Tips for treating patients suffering from chronic pain

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“You are the worst doctor I have ever met.”

This was the second patient in a row to explode at me when I explained that further back surgery for his back pain had a low chance of success. I spent a couple of minutes explaining the many successes of our hospital’s pain program. Then he exploded again: “You mean I drove five hours just to hear you tell me that you are not going to perform surgery.” He stomped out, cursing all the way down the hall.

The vast majority of my patients who came in after were eager to engage in their health and many had made significant strides. One woman whom I had written off as having given up on herself came in on fire and ready to take on the world. It was both unexpected and inspiring. Nevertheless, it’s tough not to reel from experiences like that early one.

Patients in chronic pain are usually angry. They are trapped by a very unpleasant physical sensation, and it’s easy for them to feel (sometimes rightly) that friends, family, employers, and even physicians don’t understand or believe them. They are offered endless treatments, few of which have proven to be effective, meaning their hopes are regularly dashed. In their view, no one has helped them and you — their new doctor — are most likely next in line. You know this panoply of emotions, so it’s understandable to walk into a chronic pain patient’s room with a bit of dread.

Here’s what you can do.

Start by finding agreement

Human minds function as mirror neurons. Certain behaviors will trigger activity in a similar part of the other person’s brain. The result is that both parties are quickly agitated. Over time, just the anticipation of a tense visit produces anxiety. It’s no wonder that the vast majority of physicians dislike treating chronic pain. They feel manipulated, intimidated, and helpless.

It took me a couple of decades and many harsh experiences before I realized that I could not persuade an angry pain patient to let go of all that frustration in a single, short office visit. The most compassionate thing I could do was to start to build trust. For this, the Stanford psychiatrist David Burns teaches two major approaches: First, you have to not take anything personally. Second, acknowledge their emotions by finding a way to agree. The moment you do this, you eliminate the justification to argue, effectively killing any perceived conflict.

Use the “open hands” approach

Another lesson I learned from Burns was that the more we try to convince vexed patients to engage, the more they will resist. They needs to feel thoroughly heard out first. This means listening through their whole story, even if it takes away precious minutes from explaining options. In fact, I have found out that simply giving some material to consider and letting them know they can contact me anytime has significantly increased their likelihood of taking action and working together with me to improve health.

Don’t stop at labels

Assigning labels to others isn’t inherently evil. It’s part of the human experience and necessary for survival. However, it is also critical to be aware of the labels you place on people — especially patients suffering from chronic pain — and to work around these to discover the person underneath. Taking the time to get to know your patients is one of the best ways to help them feel heard (and they are). This, in turn, creates a starting point for collaboration.

Don’t use an operation as a conflict resolution tool

Obviously, if an operation is indicated, you do it. However, I used to think that in situations where the answer was less clear — when the best result might be just a little less pain — surgery might be a good option for people who really wanted it. This approach has rarely worked and even recently when I should have known better I have watched several patients become significantly worse with pain spreading throughout their whole body. Remember that you are forming a close relationship with any individual you are performing procedures on. This relationship is disrupted if expectations are not met, and it will become harder for you to help in the future.

Enjoy your job

Revisiting the idea of mirroring: When you laugh others will laugh because there is a direct stimulation of that part of their brain. Clearly, then, if you approach the encounter with a calm, positive attitude, there is a much higher chance that your patient will have a better therapeutic experience. Better still, that person will also “re-mirror” the behavior back to you. Since I started trying this, it’s become perhaps the main reason why I walk out of clinic energized instead of drained.

In conclusion

Giving individuals the tools to solve their own pain has become a very rewarding aspect of my complex spinal deformity practice. With the right approach, angry or frustrated patients turn out to be just people struggling with health challenges. Exactly the sort of cases we can help.

David Hanscom is an orthopedic surgeon and can be reached at Back in Control.  He is the author of Back in Control: A Spine Surgeon’s Roadmap out of Chronic Pain.  He blogs at The Doctor Blog.

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