My primary care physician referred me to an orthopedic surgeon to finally figure out a solution to fifteen years of chronic bilateral ankle pain. I was optimistic but after 15 years of failed alternative methods including physical therapy, acupuncture, shambala, voodoo medicine and a bit of old fashioned "suck it up” I knew it was most likely not going to be great news. I met with the doctor and within a few minutes of examining my ankles he nodded with confidence then sent me off to get x-rays with the promise that we would discuss my treatment options upon return.

I returned to the exam room and waited, socks off, feet on the cold tile floor. He returned and assured me that as far as my ankles go, my fears were true; "You’ve got minimal tread left…about a thousand miles left on those sixty thousand mile tires”. His metaphor was clear. The course of treatment for Acquired cavo-varus deformity [aka "minimal tread left”] was going to include a fairly benign first step of physical therapy combined with orthotic inserts. No big deal. But if this process did not work I was to have a bilateral operation which he informed me would require five weeks of bed rest for each ankle and if this was unsuccessful then, "complete ankle replacement” or as a last resort there was always fused anklesas an option. The standout bold type in the preceding sentences was all my brain absorbed.

After "fused” I shut down. All I heard was the waning ostinato of "wahwahwah wahwah wah”; similar to what I’m sure Charlie Brown heard from his phantasmalteacher. In my head I was running through all of my options regarding how I was going to continue living my life as I know it with fused ankles. How can I keep running, hiking, skiing, mountaineering, surfing, etc?, All these things I love to do. How do I keep being who I am with this set of threadbare tires I’ve got? I’m embarrassed to say I think I would have been less reactive to news of a death in the family.

After "fused” I shut down. All I heard was the waning ostinato of "wahwahwah wahwah wah”; similar to what I’m sure Charlie Brown heard from his phantasmal teacher. In my head I was running through all of my options regarding how I was going to continue living my life as I know it with fused ankles. How can I keep running, hiking, skiing, mountaineering, surfing, etc?, All these things I love to do. How do I keep being who I am with this set of threadbare tires I’ve got? I’m embarrassed to say I think I would have been less reactive to news of a death in the family.

After "fused” I shut down. All I heard was the waning ostinato of "wahwahwah wahwah wah”

It has been a few days now and I’ve managed to relax a bit and problem-solve the situation with a clearer head. However, I cannot help but reflect back to that moment in the doctor’s office trying to think of what I would have done differently if I were the one giving me the "bad” news. As an integrated behavioral health provider who consults with patients on a daily basis about medical issues, what could I have said or done that would have changed my experience?

I keep coming back to two different interactions—the first being with the podiatrist, the other with my mother. The podiatrist could tell that I was bummed and offered me some story from his youth dealing with "bad knees” and how he had to stop playing basketball. Not to be callous, but I have never been able to shoot, nor dribble a basketball and to be honest; I did not care if he could either. This basketball reference did nothing for me. I retreated. My mother, in her very sincere, genuine and overly pragmatic way offered me this: "that must be hard sweetie” followed by "Aren’t we glad you are not sick like Amy,”a high school friend of mine recently diagnosed with cancer. Strike two!

Please don’t misconstrue my sarcasm for antipathy towards my doctor, my mother, or my high school friend. I do consider myself blessed in most aspects of my life. I am grateful that my knees are good and I’m cancer free, but really neither of these things has anything to with troubleshooting my ankle recovery. Sympathy is not what I needed, nor wanted. Thinking back, what might have worked better was a bit of empathy, followed by some problem solving assistance. Second I wanted to play more of an active role in deciding what the treatment was going to be or to at least to feel like I did. Intellectually I knew that the emotional child in me was standing in the way of recovery, but in reality I wondered if I could just up and change all my activity?

Then what? If I was to remove something so important in my life (such as exercise) what was I going to replace it with? And, if I found that something, what would it take to actualize it all? Lastly, at some point I wanted to be asked if I had any questions. After I realized my brain had been shut off for the past five minutes, I had a lot of them.

This visit galvanized my faith in Motivational Interviewing as a very effective way of "being with" a patient. Sympathy, apathy and antipathy do nothing for bonding with a client. The relationship is created between the provider and the patient through the use of empathy for it helps in fostering the patient’s autonomy and hopefulness. Figuratively pulling up next to a patient and reflecting back to them their difficulties with the current situation and offering empathy in accordance to their experience. How could my doctor or my mother help if they had the same feelings and ideas about this situation? What may have been beneficial was a provision of a shared experience yet through a different lens; a different point of view based on similar, yet clearly different, experiences.

Using the examples once again from the doctor and my mother we can hopefully glean some insight into a better use of their words. The doctor, instead of leading into an unsolicited story of his declining athletic prowess could have led with a simple reflection "I can tell this is going to be hard for you" and then followed with an open-ended question "when I went through something similar playing basketball in my youth, I had a hard time too. How could I help you figure this out?". The difference between these two versions is slight, but very important. First, the reflection offers up empathy letting me know he is on my team, second, the request to offer suggestions encourages me to invite him in, become refractory to his attempt at aligning with me. I believe this slight modification would have changed my reaction to him and I could have left with a plan; thus giving me confidence that I could pull this off. From him I needed a plan. Regarding my mother, although she was just trying to make me feel better,she could have stopped at "that must be hard". Sometimes less is more. I Love you mom!

Pete Fifield is the Manager of Integration and Behavioral Health Services at Families First Health and Support Center; an FQHC in Portsmouth NH. Read more of his CFHA blog posts here.