“As a family physician for more than 40 years, I have seen countless patients struggling to alleviate chronic pain, with far too many turning to self-destructive coping methods such as alcohol and opioids. Unfortunately, the struggle with chronic pain isn’t going away – and more alarming is the fact that those suffering from it are getting younger and younger. The latest data on chronic pain show patients between age 18 and 34 are reporting the most chronic pain, and they are desperately seeking relief. It’s our job as physicians to help them. Right now, we may be failing.”

Resources mentioned in the show:

Healing Oriented Practices & Environments

Wayne B. Jonas is a family physician.

He shares his story and discusses his KevinMD article, “Listening to pain in our younger patients.”

Did you enjoy today’s episode?

Rate and review the show so more audiences can find The Podcast by KevinMD.

Subscribe on your favorite podcast app to get notified when a new episode comes out.

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

Also available in Category 1 CME bundles.

Powered by CMEfy – a seamless way for busy clinician learners to discover Internet Point-of-Care Learning opportunities that reward AMA PRA Category 1 Credit(s)™. Learn more at about.cmefy.com/cme-info

Do you know someone who might enjoy this episode? Share this episode with anyone who wants to hear health care stories filled with information, insight, and inspiration.

Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/follow.

Today on the show we have Wayne Jonas. He is a family physician, and he wrote the KevinMD article “Listening to pain in our younger patients.” Wayne, welcome to the show.

Wayne B. Jonas: Thank you very much, Kevin. It’s good to be here.

Kevin Pho: So we’ll get into the article in a little bit, but first off, share your story and journey to where you are today.

Wayne B. Jonas: Yeah, so I’m a primary care family physician. I did my residency and then 20 years of practice within the military, and the great benefit of that is I didn’t have to worry about payment, right? You hear over and over again, “Well, I can’t really do whole-person care, as family medicine is trained to do, because I can’t get it paid for.” Well, what I learned in the military is that I had full payment, all my patients were covered, and I still couldn’t do it.

The reason is that I actually didn’t learn how to address the underlying determinants of what actually produced healing. Medical treatment, the things I delivered in my day-to-day 15- to 20-minute visits, only addressed about 20 percent of the actual determinants of health. So I had to learn the other 80 and how to implement that in my practice.

Kevin Pho: So I’m a primary care internal medicine physician, and we know that physicians are in short supply when it comes to primary care. Now, for those medical students who may be listening to podcasts, tell them: What are the most rewarding aspects of primary care?

Wayne B. Jonas: Well, you know, in primary care, especially family medicine, and this is also true with internal medicine, pediatrics, etc., if you really want to help a patient heal, you’ve got to pay attention to the other things that actually cause that. What we do in medicine today is largely focused on the body. It’s largely focused on delivering medications. And we know that it’s behavior and lifestyle, and increasingly the social determinants of health, that make up the vast majority of what produces health and well-being.

So you need to find the tools that will allow you to do that. I wish that I had those tools, that I had those resources, and I wish I had learned more specifically how to find out what matters to my patients in their life, not from a medical perspective but from a person-centered perspective. This changes the entire discussion. It changes it from compliance, which is a challenging thing, to collaboration. It changes it from simply treatment to prevention, which is the job of primary care practices and docs.

And it gives you tools. You need to find those tools, learn about them, and use them, tools that aren’t simply how to prescribe medicine at a particular dose and how to switch them up when they don’t seem to work: non-drug approaches. We’ve seen this now in the pandemic, and the article on pain that I wrote says, and all the guidelines now say, do non-pharmacological approaches to chronic pain. So I wish I’d had those tools when I started out.

Kevin Pho: So let’s talk about that KevinMD article that you refer to. It’s titled “Listening to pain in our younger patients.” Now, for those who didn’t get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

Wayne B. Jonas: Yeah, well, we commissioned, at the foundation that I oversee, the health aspect, a survey, a national survey that looked at pain during the pandemic. We were alarmed at the fact that the epidemic of opioid use and chronic pain that occurred before the pandemic actually tripled in terms of deaths, for example, despite the fact that the individuals were saying, “Here, you need to stop using opioids as much,” and all the national efforts to do that. So we were surprised, really, at how deeply broken the pain management, the opioid management system was, and the pandemic actually put that on steroids, or put gasoline on the fire.

