"That Last Treatment Made Me Worse"
The phone rings in your clinic. When you pick it up, a patient says, “Hi, I need to talk to you about something. I think that last treatment made me worse.”
What do you do next? Here’s an outline of how to create a positive outcome, i.e. make some safety, from this stressful and unavoidable situation. If you treat enough people, you will certainly get this phone call at some point!
But first, a word about order of operations. This is a concept borrowed from mathematics: a rule that tells you the right order in which to solve different parts of a math problem. Community acupuncture practitioners use the phrase to describe how to move safely through a busy clinic shift, and it’s also useful in this context. The most basic order of operations in the clinic setting itself is summed up as: pull, fluff, poke.
When you walk into a community acupuncture clinic space full of people either being treated or waiting to be treated, some of whom might be eyeing you impatiently, how do you decide what to do first? You don’t want to just respond automatically to whoever happens to be closest, OR rush around the space willy-nilly doing whatever occurs to you; you need an overall method for tending to the room as a whole.
The first priority is PULL, which means remove needles from patients who are ready to go. A true statement about community acupuncture: people who are waiting for you to treat them, no matter how impatient they might be, are LESS impatient than the people who want you to take their needles out. You never want to start treating a new patient while a patient who’s done is waiting to be de-needled, because you’re taking the risk that they’ll get annoyed with you and one of the following could occur: they take their own needles out, they get up with all their needles in because they need the bathroom, they yell for you to come get them and wake everybody up, or they just disrupt the peaceful energy of the space by silently shooting eye-daggers at you and the other patient. Making PULL your first priority is a way to avert any number of potential safety incidents.
The next priority is FLUFF, which means once you have de-needled any patients who are ready to leave, you scan the space for chairs that have been recently vacated. When you find one, you gently fluff the sheet in order to reveal any needles that might have fallen out so that you can pick them up carefully and put them in the biohazard container. Then you take the sheet off the chair, put it in the laundry container and replace it with a clean one. The point of FLUFF (which denotes all the aspects of changing the sheet but sounds cuter) is to prevent 1) needlesticks and 2) broken washing machines (ask me how I know).
Having PULLED and FLUFFED, you are free to POKE.
Similarly, in order to successfully navigate a conversation in which a patient wants to tell you about how a treatment you gave them made them worse, you need a method: an order of operations. Follow these steps!
Before you do anything else, you want to make sure that this conversation doesn’t create an adversarial relationship between you and the patient. You want to minimize stress for both of you, so check your attitude and reset accordingly. NERD TIME! I like to remind myself I am a safety nerd and I am here to do my nerdy thing! I’m going into this conversation with an attitude of neutrality, curiosity and empathy. I’m alert, attentive, and as relaxed as I can be.
Also, I’m either picking up a pen and paper or opening my laptop, because I’m getting ready to take notes. I am (almost certainly) going to be doing some kind of documentation, either a note in the patient’s chart and/or a report to the AERD and/or a full-on incident report, depending on what they say to me.
One way to encourage an empathetic attitude toward the patient making the call is to remember that the patient had other choices besides reaching out to you to communicate. They could have ghosted you; they could have left a nasty review online or otherwise complained to people who aren't you; they could have dutifully kept coming back for more treatments that didn't help them and never said a word. In a sense, this phone call means that someone who probably doesn't know you all that well is trying to resolve a conflict with you in a healthy way, which represents vulnerability and risk on their part. They're making an effort in good faith. Now you just have to meet them in the same spirit.
The next step is to say, “Oh, I’m sorry to hear that. Tell me about what you’re experiencing.”
And then you let the patient talk, while you take notes. If you have any prior training in active listening, that can help a lot. If you don’t, active listening is pretty simple; it’s all about encouraging the person to keep talking and making sure you understand what they’re saying. You can say, “Let me make sure I understand what you’re saying,” and then rephrase what you heard (“so about ten minutes after the treatment you started feeling queasy?”). Lots of mmm-hmms are good too. You have two goals here, equally important: to get all the information that you can and to make sure the patient feels heard.
