About 5 million people in the U.S. have fibromyalgia, and it is among the most common conditions seen in many rheumatology practices.
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“I have pain all over my body” is a challenging response after you’ve asked a new patient what brings them in for their visit. You immediately suspect that this patient has fibromyalgia.
The prevalence of fibromyalgia in the U.S. is 5 million people, and it is among the most common conditions in many rheumatology practices. Data from the Rheumatology Informatics System for Effectiveness (RISE) Registry indicates that 21% of registry patients have a diagnosis of fibromyalgia.1
Factors to Note
Approaches to patients with different rheumatic diseases are not the same. For example, rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE) typically have objective manifestations, such as joint swelling, rash and abnormal laboratory or other test results. Why is it that patients with fibromyalgia can be more challenging for healthcare professionals?
Fibromyalgia patients may have no observable clinical findings and the tests may be normal. These patients typically present with chronic widespread musculoskeletal pain, along with a variety of other symptoms, including sleep disorders, fatigue, environmental sensitivities and autonomic manifestations, such as irritable bowel syndrome, headaches and palpitations.
In addition, fibromyalgia patients usually have emotional factors you need to be prepared to contend with, such as frustration, anger and despair. Often, patients have seen multiple healthcare professionals and have had significant diagnostic testing without a definite diagnosis being made. Fibromyalgia patients frequently report being told that their problems are “all in their head.”
Rheumatologists and rheumatology health professionals need to keep in mind that it is not inappropriate for an individual to be upset if they are having daily pain and other symptoms that profoundly affect their lives, their activities and interpersonal relationships. Further, patients are frequently not certain what their diagnosis is and what they should do about it.
Visit No. 1
When evaluating a patient with fibromyalgia for the first time, there is a defined set of steps that you can begin with to help have a successful visit. Patients are often not clear about their expectations, what should go on during the visit and how to establish a relationship with their physician and other healthcare professionals. Your goals for the visit are to establish a rapport with the patient, to develop their confidence in you, to determine the diagnosis and to actively engage them in diagnostic and treatment measures. Remember that the evaluation is not only yours of the patient, but also their evaluation of you, which can have a profound and lasting impact on the success of your relationship.
When you come into the room and introduce yourself, repeat the patient’s name, and be sure to establish eye contact—all of which initiates the development of rapport.
Your first question should be, “What brings you in to see me?” After their reply, you should state the goals for their visit that incorporate their symptomatology: “We need to determine your diagnosis and decide what is the best way to evaluate and manage your care.”
You next explain that you would like to begin by asking two sets of questions. These questions provide insight into the patient’s perception of their problems, how they are managing them and their previous healthcare experiences.
The first question you should ask is: “Who is in charge of your care?” More than 50% of patients answer, “Doctor, you are.” Other possible answers include “I am” and “My [significant other] is.”
For your reply, you use the analogy that they are the “captain of the ship,” their significant others are their “first mates,” and their healthcare professionals are the “navigators” of their care. This point is then further emphasized by saying, “You are the one steering the boat, and if you are not sure who is in charge and where you are going, you are not likely to get there.”
Now that the patient’s and others’ roles have been defined and, hopefully, established, the next set of questions is intended to explore the patient’s perceptions of their pain symptomatology. The next question is: “Is your pain real?” The patient’s response is almost always “Yes.”
Because of the nature of the next question, it is useful to begin with an explanation to the patient, “The next question can be sensitive. Do you think that I believe that your pain is real?”
There are three general answers to this question: “Yes, you do,” “No, you don’t,” and “I hope so.” Over 90% of patients answer “I hope so.”
When an individual answers, “No, you don’t,” the response signals a potentially difficult patient and should be followed up with the question, “Why do you feel that way?”
The last question of this set is, “Do you want to have your pain?” The patient’s response is almost universally “No.”
To conclude this initial segment of your interview, summarize by saying, “You are in charge of your care, and I am your navigator. Your pain is real. I believe you, and you don’t want to have pain. Help me help you.”
Remember that the evaluation [during the first visit] is not only yours of the patient, but also their evaluation of you, which can have a profound & lasting impact on the success of your relationship.
Positive Approach Cemented
This initial interaction and line of questions takes between two and three minutes. It explores and validates the patient’s perception of their illness and defines your engagement with them.
You are now ready to proceed with the visit using a positive approach that focuses on the facts and not the frustrations.2
Terence Starz, MD, is a clinical professor of medicine in the Division of Rheumatology at the University of Pittsburgh School of Medicine and is in practice at Arthritis and Internal Medicine Associates–UPMC in the Western Pennsylvania area. In addition, he is involved in clinical research projects, including rheumatoid arthritis outcome studies, and has participated in classification and intervention studies in fibromyalgia. He serves on the ARHP Practice Committee.
Reference
- Yazdany J, Bansback N, Clowse M, et al. Rheumatology Informatics System for Effectiveness: A National Informatics-Enabled Registry for Quality Improvement. Arthritis Care Res (Hoboken). 2016;68:1866–1873.
- Clauw D. FibroGuide. Chronic Pain and Fatigue Research Center. 2014.