So we wanted to find out: Well, who is this affecting, and how is it affecting them? The thing that came out of that that was most surprising is that now the young people, individuals from 18 to 34, had higher chronic pain levels than older individuals. Normally we think of it the other way around, right? As you get older, you get arthritis, you get back pain, etc. But it was actually the younger individuals. And one of the reasons for that is the stress and the psychosocial problems that contribute to chronic pain, and we were not dealing with those things in those areas.

And so I wrote the article to try to give practitioners tools in order to actually address this in their day-to-day practice, and how to redesign their practice in a way that could address this underlying pain issue in a holistic and whole-person care way.

Kevin Pho: So go into more detail. Tell us about some of these tools that we should be using to find some of the psychosocial determinants of a younger patient’s pain.

Wayne B. Jonas: So our foundation, along with many, many other groups, has developed a set of practical tools for your average doc, and they don’t even have to be in primary care. We’re doing this in cancer care also now, with oncologists and orthopods and that type of thing. It’s a set of tools that we collectively call the HOPE Note toolkit. HOPE stands for Healing Oriented Practices and Environments.

Everybody learns about the SOAP note, right? You’ve got to write a SOAP note after you see somebody. It asks the patient, “What’s the matter with you?” You come up with a diagnosis and a treatment. But that leaves out many of these other aspects, the psychosocial, the behavioral, the components that make up the other 80 percent of what people get better with. And so the HOPE note is a structured, systematic way to actually have that conversation with patients and then bring those resources to your day-to-day practice.

We’ve worked closely with the Veterans Administration, which has been implementing this across their entire system. We just completed a 17-site primary care delivery network where they were implementing it in those areas. And the tools are actually on my website. They’re free. There’s a do-it-yourself guide for it. You can begin to access those, and you can deliver them tomorrow in your practice.

Kevin Pho: So take us into your exam room. Without having the HOPE note in front of us, what are some of the questions that you’ll be asking patients to get to the root cause of some of their issues?

Wayne B. Jonas: So there’s a very easy way to do this. When we started out, some of these conversations were a bit awkward, because when I started asking patients, “Well, what matters to you in your life? What kind of social support do you have? What stresses do you have? What’s your diet like?” and everything, at first they were sort of taken aback a little bit. They were like, “What? A doctor asking me questions about my life and about those types of things?” But once they understood that these were the underlying causes of their chronic problems, and that I was there to support their changes in those things, then they got very excited about it and very engaged in that process.

So we needed a quick and simple way to do that, and so we actually borrowed and adapted a very simple questionnaire we call the Personal Health Inventory. It’s a two-page questionnaire. You can hand it to your patients before the office visit, or you can have them fill it out online if you’re doing virtual visits and this type of thing. And it changes this whole conversation. It allows you to ask these questions in a non-awkward way in which they’re appreciated.

They start off with what matters to them, what’s meaningful and purposeful for them, and where their primary needs are, be it sleep, be it nutrition, be it activity, be it stress management. Those get highlighted, and then you can zero in and focus on those and provide those kinds of support and resources in those areas. And so that’s the approach and the tool. They’re on my website. For those who work in chronic pain, there’s a CME program that Tufts University has done that’s free that actually shows how you use those tools in chronic pain, which is what the survey was about.

Kevin Pho: So tell us a success story or a successful case study of how you use these tools, and kind of a before-and-after picture of that patient after successfully using those tools.

Wayne B. Jonas: Yeah, so let me give you a couple of brief ones, both of them in chronic pain, which is what the survey is about, and to show the holistic nature of this. For example, I had a patient who came in the other day. I work in a residency program; the residents saw the patient, et cetera. This was a veteran who had come in multiple times trying to get prescriptions for opioids, for psychotropics, etc., and the reason he made the appointment is that he wanted to ask about CBD. He wanted to know if he should start doing marijuana in those areas.

This was a guy who had not only chronic pain. He had, as many of the patients that I see have, PTSD. He had been deployed. He’d had some traumatic brain injury in those areas. He had depression. He had anxiety, as well as some other chronic illnesses. The resident saw him, presented the case to me, and said, “Well, I think we need to change his psychotropic medicine to gabapentin.” He wanted to change his medicine. That was the tool the resident had. The patient wanted to know about CBD. That was the tool he wanted.