This step might overlap slightly with the previous one, but you want to make sure that it doesn’t distract you from listening to the patient. This is the part where you figure out what’s going on, and it will require you to ask follow up questions. Because the tricky part is, this conversation might not be about an adverse event at all, and that’s an important distinction to make! Unless the patient says something like, “Well, my elbow pain is worse because you forgot to take one of the needles out and now my elbow is red and swollen and I think the needle might still be in there” -- in which case it’s definitely an adverse event and the conversation’s going to be really short because they’re going to urgent care! -- the conversation actually might be about something else entirely. Here are some questions to ask yourself.
Where are they in their treatment process? This is what I want to know first, because there’s a good chance that what I might need to do is help them manage their treatment process and their expectations. If they have had only a few treatments, or if their treatments have been far apart, what might be happening is that they’re noticing natural fluctuations in their symptoms that aren’t a result of the acupuncture. Most chronic conditions involve some ebb and flow, some flare-ups and temporary relief, independent of any treatment -- but people tend to attribute those ebbs and flows to any treatment that they’re receiving. Consider the possibility that the acupuncture isn’t making them worse, it just isn’t making a dent, which is a problem in its own right. And maybe they’re paying more attention to how they feel, which is great, but they need some help with interpreting the information.
It can be helpful to say "It sounds like from what you're describing, this flare-up is at the high end of where your symptoms can get to sometimes, is that right?" With consent to pursue this direction, you can move on to discussing a treatment plan: "I think we have a good chance of making some steady progress in getting this to settle down over time. If you think you want to keep trying, I can talk about how we move forward." What you say is important to the healing process, and what you are saying here is an acknowledgement of their agency.
Is this an emotional issue, particularly one related to anxiety, depression or trauma? According to an unscientific survey of WCA patients, the most common complaints treated in our clinic are 1) back pain and 2) anxiety. Both anxiety and depression can show up with physical symptoms that can be very confusing for patients to sort out; they can also strongly influence how people interpret sensations.
If you’re doing a good job of listening, and the patient is inclined to share details, they might volunteer that they’re dealing with anxiety, depression, or trauma either as a primary concern or in addition to a physical complaint. (DON’T ask them outright, “are you depressed, anxious, or traumatized?”) A patient might say something like, “I’ve been dealing with this pain for a while, and I’ve also been dealing with depression” in which case what could be happening is that both the physical pain and depression are ebbing and flowing in such a way that the person just happens to be feeling worse from both, coinciding with the day after an acupuncture treatment. OR they were starting to feel a little better from their physical pain when their depression flared up, causing them to lose hope in the process and then begin to feel the pain more. OR they might say something like, “I came in because I have a problem with anxiety but now I’m feeling like my neck and shoulders hurt all the time” in which case what might be happening is that the acupuncture is helping them connect to their body and notice physical symptoms of anxiety that they had previously tuned out. While that might seem like progress to you, you can understand why it’s not going to seem like progress to them, right?
Depression and anxiety tend to wrap themselves around pain, especially chronic pain, like a corkscrew; a big part of your job as a practitioner is to help the patient unwind them.
Is this a pain management issue? I’d like to suggest some reading from our workbook Punking: The Praxis of Community Acupuncture, specifically the chapter titled Punking, Pain Management, and Communication. Here’s a quote: “I’ve always found it helpful to imagine a course of treatment as an ongoing conversation between a patient’s body/mind and the acupuncture. Treatment planning means paying attention to how that exchange is going; what are we learning? What’s changing? Are we getting anywhere?...It also involves the skill of knowing when the conversation isn’t going anywhere, and how to suggest that someone might want to try a different approach to managing their pain without making them feel discouraged or rejected.” The conversation in which the patient tells you they feel worse might be an opportunity to help them with the overall process of pain management, possibly by helping them track how their pain is or isn’t changing.
Is this about an actual adverse event? Looking at our AERD data, “symptom aggravation” represents 2.5% of the reports we received, just below “fainting”. If the patient says something like, “I’ve been getting treated for headaches, when I came in to the clinic on Thursday I had a mild headache and by the time I left it had turned into a migraine that lasted two days and I’ve never had a migraine before”, I would call that an adverse event (and report it to the AERD).
The CNT manual suggests that symptom aggravation is sometimes an intentional outcome of treatment in the form of a “healing crisis” or a “transient inflammatory response” that accelerates tissue repair. In my experience, this is a highly subjective area, and any kind of symptom aggravation requires a cost-benefit conversation about what the patient is up for. Jersey’s excellent post about consent very much applies.
