in the next element of the joint construction of narrative, which is that the narrative must be meaningful from the patient’s point of view…Moreover, the patient has to accept that the story is truly about him.”

Howard Brody, “My Story is Broken; Can You Help Me Fix It?”: Medical Ethics and the Joint Construction of Narrative

John Quintner would call this intersubjectivity, or the ‘third space’. Here’s a link to a recent blog post on the subject. And I’m going to email those papers to you now! Please stay in touch. I love discussing this stuff and learn so much from these exchanges!

What do you all think?

Either about the topic discussed here (would love to continue exploring it!), or about sharing such exchanges in a blog post.

Do you like it? Hate it? Feel sort of meh about it? Are there any topics you’d particularly like to see explored? Or to chat about with me?

Let me know!

I have more I want to share, yet this post is already a long one! So I’ll save it for later, or share it in conversation with you, dear reader. These ideas of co-creating new narratives, and of meanings and how they change through the stories we tell or how they change the stories we tell, is one I have become increasingly interested in over the course of the past two years.

Would be happy to chat with anyone interested!

As always, thanks for being here. Thanks for listening. Thanks for making me feel heard.

The types of challenges I prefer :)
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