- Email: [email protected]
Tender points
Patient Education and Counseling 93 (2013) 357–358
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective practice
Tender points§ Adam Gilden Tsai * Department of Community Health Services, Denver Health and Hospital Authority, Denver, USA
A R T I C L E I N F O
Article history: Received 26 December 2012 Received in revised form 17 May 2013 Accepted 7 June 2013
I met Paloma in 2009, about 6 months after starting as a primary care physician at the city hospital in Denver, Colorado. Her presentation was confusing to me at first. She noted pain and numbness in her hands, headaches, occasional dizziness, even falls. She was in her early 50s and seemingly healthy, having recently supervised over 30 employees in a restaurant job. Her physical exam, hand X-rays, routine blood tests, and special tests for autoimmune diseases all were unremarkable. We tried migraine medications for her headaches, but it helped only slightly. After several visits, it occurred to me that she probably had fibromyalgia, a condition involving diffuse pain and tender points in the muscles, and increased pain perception, but with no objective physical abnormalities. Most patients with fibromyalgia have a history of being abused, and most suffer from depression. When I gave Paloma some patient education information about fibromyalgia, we both knew it was the correct diagnosis. Once we had the diagnosis, I learned more about Paloma. She told me that her stepfather had abused her sexually as a child and that her sisters blamed her for this, even as an adult (‘‘you slept with him’’ is what one of her sisters said to her). When I reflect back on that statement, I realize that it was difficult for me to relate to her. I simply couldn’t imagine how a sibling could say that to her. Paloma and I slogged through for a long time after the diagnosis. She felt better having a diagnosis but she couldn’t understand why she felt so much pain. Her perception of pain increased her anxiety level. I struggled to help her understand the connections of mental health and fibromyalgia. I tried to keep her from overusing medication, specifically the narcotic pain medication hydrocodone, which she had been taking when she became my patient. The
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Correspondence address: Anschutz Health and Wellness Building, University of Colorado, 12348 E. Montview Avenue, Room 4108, Aurora, CO 80045, USA. Tel.: +1 303 724 9053. E-mail addresses: [email protected], [email protected]
0738-3991/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2013.06.002
issue of narcotic pain medications is a particularly touchy one in our city hospital, and there is always a tension between appropriately treating pain and concerns about medication misuse or even abuse. I realize now that her requests for pain medication slowed the development of trust between us. I prescribed her two other medications, gabapentin and venlafaxine, which are similar to drugs approved by the FDA to treat fibromyalgia. At every visit, I talked to her about the need for intensive psychotherapy to deal with her past trauma and her current problems with pain and depression. She looked for counseling, but it was difficult for her to get, because she was technically uninsured under the Colorado Indigent Care Program (CICP). In the patchwork of the U.S. health care system, CICP is a state discount program for individuals who do not qualify for other medical assistance. However, CICP does not provide coverage for mental health services. Because she and her husband were not working, they did not have the money to pay out of pocket for counseling, even at one of the locations that offered sliding scale fees. I thought that Paloma was not trying hard enough to find counseling, which I attributed to her depression, but I also knew that it had to be difficult for her to find counseling. I struggled internally with what to do, especially when it seemed like what she wanted was more pain medication. I didn’t feel it was my job to be her counselor. At every visit, Paloma would ask me to do something to treat her pain. And I would say the same thing, that we were maxed out on meds, and that she needed counseling and to get regular exercise and better sleep. I prescribed her a sleeping medication. When a psychologist started work at our clinic, I asked her to see Paloma. However, the psychologist’s job was grant-funded and her role was not long-term counseling, it was short-term diagnosis/treatment and referral. Our psychologist saw her twice, agreed with my assessment, and recommended that she seek counseling at a place called RAAP (Rape Assistance and Awareness Program). Paloma called there but was told that they had a wait list of at least several months. It felt like we were back to square one. Paloma and I were not making progress. When I saw her name on my schedule, I knew each visit would be a difficult one, and I felt what a colleague once referred to as ‘‘heartsink.’’ At each visit, she looked sadly at me, as if to suggest that there was something else I should do to help her. When she looked at me that way, I felt somewhat inadequate as a clinician, although I kept telling myself that it wasn’t my fault, and that if we had more behavioral health support, I could do more for her. Certainly, Paloma’s depressed mood transferred somewhat to me, just as it does with other ‘‘difficult’’ patients. Paloma consulted with a different primary care physician, but he told her that he did not prescribe narcotic pain
