We all have patients who are hard to connect with, stubborn beyond belief despite what we think is clear evidence that refutes their deep-seated obstinence. How often do we hear, “The side effects are too great. I’d rather suffer in pain than take this new medication that puts me at risk of cancer or dying from infection.”
Figuring out the right approach for our most stubborn patients is a challenge. I often find myself falling into the role of an analytical communicator,1 providing my patients with reams of information and data to try and convince them that treating the cause of their disease is the only way to prevent their immune system from taking them hostage.
For some patients, a more effective technique is serving as the “relator” where I primarily focus on being supportive of them no matter what they may want to believe in and demonstrating that I care about them as individuals.1
Different communication styles work for different patients, and I often find myself having to quickly size up a patient when I first meet them to determine what technique they are most likely to respond to. A good example came about with Barbara, a new patient I met in the hallway 2 months ago after her recent diagnosis of rheumatoid arthritis (RA).
No matter how much evidence I provided to the contrary, Barbara was adamant that any biologic therapy would shut down part of her immune system or cause cancer, and she refused to try one. Unfortunately, her liver was already rebelling against the high daily dose of ibuprofen and hydrocodone she was taking, and her inflammation was out of control. Barbara had recently gone through the heartbreaking process of having her wedding ring cut off due to her deformities, and she was having increasing difficulty getting through each day without having to make major concessions. She could no longer dress herself, button her clothes, or care for her grandchildren on her own.
I tried explaining to Barbara that the risks of large cell tumors are no more significant in patients with RA than the general population (the incidence of lymphoproliferative malignancies is slightly higher). Patients with RA have less than a 1% standardized incidence ratio increase in the prevalence of breast and colon cancer compared to the general population.2 Nonetheless, Barbara wouldn’t budge, so I decided to try another approach.
Last year, I had the pleasure of joining a pain specialist, Ellyn Schreiner, MPH, RN-BC, CHPN, on one of the live broadcasts that are part of the Rheumatology Nurse Practice education. During our conversation, one thing in particular that Ellyn mentioned really hit home. “Ask your patient,” she said, “what the most important thing they miss that would like to be able to do again.” I tried that with Barbara and she instantly perked up. “It would be great if I could play with my grandchildren!”
That was the opening to a level-headed discussion that I needed, and I quickly moved on to other quality-of-life issues that Barbara was struggling with. “Wouldn’t it be worth trying something to help you feel better?” I asked. There were many options that might help reduce her inflammation and allow her to live with less pain, I explained, and the risks associated with these options were very mild. I reminded Barbara that inflammation doesn’t just affect the joints but also has a detrimental effect on the lungs, blood vessels that surround the heart, and really the whole body. She looked at me in shock, clearly never remembering hearing about this. “Really?” she said. “They do?”
Barbara soon after agreed to try her first biologic therapy, motivated by the goal of playing once again with her grandchildren. Happily, after 3 infusions of golimumab monotherapy (we could not use methotrexate due to her elevated liver function tests), Barbara is responding well. Her tender joint count has decreased from 18 to 4 and her swollen joints from 12 to 2. Her latest liver function test was normal.
Our conversations have now shifted from the need to try a biologic therapy to the need to stay on one. I find myself regularly reminding Barbara that she should call if there is any significant change in her health and that she needs to keep me abreast of any medical procedures she has scheduled (I can’t tell you know many times patients forget to tell me about getting an abscessed tooth removed or have impending surgery scheduled).
At our most recent visit, Barbara hugged me and told me how happy she was that she was able to take her grandchildren to the park and play with them for an hour. It’s only by listening to my colleague, Ellyn, and continuing to educate myself that I was able to break through to Barbara and get her on the right path. It was a good reminder that “one size does not fit all” when talking to our patients and that we always need to gently probe to find that pivot point that resonates and helps us to overcome their defenses.
AUTHOR PROFILE: Jacqueline Fritz, RN, MSN, CNS, RN-BC, is Owner and Coordinator of Education at the Medical Advancement Center in Cypress, CA. Her primary responsibility is working as an advanced practice nurse for a large rheumatology practice where she is involved in patient visits, research programs, and infusion center coordination. In addition, she enjoys speaking, teaching, and learning about immunology.
- Jensen DJ. Behavioral Style: Understanding Communication Styles Can Advance Your Relationships– and Your Career Prospects, Part 2. Available at www.sciencemag.org/careers/2001/04/behavioral-style-understanding-communication-styles-can-advance-your-relationships-and. Accessed January 17, 2017.
- Cush JJ, Dao KH. Malignancy risks with biologic therapies. Rheum Dis Clin North Am. 2012;38(4):761-70.