I gave him the PHI, and we did a HOPE note with him. The first thing I said is, “Where’s your social support? What kind of social support do you get?” Because he had written on his Personal Health Inventory, in answer to that question, “What’s the most important thing in your life?” he said, “My cat and my wife.” And I said, “Tell me about that.” This guy was isolated, lonely. His cat was his companion during the day, and his wife was his support during the night. He was so paranoid, so difficult, that he didn’t want to actually address his fundamental problem, which was loneliness. It wasn’t a lack of gabapentin or CBD. Those had been tried in those areas.

So we actually got him engaged in journaling, where he began to write about his issues, and we got him engaged in a yoga group with similar people to him, other veterans. He had one of those groups that was done, and he began to socialize about that. The combination of journaling and the yoga gave him an ability to address his loneliness and his pain simultaneously. And in a period of about six months, his pain was less. He started to get off his medications, and he began to actually look for a job.

That’s an example. He’d had long-term multiple visits, lots of expenses, lots of costs to the health care system, which are now on their way to lower cost, improved healing, and better function.

Kevin Pho: We’re talking to Wayne Jonas. He’s a family physician. He wrote the KevinMD article “Listening to pain in our younger patients.” Wayne, I understand you recently wrote a book on this issue.

Wayne B. Jonas: Yes, I did. It’s about my experiences in trying to address the underlying determinants of healing. It’s called “How Healing Works.” It goes through the four dimensions that actually produce healing. It is the framework around which the tools, the HOPE Note toolkit that I just described, and those resources were created. And so it’s not only the background, with examples of how it happened, but it also points you to those tools to do that.

Kevin Pho: Now, you don’t need me to tell you that in primary care, more and more clinicians are squeezed for time. There’s more bureaucratic burden, more clicks on the electronic medical record. Now, how do you reconcile that decreasing or diminishing time with getting to the bottom of the social determinants of a patient’s issues?

Wayne B. Jonas: Well, first let me point out, Kevin, that you’re already spending way more time than you need to. You’re just doing it in small increments, right? Because you need to bill for it, all right? And so you have people coming back who haven’t had their issues addressed at the fundamental causative level, and so you’re just palliating, and so you’re already spending a lot of time to do that. So if you can structure your practice, and there are examples of the way this has been done, and there are payment models that allow you to do this, and that’s in our toolkit, for example, on how to do that, then you can actually spend less time being much more effective in getting at the healing component. So let me just point that out.

Now, if you work in a system that won’t allow you to do that, what we’ve done with the tools, with the Personal Health Inventory and the HOPE Note toolkit, is structure them in a way where you could begin to at least get at the core issues. So, for example, say you don’t have an hour to go over the underlying determinants of health for an entire patient like the one I just described. But what they indicate on their PHI, what they indicate as person-centered here, is that sleep is the key issue. Then you pull that out, you begin to bring in some resources and interventions to facilitate the sleep, and then you follow up as you would normally.

So you can fit this into a shorter, incremental time, but you’ve got to reframe the conversation so they understand and are interested in what you’re doing, and they know you’re going to be with them on the healing journey. You’re not just going to throw a pill and a pro or a procedure at them.

Kevin Pho: And my final question: What are some of your take-home messages that you want to leave with the KevinMD audience?

Wayne B. Jonas: Well, I think the key issue here is that the pandemic has illustrated a deeply broken system that we have. That’s sad, but the flip side of that is it has created a readiness to change. I see this across a number of groups that we work with: thought leaders, payers, and policymakers are all saying, “We really need to redesign and re-transform these areas.” The way that’s going to happen is if the clinician does it. They work in a system; don’t be disempowered by the system. Figure out how to do it.

The tools are there. They’re available. If there’s one thing that you can do tomorrow, download from my website the Personal Health Inventory, the two-pager. Hand it to a patient and have a conversation with them around what comes out of that. This will open up their eyes, open up your eyes, and lead to a new way of delivering care that gets at the fundamental causes of health and healing.

Kevin Pho: So I’ll include a link to the tools in the show notes. But for those listening, how can people find that toolkit, and how can people reach you?

Wayne B. Jonas: So it’s at my website. It’s just my name, DrWayneJonas.com. And if you just look for Resources, or you go to backslash hope, DrWayneJonas.com backslash H-O-P-E, you’ll go right to that toolkit, and there are multiple other resources. They’re all free. I work at the Samueli Foundation, which funds all of this and is making it available anywhere in the world.

Kevin Pho: Wayne, thank you so much for sharing your time and insight, and thanks again for being on the show.

Wayne B. Jonas: Good to be here. Thank you, Kevin.