358
A.G. Tsai / Patient Education and Counseling 93 (2013) 357–358
medications for patients with fibromyalgia, and she was back in my office. And so, one day, I decided to try something different. I remembered reading that frequent visits for patients with fibromyalgia can be helpful for re-assurance and support. I knew I was not a trained psychologist and that I could not provide psychotherapy for her underlying trauma. But I had experience as a primary care doctor in treating depression, and I also had experience doing behavioral treatment of obesity. I felt that if I could start by addressing some of her lifestyle habits (sleep, exercise, self-monitoring of thoughts and behaviors), I might at least be able to achieve better control of her pain symptoms. My schedule allowed me to see her about once a month for a 20-min follow-up visit. I knew that 20 min a month was not a lot, but I also figured it could only help her and was unlikely to make her worse. So, Paloma and I started seeing each other every month. At first our visits would be taken up by her physical complaints. As time went on, we were able to talk more about sleep, about exercise, about journaling her thoughts and feelings, and about her relationships with her family. Changing the direction of the conversation was at first difficult for me, because it felt like ignoring her physical symptoms [isn’t that my job as an internist?], but with each successive visit we were able to do it more easily, and I knew that changing direction was necessary in order to better understand what was going on with her. I learned that her sisters’ behavior toward her was so hurtful that she had stopped talking to them. We talked about her fear of being assaulted physically, her sensitivity to any physical contact, and that her former assaulter still lived in the area. She told me that she feared her husband might leave her, even though he had never suggested to her that he would. She began to recognize that her pain correlated with how she felt mentally. I wasn’t providing professional mental health care, but I was providing structured care with a specific purpose, and it started to make an impact. Paloma began to feel somewhat better. She weaned herself down to lower doses of some of her medications. Most importantly, she understood how important it was for her to find a dedicated counselor, and she started to call the RAAP more frequently. After about 10 months of our monthly visits, one day she told me that she had an intake appointment at the RAAP. Paloma still has a long way to go. She will require an extended course of therapy to heal from her past trauma. She still feels a lot
of pain, and she still takes narcotic pain medications every day, along with her other medications. She is receiving disability income because she has too much pain and too little concentration to hold a job. She has missed some appointments at the RAAP, and she tells me that it is difficult for her to establish trust with new health care providers. In fact, it seems that she thinks of me as her physician and her mental health provider, all in one. We are still seeing each other every month. But, she is very different when she comes to see me now. Instead of asking me why I’m not able to relieve her pain, she tells me about what she is doing for herself (reading, exercising, spending time with her husband and with her stepson’s children). Before, she was doctor shopping, but now she says now that she would never give up ‘‘her Dr. Tsai’’, and she always wants to spend a few extra minutes with me. Her affect is brighter – she smiles, laughs, and she’s lost some weight (a goal she’s had for several years). Now I smile too when I see her, and I give her a hug. I realize now that what she needed was someone to listen to her and to care, not someone to prescribe her more pain medication. When I see her name on my schedule, I no longer feel a ‘‘heaviness’’ – I actually look forward to our visits. Like many of my colleagues, I’m still working on my skills in treating chronic pain and in integrating physical and mental health. But I’ve learned a lot from working with Paloma. I’ve realized how big an impact I can make as a primary care physician. I’ve realized the value of my time and energy, even if it’s just 20 min every month, and I’ve taken the same approach (monthly visits) with other complicated patients. Most importantly, I’m learning the value of trust and relationships, and how long they can take to develop. These lessons have been ‘‘tender points’’ in my development and maturation as a clinician. Acknowledgements The author thanks Dr. K.C. Lomonaco, Dr. Jean Tsai, and especially Dr. Rachel Swigris for their comments and suggestions on this article. ‘‘I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.’’ ‘‘I confirm that the patient/person(s) have read this manuscript and given their permission for it to be published in PEC.’’