4) CASE MANAGEMENT (this is a category of ACAOM competencies, btw)
No matter what you conclude is going on with your patient, this conversation represents an opportunity to have a therapeutic interaction! What you say might turn out to be as important to your patient’s healing process as any acupuncture treatment you give. Once I’ve gathered as much information as I can and done my best to discern what’s going on, I consciously make a shift out of nerd mode (mostly curious) and into practitioner mode (doing what I can to help).
Case management in community acupuncture mostly requires helping patients figure out what acupuncture can and can’t do for them, and how to usefully engage with the clinic in order to get the best results possible. This is an art form, actually, and like other art forms you can’t get better at it without lots of practice.
If it turns out that the issue is the patient not getting enough acupuncture to make a dent in their problem, it’s time to talk with them about how often they’re coming in to the clinic and how long they can commit to a course of treatment. I often suggest to patients that they get ten treatments over the course of a month, and at the end of those ten treatments, ask themselves if they feel like acupuncture is worth continuing -- but don’t make that evaluation until the ten treatments are complete. At that point, they should feel good about having given acupuncture a solid chance, and if it hasn’t helped by then, it’s time to move on to another modality. The idea of ten treatments is based not on any scientific research but just a gut feeling, developed over time and working with lots of people, that this is a reasonable request to make and most people will be able to do it. (A separate topic is making payment arrangements with patients who feel like they can’t afford ten treatments in a month, which at WCA we always do, because good results are worth more than whatever these payment arrangements cost us.)
If it turns out that the issue is emotional, particularly related to anxiety, depression or trauma, often listening to the patient and validating their feelings is the main thing to do. I think of the conversation as an opportunity to offer support around making a good decision for themselves about whether or not to continue with acupuncture. I might volunteer some information about how acupuncturists see the body and the mind as having a very close relationship, and how what we think of as mental health issues like anxiety and depression sometimes manifest physically. Just like physical pain, anxiety and depression take time to treat successfully. But acupuncture isn’t everybody’s cup of tea, and so if the process of getting treated is more stressful than it’s worth, it’s okay to stop!
If it turns out that the issue is pain management, this is a good opportunity to have a conversation about pain scales, including encouraging the patient to keep a journal where they can record daily pain scales, so that they can gather some more data about how acupuncture is affecting their pain over time. This kind of information-gathering can be an important step in figuring out whether or not to continue with treatment.
And if it seems like the issue really is an adverse event...there's some case management to be done also. The CNT manual states, “If an aggravation of symptoms is not the expected outcome of an acupuncture treatment, the acupuncturist should evaluate the diagnosis and treatment plan for the patient and assess whether consultation with or referral to another practitioner would be beneficial.” In my experience, there are some people that acupuncture just doesn’t work for, and one flavor of it not working is their body/mind responding to acupuncture negatively. A much more common flavor of “not working” is acupuncture doing nothing, but people are so diverse that a negative response should never be ruled out. Believe what the patient is telling you about their experience.
We're still in the early stages of digging through our AERD data, but so far symptom aggravation or a negative response (as distinct from pain/symptom fluctuations and mental health issues) show up as new types of symptoms or a change in the pattern of symptoms. So if a patient says something like, "The day after the treatment I felt intensely dizzy and nauseated and that's never happened before" or "Normally my pain is worse in the morning but after the last treatment I've had spikes of pain in the evening" please file an AERD report under "symptom aggravation". At this point we don't have enough reports to tell how common this might be, and we need more data.
5) WRAP UP
If you’ve followed the order of operations so far, the conversation is over when 1) your patient doesn’t have any further information to share or questions to ask, and 2) you both have a sense of your “action items” from the conversation -- so it’s time to get on with them.
As noted above, your action items almost certainly involve some kind of documentation. If the action item is an AERD report, you can let your patient know that you’ll be reporting their experience anonymously to a database intended to help promote acupuncture safety.
No matter what, I like to end the conversation by thanking the patient for sharing their experience.
The last step is to hang up the phone, take a deep breath, and congratulate yourself for making an effort to create more acupuncture safety.