This is a brief summary of a study published in the latest IJOM, on the important and in-vogue subject of how patients with low back pain interpret what we say, and in turn, how that affects them.
‘Talking a different language’: a qualitative study of chronic low back pain patients’ interpretation of the language used by student osteopaths (by Katie Collyer and Oliver Thomson IJOM Volume 24, June 2017, Pages 3–11)
Well, what a fantastic quote to kick off with by the versatile Rudyard Kipling
Words are, of course, the most powerful drug used by mankind
from, fittingly, his “Book of Words”. His assertion has proved to be entirely true with neuroimaging now able to show that pain-related words do directly affect your central nervous system. The trouble is, the same words mean different things to different people. We might think we are merely explaining findings; patients might interpret those findings as meaning their back is vulnerable and needs protection. That means they might do things they shouldn’t – like worry, get depressed and adopt strange postures – and avoid doing the exact things they need (e.g. use their body as normally as possible, be positive and get active).
In this study, nine patients were interviewed about the low back pain diagnosis they had been given by students at the BSO clinic in London. Aged 31 – 81, some of them had had LBP for decades. The main researcher Katie Collyer, analysed the data and looked at four things:
- the use of jargon
- the use of metaphor/analogy
- emotions that were evoked
- the general “care” that the patient felt
Anything that made the patient feel engaged and involved in their own self-care was viewed as a positive; anything switching the patient off and reducing their self-management was seen as a negative. Interestingly, the way I read, it the categories emerged as a result of the analysis, including the overarching theme of patient engagement, and was thus an emergent phenomenon, not one dreamt up at the start. This possibly has something to do with “Grounded Theory”, which I think is a kind of organic way of analysing this kind of data, and something which seems very fashionable – I have seen it pop up quite frequently lately.
The quotes from patients in this paper are so incredibly illuminating and descriptive, that it almost makes you feel like every patient you see should be debriefed after your consultation just to check that they haven’t got the wrong end of the stick and don’t need additional support to cope with what you’ve said to them. Here is the main substance of the results:-
The use of jargon
This seems to cut both ways. Sometimes it goes right over people’s heads, causing them to switch off (i.e. a disengaged, and therefore negative result):-
You just sort of switch off, you nod your head as if you pretend you understand but you don’t really
On the flip side, it can encourage patients to ask questions, and give patients confidence in the practitioner, because they feel that someone understands what is going on and is capable of dealing with it. The authors do note, though, that even for those who like it, it can reinforce that they have a biomechanical problem that the practitioner will fix (and I suppose this might be construed as a bad or wrong thing, especially if you have a biopsychosocial bent).
The use of metaphor
This can also cut both ways, depending on what your metaphor is, I suppose. Metaphors have the advantage of being easy to remember, and they seem especially useful in describing anatomy (“it’s a bit like a horse’s tail”). They are additionally appreciated if they contain the metaphorical treatment along with the metaphorical descriptor of the problem. One patient found this really helpful:-
My back was like a rusty door and every time you opened and closed it, it got a little bit looser until that door could open freely … that really explained the problems and the solutions
They can also be unhelpful. The oft-criticized jam-doughnut-disc-metaphor was used by a student osteopath here, and, confirming the beliefs of many manual therapist twitterati, it simply made the patient feel helpless as it seemed there was no treatment or solution to their problem. Some patients do absorb quite sophisticated pain science- type thinking:-
Your lower back has a sort of memory and is overreacting and so you are overcautious, unconsciously you focus on pain
Diagnoses can be either very scary or strongly reassuring. Here’s my favourite example of a negative reaction: listen to this, pure poetry from a patient in response to being told they had degeneration of the disc: –
It’s like you are getting old, 75 or 80 years old.
There is a part of your body that is twice as old as your real age so you are going to die like a tree which is completely cut from its fluid of life
Words like degeneration, scoliosis, osteoarthritis and spondylosis don’t always go down too well (“he said degeneration and I thought, right my back’s buggered”). However some of the students seemed to have the opposite effect:-
It’s the understanding and knowing that it’s not going to be a physical impairment that could potentially be going on for years and years
Sense of care
Patients liked the personal approach. A considered and individual diagnosis seems to instill confidence in patients and promote engagement in their own care:-
having that package put together for you like a bespoke package, let’s say of healthcare, it’s personal. So it really did kind of, it give me the confidence
Unsurprisingly patients were not happy when the osteopath was rushed or not communicating well. It’s not only the words we use, but our attitude towards the patient that makes a difference. Tutors come in for a bit of a hard time here, seeming dismissive and disrespectful and making patients feel ignored, and like a “third party”. There are at least two negative examples, which, considering it’s only out of a pool of nine, suggests that not only the students need to take note of this study.
I love this kind of paper, littered with quotes from real life patients – not only fascinating, but also quite useful in how to work in your clinic. The general tips I took away from it are:
- don’t be shy of displaying your knowledge and expertise – patients like to know that you know what you’re doing, but
- ensure that potentially frightening words are wrapped up in reassuring language
- don’t blind patients with science – it might just switch them off
- don’t describe discs as being like jam doughnuts – I’m sure there’s a good alternative out there which sounds a bit more hopeful – but do think of neutral or positive metaphors and analogies which help patients make sense of what’s going on
- ensure that your diagnosis is individual and tailor-made for your patient, and explain it well
Thanks for your time, I’m off to download Kipling’s Book of Words, only 94p on Kindle…..another blog to follow soon..