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Reflective practice
Tender points§ Adam Gilden Tsai * Department of Community Health Services, Denver Health and Hospital Authority, Denver, USA
A R T I C L E I N F O
Article history: Received 26 December 2012 Received in revised form 17 May 2013 Accepted 7 June 2013
I met Paloma in 2009, about 6 months after starting as a primary care physician at the city hospital in Denver, Colorado. Her presentation was confusing to me at first. She noted pain and numbness in her hands, headaches, occasional dizziness, even falls. She was in her early 50s and seemingly healthy, having recently supervised over 30 employees in a restaurant job. Her physical exam, hand X-rays, routine blood tests, and special tests for autoimmune diseases all were unremarkable. We tried migraine medications for her headaches, but it helped only slightly. After several visits, it occurred to me that she probably had fibromyalgia, a condition involving diffuse pain and tender points in the muscles, and increased pain perception, but with no objective physical abnormalities. Most patients with fibromyalgia have a history of being abused, and most suffer from depression. When I gave Paloma some patient education information about fibromyalgia, we both knew it was the correct diagnosis. Once we had the diagnosis, I learned more about Paloma. She told me that her stepfather had abused her sexually as a child and that her sisters blamed her for this, even as an adult (‘‘you slept with him’’ is what one of her sisters said to her). When I reflect back on that statement, I realize that it was difficult for me to relate to her. I simply couldn’t imagine how a sibling could say that to her. Paloma and I slogged through for a long time after the diagnosis. She felt better having a diagnosis but she couldn’t understand why she felt so much pain. Her perception of pain increased her anxiety level. I struggled to help her understand the connections of mental health and fibromyalgia. I tried to keep her from overusing medication, specifically the narcotic pain medication hydrocodone, which she had been taking when she became my patient. The
§ For more information on the Reflective Practice section please see: Hatem D, Rider EA. Sharing stories: narrative medicine in an evidence-based world. Patient Education and Counseling 2004;54:251–253. * Correspondence address: Anschutz Health and Wellness Building, University of Colorado, 12348 E. Montview Avenue, Room 4108, Aurora, CO 80045, USA. Tel.: +1 303 724 9053. E-mail addresses: [email protected], [email protected]
0738-3991/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.pec.2013.06.002
issue of narcotic pain medications is a particularly touchy one in our city hospital, and there is always a tension between appropriately treating pain and concerns about medication misuse or even abuse. I realize now that her requests for pain medication slowed the development of trust between us. I prescribed her two other medications, gabapentin and venlafaxine, which are similar to drugs approved by the FDA to treat fibromyalgia. At every visit, I talked to her about the need for intensive psychotherapy to deal with her past trauma and her current problems with pain and depression. She looked for counseling, but it was difficult for her to get, because she was technically uninsured under the Colorado Indigent Care Program (CICP). In the patchwork of the U.S. health care system, CICP is a state discount program for individuals who do not qualify for other medical assistance. However, CICP does not provide coverage for mental health services. Because she and her husband were not working, they did not have the money to pay out of pocket for counseling, even at one of the locations that offered sliding scale fees. I thought that Paloma was not trying hard enough to find counseling, which I attributed to her depression, but I also knew that it had to be difficult for her to find counseling. I struggled internally with what to do, especially when it seemed like what she wanted was more pain medication. I didn’t feel it was my job to be her counselor. At every visit, Paloma would ask me to do something to treat her pain. And I would say the same thing, that we were maxed out on meds, and that she needed counseling and to get regular exercise and better sleep. I prescribed her a sleeping medication. When a psychologist started work at our clinic, I asked her to see Paloma. However, the psychologist’s job was grant-funded and her role was not long-term counseling, it was short-term diagnosis/treatment and referral. Our psychologist saw her twice, agreed with my assessment, and recommended that she seek counseling at a place called RAAP (Rape Assistance and Awareness Program). Paloma called there but was told that they had a wait list of at least several months. It felt like we were back to square one. Paloma and I were not making progress. When I saw her name on my schedule, I knew each visit would be a difficult one, and I felt what a colleague once referred to as ‘‘heartsink.’’ At each visit, she looked sadly at me, as if to suggest that there was something else I should do to help her. When she looked at me that way, I felt somewhat inadequate as a clinician, although I kept telling myself that it wasn’t my fault, and that if we had more behavioral health support, I could do more for her. Certainly, Paloma’s depressed mood transferred somewhat to me, just as it does with other ‘‘difficult’’ patients. Paloma consulted with a different primary care physician, but he told her that he did not prescribe narcotic pain
