On Back Pain and the Discipline of Empathy

Samuel Locoh-Donou is an IUEM PGY-2 resident and part of the IUEM Avocacy Track.

“Let ME tell you how to do this dance, doc. First, I want an American doctor who speaks good English and who knows what he is doing. Second, I want my brother to get an MRI today, instead of a goddamned rectal exam. Nobody is getting a rectal exam! I have a slipped disk, so I know how you guys operate. Always trying to line your pockets by billing for unnecessary procedures!”

How did we get here? I recall vividly an angry man standing in front of me, eyes blazing, with his index finger pointed in my face. He must have been in his late 50’s, and had tobacco stains in his beard and moustache, and a hunting cap screwed on his head. His brother, who actually was my patient, was resting on the ER room’s bed, in his mechanic dark blue overalls, looking very uncomfortable with the unexpected turn of events.

I was in shock. Over the course of my clinical training, I had yet had to encounter this level of disrespectful and prejudiced speech. In the space of two seconds, this family member had made allusions to my ethnicity, my accent, and my treatment plan in a way that made my blood instantly boil. This was new for me. My experience as a healthcare practitioner in this country has always been a very positive one. My French accent and a bit formal English vocabulary (conditioned by my schooling in the British system) was generally welcomed with an initial wide-eyed curious surprise on behalf of my patients, quickly replaced by a smile and a heartfelt, mindful conversation on what brought them to the hospital.

My 55-year old male patient had actually come in for back pain, like one of the thousand others who walk into our emergency room every day with the same complaint. He worked as a mechanic, and had developed instant back pain 3 days ago when bending over the hood of a truck he had been working on. His symptoms included lumbar pain so severe that he could not sleep at night, as well as shooting pains radiating from his lumbar area into his L. calf. He had no history of recent back trauma, IV drug abuse, cancer, or chronic steroid usage. When I asked about cauda equina symptoms, he denied saddle anesthesia, but endorsed 3 recent episodes of urinary incontinence and 2 episodes of weakness in his bilateral lower extremities that had caused his legs to buckle at the knees. The patient was unable to tell if his legs gave away because of pain or because of pure weakness. His past medical history was positive for hypertension and hyperlipidemia. He had undergone hernia repair surgery in the past, and smoked 1.5 pack of cigarettes a day.

My patient was clearly uncomfortable, but pleasant and calm during the interview. As I proceeded to the clinical examination, his brother walked into the room and sat silently on a chair in the furthest corner, watching us warily. Since it is my habit to acknowledge every person in the room, I greeted the family member, and earned a grunt for a response. As I focused back on my clinical examination, it struck me that my patient was very tender to palpation in the paraspinal lumbar areas, and had difficulty with proximal and distal bilateral lower extremity strength testing. When I asked why he was weak, he said he was actually too in pain to move. His lower extremity sensation and reflexes were normal. Given his story of urinary incontinence and the findings of weakness (possibly due to pain), I decided to check for a rectal tone for my own peace of mind. I explained to the patient what I wanted to do, and the reasoning behind a thorough physical exam for the type of symptoms he was having. The patient flat out refused, and the brother erupted from his corner with his index finger pointed to me.

I maintained an attitude as professional as possible, attempted to explain the indications for an emergency MRI and the required physical exam components to precede the actual MRI, but every single word I calmly uttered only further aggravated the family member. He screamed that he wanted a different doctor for his brother, so I excused myself and stepped out of the room. I closed the door with shaking hands as I tried to quell the anger storming inside. My female staff ended the visit after walking in the room alone and getting a better history of the episodes of urinary incontinence (more related to inability to get to the bathroom in time) and lower extremity weakness more related to pain than actual weakness. The patient was discharged with pain control, return precautions, and a physical therapy referral.

As I reflected on this incident in the following days, I realized that the outburst directed at me by the angry family member was actually rooted in the love the man had for his brother, and a fear that his brother would have to suffer unnecessarily because of perceived inadequate care. Since no man is perfect, the family member’s emotions could not be detached from his personal socio-cultural canvas, and his perception of a different skin tone and accent in a healthcare provider only heightened a sense of unfamiliarity and insecurity already ignited by a loved one’s suffering. I came to terms with my initial feelings of anger and indignation, by applying to my patient’s brother the same principles of empathy I apply with all my difficult patients.

According to a 2007 study, the development of clinical empathy by physicians is key in managing difficult patient-physician encounters, and clinical empathy was defined as the ability for physicians to be emotionally engaged during conflicts with patients. In a nutshell:

– Physicians should accurately acknowledge their feelings and negative emotions as they occurred;
– Physicians should take the time to consider the meaning of their negative feelings and how they may relate to the patients’ feelings;
– Physicians should attempt to discern the emotional issues that underlie the patients’ negative reactions;
– Physicians should be sensitive to the patients’ body language, as the patients’ nonverbal cues will require the provider to adjust their own nonverbal signals accordingly;
– Finally physicians should accept patients’ criticism and negative feedback without falling in the trap of getting defensive.

I believe that the disciplined application of these key principles to not only patients, but patients’ families as well, is a healthy technique for healthcare providers to engage in a conflictual conversation with emotional intelligence and without compromising themselves. The discipline of clinical empathy goes beyond the simple doctor-patient relationship, as a provider is also engaged in some type of therapeutic communication with a patient’s loved ones. And this is the challenging beauty of the art of medicine.

J. Halpern, “Empathy and Patient–Physician Conflicts,” Society of General Internal Medicine 22 (2007): 696–700

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