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Going to the Doctor:
Pain, Ill Communication, and Partnership

Written by Dr. Skiba

As a doctor who spends more time than he should riding around with sweaty men in spandex, I hear about a lot of sports related injuries. The thing I have always found most interesting is that although my compatriots complain about various pains, strains, and abrasions, they rarely seek the counsel of a physician. A couple of weeks ago, a fellow cyclist asked me what I thought he should do about what he called his “tennis elbow”.

My first answer was (as it usually is), “I think you should see your doctor.”

This didn’t make him happy.

“Well,” I asked, “How do you have tennis elbow?”

He went on about his symptoms, and how he read up on it on the Internet. “And anyway,” he said, “It isn’t that bad.”

I hear this answer a lot, and I have a problem with it. Let me tell you the story I told him, about a hard lesson I learned through a colleague’s misfortune.

I know a physician who was an elite athlete. We’ll refer to this person as Dr. K (not her real initial). A few seasons ago, Dr. K began to have ankle pain. As Dr. K’s calf was a little sore in the back, she figured she had pulled one of those muscles and the pain was radiating down her leg. Certainly, this is a reasonable thing to think. Dr. K massaged it, did some stretching, and took some Advil. “It will be fine,” she said.

Over a period of months, the pain vacillated between better and worse, without a significant swing either way. Dr. K called it a 3 or 4 out of ten; it was feeling tight, but still certainly nothing worthy of “overreacting about” and seeing her own physician. Dr. K. started stretching some more, and took a little more Advil.

Some time later, while exercising at her chosen sport, Dr. K. fell down in excruciating pain. She had completely torn her Achilles tendon. She also had a small stress fracture in her lower leg. Dr. K was sidelined for the rest of the season, and moreover has never been able to compete at the same level.

My point is this: Her case was extremely unusual. This is not the typical course of an Achilles tendon rupture. However, it illustrates an important point. Even doctors get themselves into big trouble by self-diagnosing and treating. Your doctor earns his or her keep by catching the unusual; by noticing the things that are not immediately apparent. You are paying your doctor to look at you objectively, in the light of experience with many patients, and say “Yes, your knee pain is just a little arthritis.” Or, “No, this could be a bigger problem than it looks and we need to do a couple tests.” How much is your health, and your enjoyment of sport worth to you? If you have pain, and it is enough to make you wonder, “Should I go see a doctor about this?” the answer is YES.

Of course, a successful visit to your doctor is dependant on communication. Historically, physicians have not been viewed as great communicators. Or rather, the great communicators were considered the exception to the rule. I admit this as a physician who has had other physicians with the bedside manner of sea lions. These days, just about every medical student is required to take courses in communication, breaking bad news, and other such essentials. This is a good thing, in my opinion. Change comes slowly, however, so chances are that you may some day deal with someone who is less than stellar in terms talking your troubles over.

I am going to ask you to do something a little unusual. I’d like you to try and meet us halfway, in terms of communication. The best kind of relationship between a doctor and patient is one of partnership. Partners talk to each other. Partners usually also think along the same lines. That can be the difficult part: You may have a very good idea of what you think is wrong with you because you have tried to educate yourself. Your doctor has not yet heard your story and examined you, so he or she probably has no idea what is wrong with you besides the cryptic post-it note on your chart that says “knee pain".

Doctors usually think in pretty regimented terms. They see a lot of patients and thus must think very systematically to make sense of all the problems and remain sane. The upshot is that doctors are very good at listening for key words and phrases. (It is the only way you survive medical school.) We all learn to listen for certain things from a patient and compare those comments to a long mental list of conditions that might fit the bill. We then use the physical exam to narrow down the possibilities, and if necessary, order a few tests to confirm our suspicions. For our purposes, we will concentrate on the history. I will explain to you in general terms how most of us think, so that you can know how to talk to us and get to the bottom of your problem together, and as quickly as possible. We will use an acronym that many of us learned in medical school, which may help organize your thoughts as it does ours: COPMAPS.

C: Complaint: What is your main issue? This is what tortured you enough that you decided to waste half your afternoon hanging out in a waiting room, listening to crying children and coughing victims of god-knows what. Be as specific as possible.

O: Onset: What were you doing when it came on? When exactly did it first occur? Was it sudden, or did it come on slowly and gradually? Have you had this before?

P: Progression: What has happened in the time between the initial complaint and your coming to the office. Did it get continually worse? Did it go away for a while?

M: Mitigating factors. What makes it worse? Walking on it? Going up or down stairs?

A: Alleviating factors: What makes it better? Rest? Ice? Aspirin? Sleep? Robiutussin? You get the idea.

P: Pain: What is the quality of the pain? Sharp or dull? Burning? On a scale of 1 to 10, how bad is it? Is the pain intermittent or constant?

S: Supplementary info: This is the wastebasket category, where you include the stuff that does not neatly fit into another category. This is where you say, “I was reading on the Internet, and it made me think I might have X, which is why I came to see you.”

When your physician comes up with his or her bright ideas about what ails you, ask questions. Why does he or she agree or disagree with you? Your doctor should be able to give you solid reasons, based not only on the books but on his or her experiences. Together, you need to come up with a plan of attack. I encourage you to be an active part in this process. If you don’t think you can handle physical therapy 3 days a week, now is the time to say so. If you’d like to pass on the medication and just go with the therapy, say that too. Don’t just nod at whatever your doctor tells you, and then take or leave parts of it. The plan needs to be coherent, and it needs to be the one you follow when you leave so that both of you understand what is going on, especially if your recovery is not going as quickly as planned.

During your treatment, I encourage you to read from reputable sources, such as medical reference books you find at the library, so that you can ask good questions at your follow up visit. (Be cautious about Internet information, as it is often not well researched or even written by medical professionals). When you go back to your doctor for follow up, you should try to be as educated as you can be on what you both believe your ailment to be. Make a list of questions to ask. This is your opportunity to get more education, sort of like being with the mechanic while he changes your alternator. By learning in this way, you will better understand your injury, the mechanism of injury, and how to prevent it in the future. Alternatively, if things are not going well, this is the time to decide if it is worthwhile to stick with the plan, or alter it, or reconsider the initial diagnosis. If this is the case, you should again have your list of observations. Has anything changed? Are you getting worse, or just staying the same?

Above all, don’t just bail out because it isn’t going well. Again, you and your doctor are partners and partners don’t just abandon each other if the going gets rough. Of course, if partners have a really difficult time working together, it may be time for a change. This is expected from time to time, and neither side should take it too personally, if possible. However, you should be wary of getting frustrated because your doctor doesn’t tell you what you want to hear. Another part of partnership is that you are honest with each other. It isn’t your doctor’s job to bend the truth and tell you that can be back to 100% for that race next weekend. He or she needs to tell it like it is. Be careful not to end up doctor shopping without cause.

As always, if you have any thoughts feel free to drop me a line. Otherwise, see you next month!

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