UBC Objectives: Family Medicine, UBC Objectives: Mental Health, UBC Objectives: Care of the Elderly, UBC Objectives: Professional, Priority Topic: Chronic Disease, Priority Topic: Difficult Patient, Priority Topic: Disability, Priority Topic: Multiple Me

By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...

• Use a patient-centred approach to care of patients and families through exploration of both the disease and illness experience, understanding the whole person, and negotiating informed shared decision making regarding management
• Act in a caring and compassionate manner
• Initiate screening for mental health disorders in high-risk situations (ex: patients with cancer, chronic pain, war veterans, refugees, victims of domestic violence, etc.)
• Obtain a structured medication review including identification of potential drug-drug and drug-disease interactions (if appropriate, in consultation with a pharmacist)
  

Chronic Disease

​Key Feature 4: In patients with chronic disease, actively inquire about:

• The psychological impact of diagnosis and treatment
• Functional impairment
• Underlying depression or risk of suicide
• Underlying substance abuse

Skill: Patient Centered, Clinical Reasoning
Phase: History

Difficult Patient

Key Feature 3: In a patient with chronic illness, expect difficult interactions from time to time. Be especially compassionate and sensitive at those times.
Skill: Patient Centered, Professionalism
Phase: Treatment, Follow-up

Key Feature 4: With difficult patients remain vigilant for new symptoms and physical findings to be sure they receive adequate attention (ex: psychiatric patients, patients with chronic pain).
Skill: Selectivity
Phase: Hypothesis generation, Diagnosis

Disability

Key Feature 3: In patients with chronic physical problems (ex: arthritis, multiple sclerosis) or mental problems (ex: depression), assess for and diagnose disability when it is present.
Skill: Clinical Reasoning, Patient Centered
Phase: Diagnosis, Hypothesis generation

Key Feature 4: In a disabled patient, assess all spheres of function (emotional, physical, and social, the last of which includes finances, employment, and family).
Skill: Patient Centered
Phase: History

Key Feature 5: For disabled patients, offer a multi-faceted approach (ex: orthotics, lifestyle modification, time off work, community support) to minimize the impact of the disability and prevent further functional deterioration.
Skill: Patient Centered, Professionalism
Phase: Treatment

Multiple Medical Problems

Key Feature 4: Given a patient with multiple defined medical conditions, periodically assess for secondary depression, as they are particularly at risk for it.
Skill: Clinical Reasoning
Phase: Hypothesis generation, History

Key Feature 5: Periodically re-address and re-evaluate the management of patients with multiple medical problems in order to:

• Simplify their management (pharmacologic and other)
• Limit polypharmacy
• Minimize possible drug interactions
• Update therapeutic choices (ex because of changing guidelines or the patient’s situation)

Skill: Clinical Reasoning
Phase: Treatment, Follow-up

​Stress

Key Feature 1: In a patient presenting with a symptom that could be attributed to stress (ex: headache, fatigue, pain) consider and ask about stress as a cause or contributing factor.
Skill: Clinical Reasoning, Communication
Phase: Hypothesis generation, History

Key Feature 2:  In a patient in whom stress is identified, assess the impact of the stress on their function (i.e., coping vs. not coping, stress vs. distress).
Skill: Patient Centered
Phase: History, Diagnosis

Key Feature 3: In patients not coping with stress, look for and diagnose, if present, mental illness (ex: depression, anxiety disorder).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 4a: In patients not coping with the stress in their lives: Clarify and acknowledge the factors contributing to the stress.
Skill: Patient Centered, Clinical Reasoning
Phase: History

The first patient I saw in clinic today was the first patient I saw in clinic at the same time last week, a 47 year old female who had an extensive relationship with chronic pain. Over the years, she had trialed a significant number of medications and alternative therapies to alleviate her pain, but her pain was tenacious. During my first visit with her last week, after confirming that her pain was indeed unchanged over the last many years, and after confirming for myself there weren't any "red flags" in her presentation suggestive of more ominous disease, I reviewed her current pain management strategies, including whether or not she was using any non-prescribed substances to cope. Her approach was as chaotic as the shopping bag she brought with the countless concoctions of over-the-counter supplements and herbal remedies, including some that appeared to not be sold on Canadian pharmaceutical shelves. She was speaking very quickly, wanting to tell me so very much about everything, and I think she was probably in anxious distress and having a hard time trying to cope. 

