STARES WEEK THREE: Communication

Situation: I received a referral for a patient with chronic low back pain. The patient is in his 50's. On presentation he complained of pain in his lumbar spine and a broad pain in the lateral aspect of the thigh. The onset was insidious dating back 2 years ago. He has been working as a gardener three times a week for 5 hours a day in that time and was frustrated that he has been unable work more due to his back pain. Aggravating factors at work include lifting loads and bending. Pain is eased my sitting. After half an hour of work he needs to sit down as the pain is too severe and it takes 5-10 minutes for the pain to ease. The difficulty in communication was due to the fact that his primary language is Cantonese and although he does speak some English he tended to repeat himself and focus on how work has been so frustrating.

Task: To perform a subjective and objective assessment that was not only effective but safe.

Action: I had to make sure that I spoke clearly and precisely. I established early that it was going to be difficulty getting as much information as possible from the subjective so I decided to focus getting the basics first. Finding out where his pain was, what aggravated it, what eased it, how long its been going on for and making sure that an objective assessment was going to be safe to perform. Where I could I tried to use gestures to help. I overall had to spend more time on the assessment part of the session to get an understanding of the problem that I would normally.

Result: It was difficult to even get a basic understanding of the problem from the subjective. The body chart and aggravating factors were the two areas of the subjective that were most difficult. Even though I knew the general area of pain in both his leg and back he had difficulty understanding the concept of specifically mapping out the area of pain and couldn't really describe his pain. Nor did he have an understanding of what I meant by how bad the pain was. I was able to determine the aggravating factors to the pain but trying to get more information about them was hard. I didn't really know what part of lifting was hurting him and what the duties at work were the worst for his back. When performing an objective in the musculoskeletal setting it is important when finding the source of symptoms that we ask the patient "is that the pain you've come to see me about". Many people have pains that are not those they are complaining of but could be a contributing factor or a different problem completely. The barrier in communication meant that although I was finding structures that were painful but I didn't know if this was his main pain. Nor was I able to find a true asterisk motion segment in the lumbar spine because multiple levels were sore and he was unable to tell me which one was truly worst. Generally getting him to perform different movements was also difficult.

Evaluation: Overall I don't think I did all that well in this situation. As much as he was repeating himself I was probably repeating myself. I found it really difficult to get my messages across which meant I didn't have all the information I wanted from the subjective. I was able to get a basic understanding of the problem from the objective and eventually was able to determine which direction of movement caused his pain and what level seemed to be the worst from the way he reacted to my palpation. In saying that it meant that I had to spent a lot of time with this particular patient.

Strategies: I think next time rather then asking opened ended questions I should delve more into the aggravating factors about questioning him about certain things. Whats it like walking uphill? Downhill? Gardening above your head? and other questions of the like. Using visual cues and the reactions of the patient is also beneficial. Bentley Health Service also have the option of the interpreter so I think that if it is still too difficult next session I may have to go down that path. My hesitation to do so is that I think it makes it difficult to build rapport with the patient but I guess at the end of the day getting a true understanding of the problem is in the best interest of the patient and if communication is a barrier then it should be addressed. Hopefully my second session with the patient will be more successful.