On not being an arse

Humans are judgemental beings. All of us are. It’s part of having a big brain and wanting to know who’s ‘in’ and who’s ‘out’. Judgements help us make decisions, they’re surprisingly resistant to change, and they can inadvertently trap us into doing things we would never countenance were we able to stand back from what our minds want us to know (and feel).

My post today is prompted by a couple of conversations recently. One was with a clinician, new to a pain team, who found that experienced members of that team thought actions taken by a person with pain were a sign of ‘catastrophising’ and ‘failing to accept’ and worse – ‘not engaging in the programme.’ He’d thought the very same actions were an indication of someone trying very hard to improve their situation, of being motivated to learn and experiment, of being a self-advocate.

The other conversation was with someone who had not been referred for investigations for a new pain she had developed, on the basis that ‘hurt doesn’t equal harm’ and because she already had a chronic pain problem. She went through many years of distress and disability because her new pain was not investigated – but once it was, she got a diagnosis and the treatment that reduced that pain and relieved her distress. Sadly the psychological distress of not having her concerns addressed lives on.

How can we get it so wrong? How is it that good clinicians with the best of intentions (my assumption) make judgements about a person, their pain, and what they do about it and paint the person with pain in such negative ways?

Perhaps clinicians can be excused for holding negative attitudes towards people with chronic pain because the prevailing belief in our clinical communities is that ‘we, the professionals, know what’s right.’ We know this because we have the randomised controlled trials that show us Truth about What Works and What Does Not. I write these in capitals because while health professionals embrace evidence-based health care, I’m not sure we’re all that au fait with the original model of EBHC and its three-part definition: “a systematic approach to clinical problem solving which allows the integration of the best available research evidence with clinical expertise and patient values (Sackett, et al., 1996).” Note those last two points: clinical expertise and patient values.

We’re also not very good at being critical about research. Well, I take that back, we pull research apart when the results don’t equate with our experience or preferences, and gulp down whole the research that does… but what we don’t do nearly as well is to be critical of implicit issues with research paradigms. What I mean by this is we don’t ask ourselves whether the assumptions used in statistical analyses hold true (I’ve discussed ergodicity before); whether the participants recruited to studies are anything like the people we see (research participants are selected to reflect a ‘pure’ construct for testing, so people with multiple comorbidities, who might have difficulty with language or who might not even engage with healthcare and those who are not from high income countries aren’t represented); whether the treatment/s studied in research look anything like what is actually delivered in daily clinical practice, even how long the follow-ups are and what happens once a person is not part of a research project.

Limited critical analysis means results from research reach practice quite quickly (even though the nuances reported by the researchers in those papers often do not) and what’s worse, help to reinforce a hierarchy separating the person seeking help and us as clinicians. After all, us clinicians spend years learning all this stuff so it should count for something, shouldn’t it?

Well… not as much as we’d like it to, perhaps.

Because if clinicians judge a person based on erroneous beliefs about the superiority of what we know in theory (because quantitative research represents only a ‘failure to reject the null hypothesis‘ not definitive support for a theoretical prediction) we’re not inclined to be curious about what the person brings into our communication. Walt Whitman apparently said “Be curious, not judgemental” – and curiosity allows clinicians to suspend judgement in order to explore, to dive more deeply into detail and context, and ultimately, to be more compassionate. Don’t believe me? Take a look at this paper by Shields, et al., (2013).

“Physicians who used more certainty language engaged in less thorough assessment of pain (β = -0.48, p < .05). Conversely, physicians who engaged in more exploring and validating of patient concerns (β = 0.27, p < .05) had higher ratings on anxiety/concerned voice tone (β = 0.25, p <.01) and engaged in more thorough assessment of pain. Together, these three factors accounted for 38% of the variance in pain assessment. Physicians who convey certainty in discussions with patients suffering from pain may be more likely to close prematurely their assessment of pain. We found that expressions of physician concern and responsiveness (curiosity) were associated with superior pain assessment.”

We could replace ‘physician’ with any other healthcare professional, and my bet is we’d find the same thing.

Why does this matter?

Well, after being part of a number of “experts by experience” conversations over the years, the message coming through loud and clear is that clinicians who judge people negatively and fail to respond to what it is the person intends or needs, but instead dismiss their concerns as ‘catastrophising’ or ‘maladaptive thinking’ or even ‘not motivated to engage’ leave people with pain in distress. The psychological impact of feeling that your concerns are not important, of being dismissed, of not being heard is long-lasting. One person I’ve spoken to described her anxiety about seeking help from a clinician after a single time where her concerns weren’t acknowledged.

We might not intend to do it. We may think we’re doing the right thing – and possibly we are doing the right thing but doing it in a ham-fisted and damaging way.

• First listen, be curious and understand why a person has done what they’ve done. People don’t get up in the morning to do dumb things. There’s always some underlying reason a person does what they do.
• Then reflect in a compassionate and empathetic way – show the person you’ve heard them. Let them know what it is you’ve understood – let them correct you if you’ve got it wrong and remember that taking the time to do this saves time.
• Ask them how well their approach is working for them. Aim to understand the benefits from their perspective. Normalise their approach – humans do what humans do, try to solve a problem using the tools at their disposal, just the same way we do as clinicians. Ask about the short-term effects, and the long-term impact. Ask about the good and not-so-good of their approach. BE CURIOUS!
• Involve the person in your decision-making. Be honest about your reasoning and be real about the level of uncertainty that exists in our knowledge about pain. This person is an individual, not a number in an RCT, this person probably doesn’t even look like a participant in an RTC.
• Be specific with your reassurance. Don’t dismiss someone’s concern about a new pain: find out what it is they’re concerned about and ensure you clearly address that concern. Don’t be patronising – be authentic and real.

There is so much harm we clinicians inadvertently do because we’re not flexible, we don’t take time to really hear how a person gets to where they are in their journey with pain, and we really need to be more critical about our own assumptions.

Sackett, D. L., Rosenberg, W. M., Gray, J. M., Haynes, R. B., & Richardson, W. S. (1996). Evidence based medicine: what it is and what it isn’t. Bmj, 312(7023), 71-72.

Shields, C. G., Finley, M. A., Elias, C. M., Coker, C. J., Griggs, J. J., Fiscella, K., & Epstein, R. M. (2013). Pain assessment: the roles of physician certainty and curiosity. Health Communication, 28(7), 740-746. https://doi.org/10.1080/10410236.2012.715380