Depending on what setting or in what area you work, you sometimes deal with very ~interesting~ people. Working in an outpatient hospital-based clinic in the heart of Silicon Valley is no exception. What makes patients so interesting is that pain is multifactorial in nature. Pain is not straightforward and many times is driven by other psychosocial factors: things like cultural beliefs, family influence, work environment, and economic status. While I do get patients whose symptoms are greatly affected by their beliefs, those patients are few and far between.

Today, I evaluated a patient with a long history of pain. Let’s name her Jane. She’s had neck, shoulder, and back pain since she was in a car accident 8 years ago. She’s had prior treatment from a physical therapist, which she thought was somewhat helpful (although she stopped going to her physical therapy sessions after her 4^th visit).

During my subjective interview, she reported right neck, shoulder, arm, hand, buttock, leg, and foot pain. If I had her shade-in a body chart depicting her painful areas, half the chart would be blacked out. Oh yeah, did I mention that she was my last patient of the day? If the blacked out body chart didn’t give it away, several things clued me into the fact that this was not going to be a very straightforward evaluation:

1. Jane walked in without a limp, without difficulty getting out of the chair in the waiting room, and without any grimacing when moving around or sitting to talk to me, yet she described her resting symptoms as 9 out of 10 on the visual analog scale.
2. She reported all of her symptoms as numbness, tingling, and burning.
3. When asked what movements worsen her symptoms, she replied “Everything.”

I wouldn’t say that Jane’s diagnosis is chronic regional pain syndrome, or CRPS. However, I will say that her symptoms stem heavily from psychosocial factors. There were some other yellow flags I noticed. When asked about her occupation, she mentioned that she didn’t work and was on disability. When asked about the man accompanying her during her visit, she replied that he was her husband.

After her visit however, I noticed that she also saw her psychiatrist today, and the psychiatrist’s note mentioned that she works part time, is almost done with her bachelor’s degree, and is currently divorced. Clearly, there are discrepancies here.

One important yellow flag to note was that both my patient and her companion mentioned that they would like to get rid of her pain completely. Now, having a goal of wanting to be able to do an activity you love to do without pain – I get that. Wanting to golf without shoulder pain, wanting to cook without back pain, wanting to squat without hip pain – fine. But to specifically say “I want you to get rid of my pain completely” is a different story. To be so fixated on your pain to where it’s practically something you completely obsess over is something that needs to be addressed.

Given all of these yellow flags, should I have addressed the difference in expectations between her and me? That’s a really difficult question to answer. At the time, I chose not to. My concern was that if I were to even start to address this difference, Jane would immediately push back. And if she were to push back, any trust in me would be lost. 

But what if I did start to address it today? What if I opened up the pain neuroscience conversation? What if I briefly mentioned that pain is multifactorial and life stressors can affect the perception of pain? How would she have responded?

I’ll never know. For now, my plan is to ease into this conversation over the next few visits. My immediate goal is to get my patient to understand the meaning of exercise to improve her symptoms. During the visit, I called out her emotions: “It sounds like you’re really frustrated about how long you’ve been dealing with your pain.” I found a platform on which both Jane and I can agree on: “I’m here to help you find ways to address your symptoms.”

Most of all, I actively listened to Jane’s story, to her beliefs (whether or not I agree with them), and I showed that I cared about her.

More on this patient in a future blog.

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