Seeking inspiration daily as a pain clinician

When I finally arrived at my decision to be a pain specialist, it was after much hard work and considerations on a personal front. However, many of my professional colleagues had their hesitations for me : "Are you crazy?"; "Why would you do this to yourself"; "Why would you want to listen to suffering all day?"; 

Their doubts for me, made me seek out the deepest reason to continue down this path in clinical care - I desire to be a pain specialist for as long as I seek inspiration from my patients, everyday of my practice..

I wrote this poem in the Spring of 2014, and now it is stuck right above my work station. 

Its a daily ritual now…or even a prayer. Everyday, after I fill my cup with hot water for tea, I read this, reflect on it for a few minutes before I begin my day. It keeps me engaged on this purpose, this drive that brings me to work daily and do this job that I do consider to be a great privilege. 

May I remember this….

May I remember this for you, 
with you, 
but may I know that I can never carry any, for you.

May I be moved yet resilient,
for our collective struggles, 
May we discover that curiosity, 
That lost trail that rejuvenates every time…

May I be the rock, 
timeless and enduring at once, 
May I learn in that silence, that we breathe reassured...

May I be the canvas,
to paint, spill and pour 
May I also be there when it peels off and withers away...

May I be the sieve, 
to filter, sort and reflect 
May I see it different but never know more or know better.

May I have a moment of light, 
That I share with you in privilege ..
That sense of familiar with you, 
a stranger,
That makes it all worth at once, for ever…

May be it would be a scavenger hunt,
I with a list and you discover,
May we find all that we are looking for...

And as we part, 
With our shades on,
May I know that humbling truth
that the honor has always been mine - to nurture and to grow,
In those moments of light, darkness and rainbows…

Massage reduces inflammation and promotes growth of new mitochondria following strenuous exercise, study finds

A well designed study published recently in the journal Science Translational Medicine, finds that massage reduces inflammation using muscle biopsy and specifically looks at inflammatory biomarkers for muscle pain.

Its nice to see science catch up with patient experience...Although, we need studies done in the chronic pain population. The implicit concern here, is the symbolism of athletes somehow having legitimate pain, warranting a massage.

Inflammatory pain of musculoskeletal origin is tough to study and specific biomarkers are key to be tracked. I look forward to similar studies in the chronic pain population. This is what translational medicine is all about.

When it comes to pain - who hurts more?

"Men vs Women on Pain- Who hurts more"?
This is the title to the article that was recently published in the TIME magazine: http://healthland.time.com/2012/01/23/men-vs-women-on-pain-who-hurts-more/

The abstract for the original study the article was basing its information on, can be accessed here:
http://www.ncbi.nlm.nih.gov/pubmed/22245360

The original study's main objective seems to be, to highlight the value of electronic medical record in driving scientific research as it provides ready access to a huge pool of patient information. Then it appears to end with the calls for "increased attention to this idea" of sex differences in pain scale ratings.

The main conclusion from the study:

- Women report higher pain intensity than men, up to one whole point higher than men in a 0-10 scale.

The explanation suggested for this:
- Hormonal differences
- Cultural/social stereotyping with men being tough especially if a female nurse is the one asking the question.

This information is well known to the clinician community. Up to 80% of the patients in the head and neck pain population are female. It is true that research has time and again evaluated the role of hormonal factors influencing pain quality and presentation in female versus male patients. Also, there are studies that validate the influence of cultural stereotyping in patient's pain ratings and hence these two explanations are valid and appropriate references.

However, I do find it is interesting how Dr. Atul Butte ends the interview with the Time magazine.

“The reasons may be biological or they may not be, but we should still be aware of the bias that patients have in reporting pain,” he says. He is hoping to continue the research by following up these results with surveys of patients’ ratings after they were treated for pain. That may help doctors to better address the real pain patients may be feeling."

Ouch...
What Dr. Butte calls as "bias that patients have" here, can very well be the context of the patient's suffering that needs to be assessed clinically. When a patient rates his or her pain, the number is an indicator of both the physical intensity of the pain and the pain's emotional impact on the quality of his or her life and overall wellness. There are numerous studies in epidemiology that analyses subjective data like pain through questionnaires that do not ENTIRELY rely on the 0-10 pain scale. For example, more and more studies look at the impact of the patient's pain on the quality of their life using concurrent assessment tools for those.


Hence calling the pain scale differences as patient "bias" is quite off the mark. It is also unfortunate that the TIME magazine ends with the statement on , "better understanding of the patient's real pain" ....


An effective clinician believes the following:
"All of the patients' pain is real...It is the clinician's work to assess, evaluate and help them manage the symptoms- physical, emotional and all. To the patients, pain validation is at least as significant as the pain cure. The true bias in pain assessment lies with the doctors and that's where the awareness needs to be. 

The "art" in pain management

I enjoy art. To experience art, and especially to experience art in the making, is timeless. Why talk about art in a pain blog?

When I was in dental school and then in grad school, echoes of phrases such as  “the art and science in medicine…the art and science in dentistry” would be heard throughout the course of many lectures and talk. The art in medicine and dentistry was predominantly meant as the skill-set that required expertise in technique. However, to me, the “art” in health care is the openness and creativity that underlies every doctor-patient interaction.

Every patient, new or previously known to the doctor is a new experience. Each time the doctor interacts with a patient, the space is open. It is magical if both the participants walk in with an open-mind. Although, It is quite something to watch the pre-conceptions color a conversation, it makes it more exciting as the space opens up in that conversation to allow for a healing interaction – both ways.

