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!

Does Ritalin/Adderall cause teeth grinding?

This is a question that gets frequently asked by my patients.  Attention deficit Hyperactivity disorder (ADHD) is the most common neuropsychiatric disorder diagnosed in children but more and more adults are also being diagnosed with this condition. Patients with this diagnosis also tend to have other comorbid disorders such as anxiety and obsessive compulsive disorder. Ritalin (Methylphenidate) and Adderall (Dextroamphetamine) are medications that have gained clinical traction for their effectiveness in the management of ADHD.

Based on systematic clinical observations, patients with ADHD tend to have higher co-occurrence of oral habits such as nail-biting, teeth clenching, a phenomenon also known with anxiety disorders. So, these patients on Ritalin or Adderall may already have a higher tendency for oral habits of teeth clenching or teeth grinding.

With respect to Ritalin and Adderall, teeth-grinding is not listed as one of the significant side effects by the manufacturers. The side effect listed is "involuntary muscle contraction" which can be only vaguely correlated for jaw clenching/ or teeth grinding. Indeed scientific research is also lacking in evidence for direct correlation.  However, plenty of anecdotal evidence exists, as well as published case reports suggesting that Ritalin especially can contribute to increased teeth grinding.

So what can we conclude?

• If you are diagnosed with ADHD by your physician, and are on either Ritalin or Adderall, inform your dentist about the new medication so that your dentist can observe for teeth wear pattern.
•  If you already know you grind your teeth, and you are beginning a new medication, obtain a night time mouthguard for teeth grinding through your dentist/facial pain specialist who can monitor your oral health and behavior for you.
• If you have ongoing TMJ disorder and you are beginning to take Ritalin or Adderall, inform your specialist on the new diagnosis and treatment plan, as increased bruxism can also potentially aggravate your TMJ disorder related symptoms.

Listing some references on this topic:

- Behavioral and orofacial characteristics of children with attention-deficit hyperactivity disorder during a dental visit, J Clinc Ped Dent (2006), vol. 30 iss. 3, pg. 183.

- Adverse response to methylphenidate in combination with valproic acid, J child & Adolesc Psychopharmacol (2000), vol. 10, iss. 1, pg.39.

Not coping with stress may increase teeth-grinding

An article that appeared in Time magazine cites a single study discussing the relationship of poor stress coping to increased teeth grinding. Both doctors and the scientific community have known this connection for years.

You can find the original Time Magazine article here:-

Not coping with stress may increase teeth-grinding

Although up to 70% of people who grind their teeth do not report having jaw pain or other TMJ disorder related symptoms, some people do experience jaw pain, and grind their teeth and recognize their difficulty in coping with stress.

The enamel (the outermost layer of our teeth) wears down in a distinct manner if you were grinding your teeth and this can be identified by your dentist. So if you recognize recent difficulty to cope with stress and you are experiencing jaw pain or headaches, talk to you dentist.

Teeth grinding as a response to stress is believed to a subconscious reflex driven by a part of our brain called the limbic system that co-ordinates all our primitive responses to stress. Cognitive Behavioral therapy and relaxation therapy through a trained health psychologist are very effective strategies  to decrease the distress from the teeth grinding behavior. Unfortunately, due to the social bias regarding these treatment options, people hesitate to seek the support. But with more scientific data shedding light on the benefits of these treatment options,  and with more and more health care professionals becoming aware of those benefits, patients can seek support from their dentists and doctors more readily.

So, thank you Time magazine for not feeding into popular myths but really featuring what is clearly important information that needed validation.