Plenary 4 egener forging a relationship with the patient
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This document discusses forging relationships with chronic pain patients and addresses transference and countertransference in the doctor-patient relationship. It provides guidance on understanding a patient's perspective and how their past experiences and illness can influence their relationship with their doctor. The document also cautions doctors to be aware of their own preconceptions and stresses the importance of empathy, positive regard, and self-exploration to help patients cope with chronic pain.
Plenary 4 egener forging a relationship with the patient
- 1. Forging Relationships with Chronic Pain Patients Barry Egener, MD
- 3. Transference: the set of expectations, beliefs, and emotional responses that a patient brings to the doctor-patient relationship based, at least in part, on the persistent experiences a patient has had with other important authority figures throughout his life
- 4. Transferential Responses to Illness Perception: • Lowered self image anxiety • Threat to homeostasis denial • Failure of self-care depression, blaming • Sense of loss of control regression, isolation, dependency, anger
- 5. To understand the transference perceptions ask: 1. How has your illness affected the way you feel about yourself? 2. Do you ever blame yourself for your condition? 3. Do you ever feel like you are losing control? 4. Are you ever afraid that you will fall completely apart?
- 6. Counter transference: the set of expectations, beliefs, and emotional responses that a doctor brings to the doctor-patient relationship………….. Physicians often have unconscious or unspoken beliefs about the patient A “Good” Patient: • Severity of symptoms correlates with an overtly diagnosable biological disorder • Compliant and does not challenge treatment • Emotionally controlled • Grateful
- 7. How Might These 3 Patients Present? • 86 yo man with COPD, end-stage cardiomyopathy, ischemic foot ulcer • 51 yo woman chronic low back pain, domestic violence victim, fibromyalgia • 33 yo addict with “complex regional pain syndrome” after an injury to the brachial plexus after a fall from a ladder
- 8. NW Center – Egener Physiologic Social Psychologic PAIN
- 10. Boundaries Beware the Monkey! Whose pain is it? I didn’t cause the pain; I’m not responsible for the pain; I can’t “fix” the pain The patient’s anger (distress) is about him/her There is no reason to get angry at the patient. Beware Working Harder then the Patient You may be meeting your needs, not the patient’s!
- 11. So What If Not Opioids? • Use Yourself! – Empathy – Unconditional Positive Regard – Genuineness • Guide a self-exploration: – How do you assess where you are right now? – What is important and meaningful in your life? – What small step are you willing to commit to to get there? – What help do you need? • Assist with coping
Editor's Notes
- In this session, I’d like to reflect with you on the interpersonal aspects of working with chronic pain patients, to take a kind of humanistic perspective on what it’s like to be in relation to a group of patients who face us with some of our most challenging interactions.Here’s how I got here. As an internist, I generallydon’t cure disease. I manage chronic illness. I’ve come to believe that relationship is half of what makes me a healer. It’s what creates the leverage for behavior change. So I’d like to talk about forging that relationship
- Agony 1912, Man and monk.Although this 1912 painting by Egon Schiele is called Agony, I don’t use it to refer to chronic pain. Schiele believed that artists, like priests or monks, are spiritually enlightened beings whose mission it is to share a vision. Schiele also believed that artists, like saints, must suffer for their beliefs, a nineteenth century German Romantic notion. In other paintings Schiele cast himself as the acolyte and Gustav Klimt as the master, although this painting is a more generalized interpretation of the subject. Consider that this might represent a doctor-patient relationship, the patient suffering from illness, benefitting from the ministrations of the healer. Red/GreenNote this similarities: the faces are identical. At the core, these are both human beings, but they come to the relationship with different histories, different roles, which profoundly affect their interaction Similarly, each comes to the doctor-patient encounter with his own baggage. What each brings to the relationship has profound implications for how it plays out. Transference. Countertransference. Although I’m going to use these terms that you may not have thought about since your psychiatry rotation decades ago, the dynamics I’m going to talk about are present in every interaction with a patient that you have – this is not about being a psychiatrist. But these dynamics are particularly important in working with chronic pain patients. I’m going to show a video. Don’t think about what the diagnosis of the patient is; not what diagnostic or therapeutic tools the physician, who is off screen, might bring to bear. Imagine instead, what stuff the patient brings to the relationship, how she describes her life, and imagine what she might be feeling as she relates it to you. Also notice what response she might elicit in you, if you were sitting on the other side of the desk. ApologizeThen ask audience what she elicits
- Let me suggest that it is not your job to uncover this part, the part in yellow. You can if you want and have the skills, but I don’t think it’s critical to making the interaction work. On the other hand, the result of this history, what’s in white, is critical to understand. Because that’s the stuff, in the here and now of the interview, that affects how the interaction works out. But that’s not usually the subject line of the interview, is it? The subject of the interview tends to be about pain, medications, etc.
