I was getting sick. Ugh. I was able to hold off long enough to finish my caseload, but once I was home, I let my resistance to the bug go. My clinical crew knew I wasn’t feeling well, but I thought I’d be back by the next day.
Next morning: nope. I needed to stay home. I tell my wife I’ll be staying home as she leaves for work, “s’all good, honey.”
So I call in to the clinic to let them know. When they answer the phone my voice changes a bit ( I notice retrospectively). I explain I’m worse *cough*, and thank them for arranging the schedule to cover me *cough*. Then hang up.
What was that about? I ask myself. I was not sure that I sounded sick, or did I? Did I just throw in an extra throat-clear for emphasis? I realized that I felt a strong urge to sound sick, to “sell” that I wasn’t feeling well. My sickness was the truth. Yet, I was pulled very strongly to embellish it in my short 30 second interaction… hmmm.
The purpose of communication is often to get a point across to some audience outside of yourself. You express yourself so others will know what you mean, how you feel, why you think, etc.
As the receiver, once you think there is an alternative motive to communication, things start to unravel. It can happen when an “information session” turns into a “sales pitch.” It can happen when you find out that some conflict of interest is present, etc, and the ‘Horn effect’ (opposite of Halo Effect) can take hold. You turn up the volume on your skepticism. Now, you believe nothing at face value.
This is often present in the case of treating a patient that is currently litigating, or has a worker’s compensation claim. The biases kick in, and after a few prior events of someone “abusing the system” we are no longer prepared to openly treat this population, at least not without some reserve.
It is a shame. It is natural.
It is hard to undo those experiences and reset ourselves to see this patient as a clean honest slate.
Upon Eval most interactions will go extremely well. The subjective portion of the exam is fairly clear, a mechanism of injury is present which is disturbing home life and sleep and limits the person from completing their work tasks. At this point, you have strong empathy towards the patient. They were working hard, hurt themselves, now they are just trying to get back to that job so they can support their family, do what they enjoy and not hurt.
- The context is often a factor in these cases, as in: if you get hurt doing a hobbie you love, it will bother you less, vs getting hurt while doing something you are forced to do because society tells you you have to be away from your family and work this job and make money to buy things and now you’re hurt because of it… and on. (read as: Perceived Injustice. See reference here.)
- It matters what you were doing when you hurt yourself. Consider this: When someone dies filming hungry sharks in the Pacific, we say “Oh, at least he died doing the thing he loved” etc. We do not often say such things when someone dies when crushed by a truck, etc. Context matters in how we absorb life’s events.
- Other contextual food-for-thought: Notice how many litigating patients who were in Motor Vehicle Accidents are the ones who got hit, not the one who did the hitting. Think about the lost locus of control here. It happened TO them and by nature that is more painful…
After the Subjective comes Objective. It is here that I see an inability to flex the shoulder above 80 degrees, and yet she can fully demonstrate a normal Appley Scratch test? This is when you see a patient jump out of their seat with light touch of their calf, when they clearly just pulled their tight jeans up over the same soft tissue structure. Uh, oh… what’s happening here?
I am as inclined as anyone to start to view this person as a “symptom magnifier” and report “variability” and “inconsistency” in movements seen in exam. Should I question the validity of these movements? This line of thinking can be exhausting, and can really limit your clinical and critical decision making and skills as it relates to treating the person in front of you.
So I point you back to the first paragraphs of this post. Sometimes the truth wants to be told so bad, that it becomes distorted in transfer… The information is embellished to bring home a point, to share a story, to make, to force, to urge, the other person to understand you hurt.
So yes, malingerers and abusers of the system exist. 100%. But to clean the slate and wash the palate between patients I offer these few mantras to keep yourself open to. Think about how it feels to try to express that you hurt.
“I need this person to see I am in pain. Or they might not believe me.”
“I’ve never been in PT before. My lawyer said that this is an important part of my case. Is this a test?”
“If I feel better after the first visit, do I not get my compensation pay from the fall?”
Attempt to view the interaction with some nuance. You may know that you are getting 2-3 different ROM measurements for cervical rotation per trial. They may be reporting increased neck pain with different tests revealing an unclear musculoskeletal picture. Yes they could be completely faking. But, as it was put to me ever so bluntly: “It’s not your job to see if they are faking. It’s your job to help them improve.” See it as a call for help. Focus. Help them move and feel better.
None of that is easy, and it can feel as though you are just part of a system, caught in the middle and spinning your wheels. But it is a much more satisfying approach to believe the patient, and coach them past their movement fears.
Remember: A main purpose of communication is simply to be understood, not necessarily to transmit the objective truth.