Pearls: Effective Communication Strategies for the Biopsychosocial Paradigm of Musculoskeletal Medicine

Surgeons tend to get straight to the point. We tick boxes on the “to do” list and move down the list until it’s complete.

Soon after my residency, I developed a growing appreciation for evidence about the limitations of modern medicine, which demonstrated the degree to which thoughts, emotions, and circumstances affect illness [2, 4]. I wanted to teach the patient about this, tick the box, and move on to the next patient.

It was not a good strategy.

A person doesn’t care what you know until they know that you care. And my transfer of expertise devolved to a contest: the patient’s experience versus my expertise. My talks often took the form of a long monologue, much of it technical, and likely uninteresting to the patient. Those were the longest, least satisfying, and most stressful visits.

I became a student of effective communication. One instructor led with: “I know what you’re thinking. You don’t have time for this … I promise that effective communication will make your visits more efficient.” And they did.

My first lesson involved active listening and making it clear that I am hearing the patient’s story, I am legitimizing and normalizing any concerns, I am introducing options, and I am following patient preferences. I learned to condense my expertise transfer to a few key points, crafted to inform and empower while improving hope. I developed an internal timer that I feel goes off at about 30 seconds and try never to talk longer than that. My goal is that the patient talks more than I do.

When my expert advice conflicts with the patient’s experience, I note that conflict and acknowledge that it can feel uncomfortable. I promise to be there for them over time as we figure things out. It’s more effective to incrementally guide people to an accurate understanding of their condition over time than to abruptly direct a person towards healthier thoughts about the condition. Expect this evolution of the inner narrative to take more than one visit and perhaps more than one communication medium. I offer email, portal, phone calls, and now telemedicine to extend the discussion. Reorienting the human mind’s misconceptions (“this is a new problem”, “I injured it”, “I can’t return until I’m pain free”) is more a matter of relationship than teaching.

I also learned to tone down the medicine. It’s usually easy to arrive at a discrete, objective, and verifiable diagnosis. When it’s not easy, (1) remember that time is both diagnostic and therapeutic and (2) be mindful of the interrelationship of mental, social, and physical health. You may be sensing important mental and social health opportunities.

Anticipate at least one misconception about the symptoms [1, 3]. Symptoms are common and often well accommodated. What brings people to a specialist is usually a combination of a symptom and a concern. People will often lead with the concern, often based in a theory about why they have the problem, and also linked to what might happen to them in the future: “My job involves a lot of …” or “I was fine until I …”.

If you anticipate common misconceptions and concerns, you’ll be more likely to hear them. Curiosity can demonstrate compassion and genuine interest. Noticing these aspects of the illness can help build a trusting relationship. Reply with: “Wow. That sounds [guess their emotion: sad, scary, frustrating]. I’d like to hear more about that.”

As you work towards more effective communication strategies and better relationships with your patients, anticipate a little backsliding to your prior habits. I find it happens most when I feel I’m behind in the office and I put pressure on myself to catch up. Keep the schedule reasonable. Use effective communication strategies to limit the length of visits (“in our last 5 minutes together …”, “How shall we pick this conversation up anew? Can I call you next week?” Expect to get thirsty or need to go to the bathroom and take personal breaks. Recognize when you need to recharge. One tip is to prepare for each new patient. I pause outside the door while I’m working the hand sanitizer through my hands, I close my eyes, and say to myself, “Soothe, not solve.”