A 54-year-old man comes to the office for an initial appointment to evaluate lower back pain. The patient's medical record shows that he has seen several physicians for back pain treatment. He has been prescribed multiple pain medications and physical rehabilitation services but often stopped prematurely or did not follow through with recommendations. At the beginning of the visit the patient says, "I'm tired of living with back pain, and I haven't been able to work in years. Nothing has helped me-at this point I might as well just give up and go on disability." Which of the following statements is the most appropriate initial response to this patient?

Question

A 54-year-old man comes to the office for an initial appointment to evaluate lower back pain.  The patient's medical record shows that he has seen several physicians for back pain treatment.  He has been prescribed multiple pain medications and physical rehabilitation services but often stopped prematurely or did not follow through with recommendations.  At the beginning of the visit the patient says, "I'm tired of living with back pain, and I haven't been able to work in years.  Nothing has helped me-at this point I might as well just give up and go on disability."  Which of the following statements is the most appropriate initial response to this patient?

Quizplus · Accepted Answer

This physician is confronted by a patient who has not experienced benefit from previous treatment and feels hopeless that his condition will improve. Such challenging patients can often cause the physician to feel defensive, manipulated, or hopeless as well, leading to premature referral to a specialist. Although strategies to improve treatment adherence will be important for improving outcomes, the best initial approach is to build the physician-patient relationship by empathizing with the patient's frustration and disappointment with past treatments. In this way, the patient will feel understood rather than blamed for past treatment failures, and he will be more willing to work with the physician to develop a collaborative plan focused on realistic goals. (Choice A) This patient requires a thorough history and physical examination to assess his condition. Referral to a pain specialist is premature. (Choice B) This statement is likely to be experienced as unsupportive because it challenges the patient's proposal regarding disability and does not offer any suggestions in its place. (Choice C) This statement attempts to point out the patient's help-rejecting pattern of behavior, but it would likely be perceived as judgmental, especially at this early stage of the physician-patient relationship. (Choice E) Although at some point the physician should address the importance of adherence to treatment in achieving a better outcome, this statement is critical and blames the patient for past treatment failures. Empathizing with the patient's frustration at this early stage would be more effective in developing a treatment alliance. Educational objective: Physicians may become frustrated with a patient who is hopeless about treatment, often compelling the physician to refer the patient to a specialist prematurely. Empathizing with the patient's frustration over past treatment failures can help build the physician-patient relationship. __________ References: Managing difficult encounters: understanding physician, patient, and situational factors. (http://www.ncbi.nlm.nih.gov/pubmed/23547575)

A 54-Year-Old Man Comes to the Office for an Initial