If I had a dollar for every time I heard a patient say “the doctor said I’m bone on bone” I could’ve paid off my student loan debt by now. You probably could have too. These types of patients are usually not our favorite. They typically carry a sense of hopelessness about their rehab potential and often never seem to “buy-in” to the rehab process. So they’re not exactly favorite-patient material.
As much as we’d like to blame it on the patient’s attitude, it’s usually not their fault they’re like this. Sadly, many physicians (PT’s included!) don’t realize how much our words matter when it comes to patients’ perceptions of pain and diagnoses. However, we can prevent (or even undo) some of the misperceptions planted by other people through safe patient language. Is it frustrating? 100%. Absolutely. But is it sometimes necessary if you really wanna get anywhere with a patient? Absolutely.
What is Safe Patient Language?
Safe patient language is a vague term that means a lot of things. It refers to physicians talking to patients in a way that makes the patient feel respected, helps them understand their treatment plan, and encourages them to take an active role in their care. Safe patient language also includes avoiding jargon, using visual aids to help with understanding, using active listening, and encouraging questions. There’s a lot that goes into it.
This blog post focuses on using our words to reduce catastrophization and is only a small part of what falls under safe patient language. Trying to talk about all of safe patient language would result in a blog post that might as well have been a book. I chose to focus on reducing catastrophization because we deal with it A LOT – perhaps more than many other healthcare providers. Castrophization can also be a huge road block to patient progress. Being intentional and mindful of our word choice to reduce fear and anxiety can improve a patient’s receptiveness to their treatment plan and encourage active participation in their rehab.
Key Components
There is a bit of a strategy to using language to reduce patient catastrophization of pain. If you want to get good at this, there are a few components you’re going to need to be aware of and master.
The first is Active Listening. In PT this means paying extra attention to how patients describe their pain, including anxiety and fear. It also means showing patients they’re truly being heard. You can do this by asking relevant follow up questions at appropriate times, making good eye contact (but don’t make it creepy), and avoiding distractions (put the computer down!).
Another technique I like is summarization. This is when you repeat back the information in summarized form to the patient. I don’t go wild with it. I don’t go into a whole awkward monologue of “Okay so in summary what I heard is ….” To still be efficient with my time I will summarize what I heard and ask a relevant question at the same time. For example I’ll say: “So when you have pain in your ____ when you do ____ and it’s feeling really bad after, what seems to help the pain?” A statement like this summarizes but still keeps us on track and gets me the information I need.
The next key component is Validating Experiences. This is where we as the healthcare provider take a moment to acknowledge the impact the patient’s pain has on their lives – physically, emotionally, or mentally. I think this is one we either don’t do at all or we actually try to do the exact opposite. With the best intentions we will attempt to minimize the patient’s experience. We’re not doing this out of spite. We’re trying to make their outlook less grim, provide some hope, and decrease their fear and anxiety about the situation. Again the best of intentions!
However, oftentimes this ends up backfiring. The patient takes it as the physician being dismissive or like we’re trying to imply they’re being dramatic. Not a great way to start a physician-patient rapport. The fact is, everyone likes it when someone agrees with them! Instead of minimizing, validate. A statement like “That would be really difficult feeling limited every day by your back pain.” Or “It would be really frustrating not to be able to train like you want.” can go a long way. The patient feels heard and understood and THAT’S how you build rapport.
I think this next component is another one we skip a lot, but can be really useful. We can use Framing to help return a sense of hope and control to the patient. A lot of patient’s fear and anxiety come from lack of hope (think the patient that says “I feel like it’s always going to be like this”) and/or the fact that they don’t really feel in control of their own body anymore.
Now let me be very clear – NEVER lie to a patient about their prognosis and never make a promise you can’t keep. However, if you think someone’s prognosis is pretty good, tell them! I’ll often say something like “based on what I’m seeing, I definitely think your prognosis is good with PT.” A lot of times people just want to know there’s at least a chance they’re going to be okay. Hearing their healthcare provider say so can really increase their hope.
With framing we also shift focus to what the patient can control versus can’t. Remember we’re not minimizing or ignoring the parts they can’t control and how it affects them. But it’s always easier to remember the bad than the good, right? We’re gonna remind them of the good. Shift their focus on how they can positively affect their pain through their HEP, pacing their activity, or using pain relief methods. Remind them of all the things they CAN control about their situation. This increases the patients self efficacy and encourages them to take an active role in their care.
The more patients understand pain and pathology, the less scary it seems. By Educating Patients on Pain Mechanisms we can decrease pain catastrophizing. At this point, I’m sure we’ve all heard of pain education like gate-control theory or pain doesn’t always equal pathology. That’s a whole other blog post, but that’s partly what we’re talking about here. I’ve found chronic pain education to be super helpful in my practice. If you don’t know much about it I recommend looking at some classes from Evidence in Motion.