358
A.G. Tsai / Patient Education and Counseling 93 (2013) 357–358
medications for patients with fibromyalgia, and she was back in my office. And so, one day, I decided to try something different. I remembered reading that frequent visits for patients with fibromyalgia can be helpful for re-assurance and support. I knew I was not a trained psychologist and that I could not provide psychotherapy for her underlying trauma. But I had experience as a primary care doctor in treating depression, and I also had experience doing behavioral treatment of obesity. I felt that if I could start by addressing some of her lifestyle habits (sleep, exercise, self-monitoring of thoughts and behaviors), I might at least be able to achieve better control of her pain symptoms. My schedule allowed me to see her about once a month for a 20-min follow-up visit. I knew that 20 min a month was not a lot, but I also figured it could only help her and was unlikely to make her worse. So, Paloma and I started seeing each other every month. At first our visits would be taken up by her physical complaints. As time went on, we were able to talk more about sleep, about exercise, about journaling her thoughts and feelings, and about her relationships with her family. Changing the direction of the conversation was at first difficult for me, because it felt like ignoring her physical symptoms [isn’t that my job as an internist?], but with each successive visit we were able to do it more easily, and I knew that changing direction was necessary in order to better understand what was going on with her. I learned that her sisters’ behavior toward her was so hurtful that she had stopped talking to them. We talked about her fear of being assaulted physically, her sensitivity to any physical contact, and that her former assaulter still lived in the area. She told me that she feared her husband might leave her, even though he had never suggested to her that he would. She began to recognize that her pain correlated with how she felt mentally. I wasn’t providing professional mental health care, but I was providing structured care with a specific purpose, and it started to make an impact. Paloma began to feel somewhat better. She weaned herself down to lower doses of some of her medications. Most importantly, she understood how important it was for her to find a dedicated counselor, and she started to call the RAAP more frequently. After about 10 months of our monthly visits, one day she told me that she had an intake appointment at the RAAP. Paloma still has a long way to go. She will require an extended course of therapy to heal from her past trauma. She still feels a lot
of pain, and she still takes narcotic pain medications every day, along with her other medications. She is receiving disability income because she has too much pain and too little concentration to hold a job. She has missed some appointments at the RAAP, and she tells me that it is difficult for her to establish trust with new health care providers. In fact, it seems that she thinks of me as her physician and her mental health provider, all in one. We are still seeing each other every month. But, she is very different when she comes to see me now. Instead of asking me why I’m not able to relieve her pain, she tells me about what she is doing for herself (reading, exercising, spending time with her husband and with her stepson’s children). Before, she was doctor shopping, but now she says now that she would never give up ‘‘her Dr. Tsai’’, and she always wants to spend a few extra minutes with me. Her affect is brighter – she smiles, laughs, and she’s lost some weight (a goal she’s had for several years). Now I smile too when I see her, and I give her a hug. I realize now that what she needed was someone to listen to her and to care, not someone to prescribe her more pain medication. When I see her name on my schedule, I no longer feel a ‘‘heaviness’’ – I actually look forward to our visits. Like many of my colleagues, I’m still working on my skills in treating chronic pain and in integrating physical and mental health. But I’ve learned a lot from working with Paloma. I’ve realized how big an impact I can make as a primary care physician. I’ve realized the value of my time and energy, even if it’s just 20 min every month, and I’ve taken the same approach (monthly visits) with other complicated patients. Most importantly, I’m learning the value of trust and relationships, and how long they can take to develop. These lessons have been ‘‘tender points’’ in my development and maturation as a clinician. Acknowledgements The author thanks Dr. K.C. Lomonaco, Dr. Jean Tsai, and especially Dr. Rachel Swigris for their comments and suggestions on this article. ‘‘I confirm all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.’’ ‘‘I confirm that the patient/person(s) have read this manuscript and given their permission for it to be published in PEC.’’