At the first visit, we reviewed the past history of her chronic pain - all of the previous investigations that were done and all of the specialists she had seen - and what the conclusions were. We then proceeded to clean up her pain medications and reduce them to the ones she felt confident were making a real difference in her pain. And then our time was well up. We ended this visit with an organized regimen of pain medications and a followup appointment to reassess how things were going in one week. And now here we were. She sat down in front of me and after a polite exchange of hellos she gently asked what we should do this week to modify her pain medications.

There is so much about chronic pain we have yet to understand. The pathophysiology is still highly theoretical. We are aware of its association with mood disorders and psychosocial stressors, but we do not understand at a level of utilitarian specificity as to why this is the case. Chicken, egg, or both? In any case, no matter how we arrive at chronic pain, we do know that it worsens mood and aggravates social stress, just as mood and psychosocial stress negatively modulate perception of pain. By extension, if I can do anything to improve mood and psychosocial stress, I may alleviate suffering, and the corollary argument also holds that if I alleviate pain I may improve mood and attenuate psychosocial stress, thereby enhancing quality of life. 

Knowing the connection between chronic pain, mood, and stress, and now that I had the medical facts straight, during this follow-up appointment I decided to explore what was going on in this patient's personal life. As for mood, although she did not think she was clinically depressed and denied active suicidal ideation, it was certainly suboptimal, compounded not only by her pain but by her debt of sleep secondary to her pain. As it turned out, she attributed her low mood to the stresses in her life: her father living overseas was currently admitted to hospital for life-threatening cardiac disease, and her husband was riddled with aneurysms from his aorta to his renal arteries and was awaiting urgent surgery to prevent sudden rupture and possible death. Wow. Suddenly her pain had context, and was only a part of what I felt was infringing on her quality of life. The focus of our conversation shifted entirely away from her pain at this point, and she opened up about her fears of living life without her most significant others as well as her concerns regarding return to work as she felt she needed to prepare for a future with less financial stability, which was already troublesome. I did not have any advice for her anymore, and instead I just sat there listening to her experience with ache in my heart. 

After she shared the most salient aspects of her personal life stressors and the impact they were having on her ability to function or create disability, we rerouted the conversation to some practical takeaways to manage things for now, with planned follow-up again in one week. We decided that what was best right now was probably not to make any significant changes to medications, and rather to first have follow-up counselling later this week with her psychologist whom she endorsed having a strong relationship with. At this time she was not interested in any support groups or other community supports, but she said she would consider it in the future depending on how things progressed. She had come to the clinic today asking what we should do to modify her pain medications, and she left saying she was happy we weren't making changes to her current medications and that we were instead focusing on other ways of modulating her pain (I think this must have been partly because she had so many futile experiences with inconsequential medication changes over the years and didn't have much faith that yet another medication change would be her solution). As she was getting up to leave the examining room she said, "I'm now leaving here with more hope, and it's what I really need right now." 

When I first encounter patients with very complicated medical histories, either because of the number or significance (ex: cancer) of the comorbidities, I find myself feeling stunned by the complexity, oftentimes not knowing where to begin or to what depth I should delve under the pressure of time constraints. Indeed, this is how I felt when I first met this patient.  In vain, I have felt personally overwhelmed by patients with multiple somatic complaints, serving only to increase my stress without making any difference in quality of patient care. Instead, these feelings ought to serve as internal cues to the fact that if I am feeling overwhelmed, it almost certainly means the patient is feeling this too, and likely with greater whelm. In that midst of overwhelming complexity, taking time to move beyond exploration of the disease process to exploring the illness experience, can, as this patient taught me, be the basis for a restoration of hope, alleviation of suffering, and improved quality of life.