I recently had the opportunity to interview Beth Darnall, PhD — Assistant Professor at the Department of Anesthesiology & Perioperative Medicine at Oregon Health & Science University, about how to optimize the patient-doctor rleationship, for effective treatment of chronic pain:
Loolwa Khazzoom: What is the cultural backdrop of the practitioner-patient relationship?
Beth Darnall, PhD: The patient-provider relationship is dynamic. It depends on the expectations and resources both people bring to the table. For instance, a patient may be passive about their medical care and be cure-focused. A provider may enable this attitude by over-focusing on pain medication and doing little to encourage and connect the patient with resources that would promote active rehabilitation.
Historically, the culture has promoted the view of doctors as being authority figures and the people who “fix” health problems. With chronic pain, reclaiming quality of life involves a large focus on modifying lifestyle choices, focusing on activity, stress management, and the like. Rarely is there an external “cure” and it is unrealistic for patients to expect one—it sets them up to experience a sense of failure.
If as providers we can steer patients in the direction of learning to acquire skills and tools that allow them to help themselves, we can do a great service. Medication may be one part of the equation, but it is just that—one part. It’s not a cure-all.
LK: How might various physical and symbolic factors play into the practitioner-patient dynamic?
BD: The power dynamic can be formidable. Add into the equation gender roles: Women patients may struggle to be assertive with male authority figures and thus be less likely to advocate for themselves. On the flip side, some research has shown that physicians of both genders may be less likely to take women’s symptoms seriously and thus their medical treatment may be compromised. Male and female providers alike bear a responsibility to be aware of their own biases.
Some of the physical and symbolic factors that influence the practitioner/patient dynamic (e.g., the white coat) may be necessary in a medical setting for various reasons. Professional providers are often more formally dressed than the patient, and professional dress is appropriate in this context. Regardless of the dress, a medical provider may convey compassion, warmth, intent listening, and a desire to help the patient. These are the most important qualities to bring to the provider-patient dynamic.
LK: What do you see as the difference in dynamics between being an occasional patient and a patient with a chronic health condition, like chronic pain?
BD: Chronic pain is often stigmatized, and it presents several unique challenges. For instance, opioid medications may lead to tolerance, dependence, and hyperalgesia (heightened pain). While these are medical consequences from prescribed medication, they are also the same consequences one experiences as a result of medication misuse. The iatrogenic effects from opioids may be difficult for the provider to tease apart from misuse behaviors, and this can lead to strained patient-provider relations.
LK: What is the potential consequence of being labeled a “difficult patient”?
BD: Certainly, some people are unwilling to follow recommendations and may over-rely on medication to treat their pain. This person may be viewed as difficult because they are not participating in their care. However, some people may try many things in an effort to help themselves and are simply not successful in gaining relief. The provider must remain clear that lack of success with treatment does not necessarily mean “difficult.”
Certainly, the patient may present a difficult medical case, but that needs to be distinguished from being a “difficult patient.” It’s natural for providers to feel helpless at times, given that none of the options may be working. It’s important for the provider to recognize their own emotional experience of frustration or helplessness and avoid projecting that onto the patient. Again, as providers, we bear a huge responsibility to be aware of—and take responsibility for—our own emotional experience.
LK: What do feel healthcare practitioners need to do, to facilitate an environment of safety, invitation, and partnership?
BD: Providers need to be willing to take time to listen to the patient and ensure that the patient feels well-received and -validated. Our nonverbal communication plays a large role in the dynamic. Providers should make eye contact throughout the initial meeting. Give patients enough time to complete their thought. Ask if there is anything else they would like to add. If providers are obviously hurried in their approach to the patient, the patient will not feel at ease and will be less likely to communicate effectively.
LK: What tips do you have for a patient, in terms of communicating and asserting their needs?
BD: Be clear on how much time you will have with your doctor. Ask for an extended visit if possible, so that both you and your provider will not be rushed.
In advance of your appointment, write down everything you want to address with your provider. Come to the appointment with your list in hand, and let your doctor/provider know that you have the list. Since you already know how much time you will have, prioritize which points are the most important to address that day.
Keep in mind that it is essential for you to feel comfortable with your doctor or provider. If you do not believe your provider is a good fit for you, look for another one. Ask for recommendations from other providers you may be seeing or from other patients who have a similar medical condition.
LK: What advice do you have in terms of determining whether a practitioner is safe or whether it is time to find a new one?
BD: I won’t speak to the safety issue here. I will say that a patient is entitled to feel respected at all times. If you do not feel respected by your doctor or provider, please consider seeking a new provider.
LK: What are some steps a chronic pain patient can take, to maximize emotional and physical safety, as well as practitioner receptivity, when s/he may need to bounce around from specialist to specialist?
BD: If the issue is bouncing from medical specialist to specialist, consider working with a pain psychologist to help establish continuity, to help problem-solve the issues at hand, to understand whether the role you (as the patient) be playing in the dynamic, and to develop skills that will help minimize reliance on medical providers for pain management.