- How does this transference appear in the interview?Again, what you see is anxiety, denial, depression, anger – indirect reflections of low self-image, fear, loss of control.So how might you bring the elements that are critical to address into the interview, if you’re not a psychaitrist?
- Credit to Mick Oreskovich, a psychiatrist (and surgeon) and longstanding faculty of this course, for sharing these 4 questions and much of the material for this presentation, with me.
- Each of these patients comes in with the same complaint: “My pain is uncontrolled. You’re not helping me, doc.”
- You may have noticed that some of your patients, those who are more straightforward, respond as expected to opioids. Others, many of whom have more “complicated” lives, do not. How can we predict who will respond as we would hope, thus simplifying our lives and improving the odds of a therapeutic prescription? To me prescribing opioids chronically is all about patient selection. Pain is an expression of distress. While distress may have many sources, not all patients have the vocabulary, indeed the insight, to identify the source of their distress to their physician, whom they nevertheless expect to afford them relief. Just as patients may have limited vocabulary and insight, we have limited tools. So if I’m a surgeon, I try to find something I can cut out. If I’m a primary care doctor, I prescribe opioids. So for me as well as the patient, there is a temptation, if I feel impotent to change the sources of distress, to palliate those symptoms. Benzo’s for bottom two points. The problem is that medications don’t work well for these two. It’s important to recognize a) the nature and source of the patient’s distress, b) when medications will help, and c) where you’re limitations are. You help the patient get relief when you take a holistic perspective and help him take responsibility for the parts that only he can fix. When we prescribe opioids for conditions that they cannot help, the risks exceed potential benefits, but perhaps more pernicious is the fact that we deprive patients of the opportunity to find better ways to improve their lives
- Note the attempt to contain the patient’s agony, to clarify the boundaries. An alternative shamanistic approach is the incubus
- Sometimes it’s hard to maintain compassion for the patient, when she may be upset with us for not not providing opioids that we believe is not in her best interest. When we are emotional because we feel unfairly accused when we’re doing our best. These visits, in which we find ourselves negotiating with patients are often the most emotionally charged of the day: emotionally charged for the patient, who wants something he doesn't have power to get without our permission, and emotionally charged for us, because the patient does not seem to understand, or to want to understand, the persuasiveness of our logic. In my role as healer I can palliate symptoms, I can use myself as a therapeutic agent, I can relieve distress by witnessing, by hearing her story, but most importantly, by helping the patient to solve her own problems. But as soon as I allow her to put the monkey on my back, which is what happens when she says, “Fix me, take my pain away” while I, the patient, remain passive, then I have conspired with the patient to prevent the real solution. I am talking about chronic complex pain, not acute post-operative pain. The most pernicious aspect of that conspiracy is that it prevents the patient from finding the real solution. What motivates the patient to solve these problems? PAIN. If I take the pain away, I take away the motivation for true recovery.
- In conclusion, I’ve presented a paradox:Healing requires making a connectionOveridentification can erode boundaries, tempting us to collude with the patient to palliate distress with medications that cannot reach the source of that distressThis could actual harm not help.Self-awareness is an import tool working with these patients.