Book update, and why are CES conversations difficult?
Thanks for reading the 49th edition of my newsletter. This newsletter tracks my research as I write a book about sciatica, and another one (out soon) about cauda equina syndrome.
Hello from McDonalds,
I'm a full time dad, which means most of this CES book has been drafted, written and edited in our apartment, either before baby Hannah wakes up or during her nap times. Here's a photo of my ‘work station’ from shortly after she was born…
At the moment, my parents are visiting from England. They can look after Hannah, which gives me time to work elsewhere, like this McDonalds. It's a luxury to concentrate without one eye on a baby monitor. And as you can imagine, I've been much more productive since they got here.
Which means the CES book is pretty much finished! We're waiting for a few expert readers to get back to us. Some expert readers have already given the book their thumbs up, as well as added some invaluable suggestions.
I ordered a test printing from a printing company, which arrived last week. The book seemed good quality to me so we'll use that printing company for the final run.
In the old days, you used to have to guess how many books you'd sell, order that many, and then keep them in a warehouse or your garage and post each one out individually. These days, you can use a 'print-on-demand' service. Essentially this means the customer orders the book from you, and the print-on-demand service gets pinged to say 'print one book and post it directly to this customer'. Much better than us doing the warehousing and posting ourselves. Each printed-on-demand copy of the book costs about $7, which I think is pretty good and means we shouldn't have to charge too much for the end product (although there will be other fees and overheads).
I'm also pleased to say that instead of just a pdf (like the last book), this one will be available in epub, so it will transfer and format well for kindle etc. Step by step, I'm getting more professional at all this.
As long as there's no snags with the printing, we should make our publication date of Tuesday 28th June!
Why are CES conversations difficult?
We've aimed to make our book about more than just giving people information. As well, we want to coach people through all the difficulties that come with managing potential CES.
One of these difficulties is speaking openly and plainly to patients about the symptoms of CES. For some reason, CES conversations in particular can be overly short and closed off, or fraught with misunderstandings and missed connections. This week I wanted to think a bit about why that is. Here are a few possible reasons I can think of:
We avoid CES conversations because we’re not confident navigating them
This was a big one for me for a long time. If I was asking someone about their bladder function, or their sexual function, I'd be really worried that they would say anything other than 'everything's fine', because that would mean I'd have to try to navigate a conversation about the topic. So, half subconsciously, I would ask really bad CES questions to avoid having to get into a proper CES discussion.
For example, I'd ask closed questions that nudged my patient to tell me nothing was wrong so we could move on, questions like ‘No problems with your bladder and bowels then? Good. And no loss of feeling between your legs?’
The obvious answer to this lack of confidence is to learn more about CES. Just knowing more stuff does solve a lot of problems, and this is one of them.
Another important thing though is to get into the habit of asking a very simple and very useful question: ‘Is that normal for you?’ I find this question often gets you out of trouble when you’re getting lost in a CES conversation. After all, you might not be an expert in sexual dysfunction, but the patient is the expert in their symptoms and what’s normal for them. Let them guide you!
The curse of knowledge stops us from speaking plainly
I've written before about the curse of knowledge, the phenomenon that once you know something it's very hard to simplify it for other people.
One obvious way the curse of knowledge spoils CES conversations is the phrase 'the saddle area'. This phrase means nothing to anyone who isn't in our little clinical circle. (The best misunderstanding I've ever heard for 'the saddle area' was from someone who thought it was the area of their back that would be covered if they were wearing the saddle).
The curse of knowledge also hides in less obvious places. I'm certainly guilty of using CES-related phrases like 'the sensation between your legs', 'a potential injury to the nerves in your spine', 'urinary incontinence', 'sensation in your skin' and 'emergency care'. I'm fairly certain those phrases aren't properly understood by many laypeople. I certainly didn't really understand them before I became a physio.
One answer to the curse of knowledge is to simplify your language, as you would do anyway, but then to account for the curse you simplify your language again, past the point where you feel you need to. For example, when asking about bladder and bowel function, it might be a good idea to use words like 'wee' and 'poo’.
And a good way to ask about saddle sensation might be to describe the area properly: ‘the skin between your legs: around your private parts, around your back passage, or the skin between the two; or the bum cheeks and between your thighs’.
We're embarrassed to use simple language
It's all very well to say 'simplify your language', but there's a reason we like our complicated language and euphemisms which is they save both parties from feeling embarrassed. 'Saddle area' is one such euphemism, as is 'sexual function' and 'bowel movement'. Arguably, I've used some euphemisms in the previous point, 'back passage' and 'private parts', when I should have said 'anus' and 'genitals'.
I think most of the embarrassment here is on the clinician’s side, not the patient’s. In my experience, many MSK clinicians understandably baulk at asking their patients about erections and orgasms because we’re just not that practiced at it. But most patients are comfortable with licensed healthcare professionals asking them about such things and take it in their stride. Maybe I’m wrong.
I used to feel pretty embarrassed about using certain very simple and clear words with my patients, but I found that embarrassment eased quickly if I just kept at it. I also found it helped to say something like ‘This is probably the most personal thing I’m going to ask you today, apologies if it’s a bit embarrassing but I have to ask….’
We don't want to talk down patients
Closely related to the fear of embarrassing your patient is the fear of patronising them. This one always bothered me a lot. Using words like 'poo', 'pee’ or 'wee', I would worry that my patient would think 'Why is he talking to me like a child?'
One answer to this is to guess your patient's preferred 'level' of communication. Maybe they’re okay with ‘defecate’ and ‘urinate’? Often this does work, but you can fall victim of the curse of knowledge again because you are likely to over-estimate your patient’s level of understanding. Maybe it’s safer to stick with the simple words but just explain why. Something like 'I’ll use very simple language, so I’m sorry if it sounds silly but it’s just really important to be clear…'
In my opinion, even with patients whom we suspect might understand our lingo, such as doctors, nurses and scientists, it’s often best to stick to the simple words and phrases. For patients like this, you can just strengthen that face-saving preface, saying something like 'Please don’t take this as patronising, but just so we’re clear about everything I'm going to use the same language as I do with all my patients'.
Well, those are my thoughts on why CES conversations are often so cagey and marred my missed connections. One of the reasons I wanted to write this book with my coauthor Rob is that I had always found CES to be difficult, especially this aspect of CES (and Rob had always helped me through it). Hopefully reading these points might help you a bit if you have trouble with this too! I’m curious to hear your thoughts—do get in touch!
Okay, back to work now. 28 June is coming up fast…
Til next time,
Tom