- 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. (light electronic music) 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. (light electronic music)