The technique in health care- both medicine and dentistry is imperative. Without it there is no core. It is the very skeleton to that trusting bond between the doctor and patient. But the art is the life of that interaction. Art lies where the doctor uses his or her intellectual, emotional and technical skill sets in a creative, patient-centered manner. It lies in steering the conversation as it un-folds. It lies in being open from moment to moment to receive what the patient has to say and then guide appropriately, in terms of the treatment.

In my clinical practice, when I present treatment options, often times I use the analogy of an empty room with multiple doors. The patients choose the treatment that suites their belief, their needs and personal goals. The technical expertise lies in defining those treatment choices for the patient, but it is indeed an art, in exploring the patient’s needs in their own terms and then watch it all unfold in front of you.  Art give that interaction a certain element of timelessness. Already, for a lot of chronic pain patients, time is irrelevant, as they have tried so many “interventions” and treatments over so many years. Hence, sometimes, a patient conversation lasts 60 minutes and sometimes its 10 or even 5 minutes, but the time is only guided by the patient’s goals. It can also be influenced by the doctors intentions, but I have found it best to be a receiver and then a guide than first the guide and then the receiver.

So, this is something I emphasize to visiting students here…allow your expertise to be your core strength, but develop an openness to your patients, and a certain awareness…develop a compassion to listen to your patients and a certain readiness to be in the moment of those three important words…clinical decision making…because there in lies the he-“art “ of medicine.

The skill set of a "good doctor"..

Each one of us have been through this process ourselves when we go to visit a doctor...Whether it is a routine wellness check up or a sick visit, each time, the visit reinforces the trust or lack there of based on our interactions with the doctor. The initial appointment is all about gauging the trust factor. Its based on the biography of the doctor we "google" up, the doctor's chair-side manner, but most importantly the doctor's ability to instill the confidence in us with respect to the treatment course. That confidence is distilled from clarity in their clinical decision making, what they call as "thinking on their feet".

In my teaching world to budding dentists, I talk to them extensively about building their strength in listening to the patients- both to their verbal as well as their non-verbal communication, synthesizing the information they gather during the interaction to arrive at a clear, treatment course based on quick distilled clinical decision making process.

To my joy, I see the medical education here reforming. Now, in their interview process for future doctors they have started to look for just this ability- the ability to "think on their feet"- decision making.

This article recently published in NY Times, gives an insight into this refreshing change:
http://www.nytimes.com/2011/07/11/health/policy/11docs.html

As much as academic training and textbook knowledge empowers a professional, it is their ability to integrate that training in a clinical setting with good listening skills, and arrive at clear decisions  that makes him or her a good doctor.

So, your next doctor visit how do you know he or she is a "good doctor"?

- Professional demeanor (chair-side manner)
- Professional training biography
- Confidence that instills trust in you, through eye contact and  body language.
- Clarity in educating you with the diagnoses
- Good listening skills and taking the time for that.
- Effective communicator of the course of treatment based on a clearly thought out clinical decision making path.

From one doctor to another....

I recently listened to an inspiring interview of a physician on the radio. It was one of those "highway moments" where you want to pull over because what you are listening to is so insightful and calls for all your attention.


Dr. David Loxtercamp , or simply "the country doctor" as he likes to call himself shared his inspirations and experiences which I see deeply resonate with myself in my clinical practice and I'm sure my colleagues can relate to as well.  You can listen to his interview and discussion here.


I have shared some of the quotable quotes that I carry with me now, since his conversations.  I have even taken the liberty and borrow it for my patients, but always try and reference him.

• "Health is not a commodity. Risk factors are not disease. Aging is not an illness."
•  "To fix a problem is easy, to sit with another suffering is hard."

• "Patients cannot see outside their pain, we cannot see in, relationship is the only bridge between. Time is precious; we spend it on what we value."

And two of my most favorite quotes:

• "The most common condition we treat is unhappiness. And the greatest obstacle to treating a patient’s unhappiness is our own." 
• "The foundation of medicine is friendship, conversation and hope.”

For anyone interested in knowing more, I recommend his book, "A Measure of Days: The Journal of a Country Doctor". Its definitely biographical as the title suggests, so be prepared for a slow, but interesting read.

Softer food, smaller bite-size - but of course follow the new USDA food plate guideline!

Summer is the time for corn-on-the-cob, but for someone with recurrent jaw pain and jaw locking symptoms, the thought of biting into corn-on-the-cob can be unpleasant and at time fear-invoking due to the risks associated with a painful jaw locking. 

To our Temporomandibular joints (TMJs) , activities such as yawning, taking a bite off a sandwich, can be extremely demanding in joint stability, integrity and conditioning. Also, chewing movements that are complex, whether it is chewing gum, meat or crunchy foods like carrots, can be demanding in terms of the musculoskeletal endurance.

The common advice that facial pain clinicians give for painful jaw symptoms is the recommendation to eat softer foods in smaller bite-size. Why softer food and not soft-soft food or hard foods? - The chewing system of TMJs and muscles need to stay active to the right extent avoiding fatiguing risks as well as avoidance-related muscle guarding and/or disuse risks. Why smaller bite-sizes? - For smaller bite-sizes, the range of motion of these ball-and-socket joints is limited to a mostly symmetrical hinge movement which facilitates stability thus avoiding a risk for locking with unstable extremes of range of motion.

So, with the new USDA plate replacing the food pyramid, which I'm all in favor of by the way, keep in mind to not take for granted, those well oiled biomechanical powerhouses in your face that help you enjoy your fruits, vegetables, grains and protein, one small soft bite at a time!