Doctor Versus Patient—The Case of Chronic PainDr. Matthew Edlund, MD, MOH
When words don’t mean the same things to people
Posted July 16, 2012
If there are fifteen treatments for an illness, chances are good that many don’t work very well. That’s the case with chronic pain.
Pain is really an information issue. The brain senses something is very awry. We then call that feeling pain. And our sense of pain may have nothing to do with medical test results.
Example: the gut does not have pain receptors. We have pressure receptors. Pressure is perceived as pain. Blow your colon up with air in order to perform a colonoscopy and people might feel a lot of pain. But put a red hot poker through the gut of a live animal and there may be little pain at first.
Example: my grandmother had a spine that looked like a Roman ruin. She did not complain of back pain, though surgeons might have been quite eager to treat her. How do we know? A famous San Francisco study of 100 people without back pain whose CT scans showed “abnormalities” in 39%. The surgeons felt that 6% needed surgery, 3% “emergently.”
Translation: people can have horrible test results with no pain. They can have “perfect” X rays, MRI and test results and experience horrific pain.
Eighty percent of the adult population complains about back pain. But what happens when it becomes so severe that it wrecks your life? That’s one of many places where physicians and patients come to odds.
Tale of an Operation
One of my patients is a woman who has been miserable. Pain rules her life. She has gone from surgeon to surgeon, pain doctor to pain doctor. Highly intelligent and empathetic, she has sleep apnea and depression as part of the picture, as well as a tragic history.
But like anybody else in her situation, she will do almost anything to feel better—or at least decrease the pain. Not much has worked. So when a surgeon told her he could fix a “really wobbly” joint in her back she took the chance.
According to her, he originally told her it would take 3 months to feel better; three months where she might be mostly bed bound. She said she understood.
The surgery went according to plan, but the pain did not die out. Fluid appeared through the lower back. Sometimes the pain was worse. She started looking things up on the Net. Many people wrote that after similar surgery it took a year to get better.
Conversations between her and the surgeon go like this:
Patient: “I still have a lot of pain.”
Doctor: “The surgery went well. Let me show you. All the screws are in the right place. The joint looks good.”
Patient: “I’m still in pain. What can you do about it?”
Different Definitions of Health
Patient and physician goals may appear to be the same. Yet often they are not.
My patient’s goal was to at the least to decrease her pain. A wobbly joint was uncomfortable but something she could live with. That it was increasing her intolerable pain was, however, not tolerable.
The surgeon saw a “lesion.” The joint was out of whack. He could fix it. If he fixed that joint, her pain should should go away. It did not. But that was not “his” problem. He had fixed the joint. It looked great on x-ray.
His job was done.
Both patient and physician are now dissatisfied. The patient continues to feel awful—that the difficulties she went through with surgery were for nought. The surgeon is dissatisfied that the patient did not respect his good handiwork.
Were the different interests of patient and physician discussed before the operation?
From the standpoint of medical “science” chronic pain often does not make sense. People with horrible test results have no pain, people with “good” results have lots. From an information based, regenerative model, however, they are more understandable.
Pain is a perception by the body. Perceptions can and are changed by environment; mood; circumstance; age; sex; other intercurrent medical conditions; family life; social support; religious expectations, and culture, just to name a few factors.
All of them change the information matrix. All change what people perceive. In pain experiments, expectation can vastly increase or decrease people’s sense of pain. Yet few patients have such a comprehensive view of what is happening.
And few physicians. Physicians are taught to look at what they can see and measure. It’s hard to measure “environment”, or “depression”, or “culture.” Often when it’s hard to measure things it’s easier not to.
So you do what you can do. You see a joint you can fix. You fix it. If the patient doesn’t feel better—well, that’s out of my department. I did my job.
Patients notice their symptoms. If they’re better, the physician is great. If not, he’s a loser. But symptoms often don’t line up with tests—or much of what people can measure.
A Way Out
The regeneration paradigm of health takes a different tack. Health is about well-being—physical, mental, social and spiritual. Under this paradigm, the patient can look at all the different aspects of what affects health—and then do what she can to make it better on her own.
She can also look at what medical care has to offer—where it might help regeneration—and where it might not.
As part of this different health perspective, physicians could listen to the problem, explain the limits of their understanding and talent, explain what probably might help, and what would not. And they would treat the patient not the joint. If surgery did not help, they could point to other treatments, other therapies, other social and psychological supports, other points of view that might help.
But such a regenerative approach takes time and much effort. Physicians are usually paid for treatments, not education. With a few exceptions, the less time they spend talking to patients, the more money they can make. Procedures pay—not long office visits describing the limits and probable success of medical treatment.
So patient and physician remain at odds. They often don’t realize their goals are different.
Or that they’re talking about different things.
Dr. Matthew Edlund, M.D., M.O.H., is an internationally recognized expert on rest, sleep, and body clocks. His books include The Body Clock Advantage, Designed to Last, and Psychological Time and Mental Illness. His new book, The Power of Rest, shows that rest is a skill that rebuilds, renews, and rewires mind and body, and can increase productivity, health, and pleasure. For more information, visit his website, TheRestDoctor.com. You can also subscribe to his new Fitcast via the iTunes Store.