A few years ago, I evaluated a retired businessman for pain down the front of his right leg. It had begun about eight months earlier. The pain was moderate but frustrating. He had not experienced prior back problems and was not used to dealing with pain. It was unclear what might have precipitated this pain. His wife, who was a retired businesswoman, accompanied him.
Defining the problem
I mail an extensive twelve-page spine questionnaire to my new patients. It includes questions about sleep, stress, work, as well as medical and family issues. I noticed before I walked into the room that he had only filled out the part of the form dealing with his spine pain and medical problems, but he had skipped the questions that dealt with any personal issues. I looked at the MRI of his lower back before I walked into the room and noticed that there were some small bone spurs, but they were on the opposite side of his body than they would need to be in order to cause his symptoms. This meant that I did not have a structural explanation for his symptoms.
I walked into the room and explained that I needed to have him fill out the rest of the intake questionnaire before I could fully engage in the interview. I walked in about five minutes later and he stated that he did not want to fill the personal profile section because he was not a chronic pain patient. I took about ten minutes to explain that even if there was a structural problem that I could fix, I felt that surgery was only about a third of the solution. I felt that rehab and conditioning was a third, and that dealing with the central nervous system was at least a third of any solution. I also explained the phenomenon of phantom limb pain and that after six months of pain the neurological circuits were a major factor. It was my wish to give him the best chance at a good result if surgery was required. I had not even gotten to the fact that I did not see anything I could operate on and that I was planning to order more tests.
“I am not angry”
Well, to make a long difficult story short, he started to scream at me that he was not angry and that all he needed was an operation to solve the problem and to get on with his life. He had a long vacation planned in three weeks. He turned to his wife and said, “Well Mrs. X, what do you think about what he is saying?” Her reply was, “I think you had better listen to him.” I finally had to bring in my most experienced nurse to talk to him. She could not calm him down and offered to have him see one of my partners.
I have watched countless patients succeed and fail at surgery. If I perform a surgery based on questionable lesions, it almost always fails. If I operate on patients who have refused to engage in the overall rehab program, the results are OK but often not great. The patient will often become very focused on the small amount of residual pain or pain in another area of their body and are often still unhappy. My patients who fully engage in the rehab program usually become essentially pain free. This includes both surgical and non-surgical patients. If there is residual pain it is not a major issue. As they move on with their lives, it becomes a non-issue.
What should I do?
I was not happy about any part of the interaction with this angry patient. I am continually challenged by my inability to break through to a given patient in a situation like this. Should I have waited to present my practice concepts until the second visit after the myelogram was done? Would it be better if I requested that a new patient read some of my material before they meet me? Should I just proceed with surgery knowing that the results are not what they could be?
I occasionally get through to many patients who are extremely angry but I frequently fail. In fact, I would say that every patient I work with in chronic pain is pretty frustrated. Somewhere between three to six months into this process, while working through anger issues, the pain will often markedly abate. I don’t wait until that point to perform surgery if it is required. I just need to have a working relationship with them. Know your surgeon – before surgery
The DOC project is a work in progress and I am a work in progress. Anger is a huge block to success in this program. My first challenge is to continue on my own journey and see when and where I am blocked. In doing so, I will have a much better chance of figuring all of this out.