Pain mechanism education also includes explaining anatomical pathology. Remember, you can use models, videos, metaphors, etc to help explain this to patients. Try not to use overly complicated medical jargon. If you have to use anatomical terms make sure to explain them.
One piece of pain education I’ve really found helpful is explaining imaging. People sometimes catastrophize when they hear scary words like arthritis, tear (even if small!), tendinosis, or degenerative changes. Many times these terms are thrown at them and not explained. It’s also not frequently mentioned that imaging is not proportional to pain level or fully explains pathology. I cannot tell you how many times I’ve had patients who focus on the fact their imaging said they had OA, even though their pain is clearly more muscular in origin. I’ve frequently noticed mindset shifts with patients once I do some pain mechanism education. They’re much more open and optimistic to their plan of care.
The last component is Collaborative Goal Setting where you and the patient work together to set real and achievable goals for the patient. I’ve said it in other blog posts, I’m about to say it again – the goals MUST be important to the patient. This is where I use our patient intake forms to help me out.
On the intake forms at our clinic we have a question: “What do you want to be able to do after therapy?”. I use their answer to that question to get the ball rolling. If it hasn’t come up already I’ll say “I see you wrote on your paperwork you want to be able to ____ after PT correct? Any other goals for PT or anything else I missed?” The patient can then confirm or give more information if they need to. From there I give them a quick run-down of what the path to those goals may look like from a rehab perspective. Somewhere in that conversation we get at least 1-2 of those personalized goals for the patient.
You won’t have to use every single one of these components with every patient. Learning how to use even just one or two in any situation though can make a big difference in your patients’ attitudes and beliefs about their PT, affecting their outcomes for the better.
Real Life PT Examples of Using Language to De-Castastrophize
Let’s look at a few common examples of how we may use this in practice
Situation 1: Patient with OA comes to PT for conservative treatment. This is one of the first things out of their mouth: “The doctor says I’m bone on bone.”
Possible PT Response: It can feel really scary to hear that you have OA (Validating). However, imaging doesn’t always equal pain. Statistics show you could xray everyone in this room and you would probably find everyone has OA somewhere, but not necessarily where they have pain (Pain Education). If your pain is coming from the OA, there are still things we can do. You’re right in that we can’t reverse OA, but we can do something about it. Through your HEP we can strengthen the muscles around the joint and in nearby areas to help support it to become less painful. I will also teach you pain relieving techniques and modifications that should help. Many people live with well-managed OA for a long time before needing more invasive treatments (Framing).
Situation 2: The chronic pain patient who feels helpless about their situation. Feels like they’ll never be able to live how they want.
Possible PT Response: It would be super frustrating not to be able to do all the things you want, like going hiking with your family and taking the dog for a walk. That takes not only a physical, but a mental and emotional toll (Active Listening and Validating). However, I can tell you’re super motivated and I do think we can get you to a place where you don’t have so much pain and can tolerate more activity (Framing). First we need to get you tolerating shorter distances, maybe that you can do with the dog and then we can work into longer ones like hiking with the family. How does that sound? (Collaborative Goal setting)
Situation 3: Patient who didn’t respond to conservative treatment for their knee OA and now getting surgery… but they are NOT excited about it.
Possible PT Response: Surgery is definitely scary. There’s always a certain level of risk and fear. While knee replacement is a fairly routine surgery, it’s not necessarily minor either. A lot of people confuse the two. So I understand your anxiety about it (validating). Surgery and the rehab after is a lot of work but, in my experience most patients are happy they did it because their quality of life is so much better afterwards. They’re able to do so much more than before surgery (Framing). If you’d like, we can keep working together to make you as ready for surgery as possible. Is there anything you feel like you need to get better at or work on between now and surgery that would make you feel better about it? (Collaborative Goal Setting)
What do you think of these examples? Anything you’d say differently? What other common examples can you think of and how would you use the components to address them?
Using language to help patients stop catastrophizing their pain certainly helps them, but it also helps us. Catastrophizing acts as a huge barrier to communicating with our patient. We often become frustrated because we’re yelling over one side of the barrier about things related to the patient’s rehab. However, the patient isn’t able to hear us because they’re on the other side with their fears and anxieties. Which are all very valid. As the healthcare provider it is our job to try to take down the barrier so the patient can join us in moving forward through their plan of care.
Hope you found something helpful in this blog post that you’ll try with your patients. If something stuck out to you what was it? I’d love to know. If you want to catch up on past blog posts head over to the blog page. Lastly, subscribe below and follow on Instagram @the_pt_page to stay up to date on all things PT.
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