Sharing The Recipe For Managing Patients With Chronic Pain

It could have been the biggest group psychology session, perhaps in history but at the very least, the most prolific among extremity nerve surgeons. Not only was this “session” attended by most of the attendees at the 2014 Association of Extremity Nerve Surgeons (AENS) Annual Meeting in Scottsdale, Ariz., but everyone wanted more “therapy.” Well, guess what? They are going to get it next year in Denver, same time next year.

Now I had to drag and coerce three of my collegial cohorts (read: “newbies” who had no clue) kicking and screaming to this session. I know they hated me at first but at the end of our session, they had more neurons on fire than there are patients with neuropathy in the U.S. (That is about 21 million if you care.) Believe it or not, they thanked me and jettisoned their hatred. It is easy to be a “hater” when you do not know anything about the subject. Maybe percentage wise in a normal cohort, these neurons would seem miniscule for an amount of neuronal activity but for these fellas, we are talking a much higher percentage.

The “therapist” was Kern Olson, PhD, a world-renowned pain psychologist who counseled (read: lectured) us about how to improve our surgical “batting average.” You see, the “patients” at this group therapy session are all extremely dedicated and passionate peripheral nerve surgeons who end up dealing with the absolute “worst of the worst” patients. Not that they are bad patients but when folks are in pain for a long time, they become difficult to say the least. They “catastrophize.” They do not sleep well, they are depressed and they are anxiety ridden to mention a few. Not all of them manifest all of these traits but some do.

Those are the most dangerous ones. Some may just have one of these traits and they might be less venomous, depending on the given trait. There is no doubt that these folks all need help but the simple fact is that we cannot help every one of them and the stress of operating on that “wrong” patient can be daunting and draining, ending up requiring more therapy for both the patient and the surgeon. “Aha,” you say, “give me the recipe.”

What does any psychologist worth his or her salt say when you ask a question? “Well, how do you feel about it?” Yes sir, no recipe here, as Dr. Olson would only give us his framework for us to build our own recipe.  “Damn it,” you say. “I’m a busy surgeon and I want a recipe not a framework.” Who would I be to argue with you? I wanted it as well. 

As the “therapy session” unfolded, our therapist laid out the framework for each of us to individually figure out because as he so eloquently pointed out, each of us is different and there is no one recipe for us all. However, there is a valid and solid foundation for all of us to build on.

So how much basil, thyme and rosemary do we mix with the olive oil and garlic to get that perfect, mouth-watering dish? While we all have different palates, I know of not one surgeon who wants a less than ideal outcome for all of his or her patients. 

After reflecting back on my session, I started to recall the last decade of surgical experiences and I have come up with my recipe. Now don’t just take my Martha Stewart advice here. Do your own introspection. Go to a cave in the Himalayas and hang out with some monks if need be, but maybe take a little of the following of my experience and see if you can come up with your own recipe.

First of all, ask questions and try to get a feel of patients’ optimism and motivation to get better. (This was Dr. Olson’s recommendation but I copped it from my session this morning with him so I am claiming it as mine because it is now in my recipe. That is the really cool thing about this whole deal. You can “steal” any of this stuff and use it for your patients, and no one cares. I actually encourage this type of larceny but I always try to acknowledge the victim I took it from.) As Dr. Olson pointed out, if patients are at your office because a family member or spouse is dragging them in there, like I dragged my “cohorts” to this AENS meeting, then maybe they are not motivated to get better. 

What is the patients’ support staff? Do they have someone who cares for them or do they live alone? Good question. Fact is that folks with folks who care about them are more likely to be better surgical candidates. 

How Spicy Is The Patient’s Pain?

Now we are getting to those hot spices of the recipe. Look the patient right in the eyes and ask him or her point blank, “How well do you sleep?” If the patient says not very well, then “Houston, we have a problem.” That might be the curry, not really hot and biting, but a distinct flavor that is almost always recognizable by even the most Neanderthal palate. 

If you detect habanero pepper, think catastrophizing, which is a much more difficult ingredient to deal with. When patients say they are a “15” on the 1 to 10 pain scale, try not to bite down on the pepper. You may want to prepare this one a little differently. 

Now the serrano pepper can make the habanero look like an Irish stew of potatoes and carrots with some tasteless brown sauce. What is the serrano you ask? Constant pain. If patients say they have constant pain and it never changes, think central sensitization. This is one venomous snake with really long fangs and its bite is deadly. Try not to delude yourself that you can do something peripherally to totally solve the problem when there is cortical and thalamic imprinting. You can help some of these patients but they can be stingrays when you are a crocodile hunter.

Depending on the amount, garlic can be an enhancement to the dish or a culinary assassin. This would be anxiety and depression. All of us have variable amounts of anxiety and depression, but the trick here is to figure out how much patients have. Trust me, the more they have, they more you will have after you make that first incision.

Just as with any recipe, you can change the amounts of ingredients to obtain a different and hopefully more savory meal. Here are my weighted ingredients:

Serrano pepper (constant pain) *******

Habanero pepper (catastrophizing) ******

Garlic (anxiety and depression) *****

Curry (ability to sleep well) **

Mix them based on your “gut” feel and do not hesitate to change the recipe from patient to patient and from practice to practice. 

As I have always told my students, sometimes the best surgery you will ever do is the surgery you never do. That is hard for us as deep down in the core of all providers is the delusion to believe that we can always “hit the home run.” If you do notcome to next year’s AENS annual meeting in Denver, you are still going to be “batting” at a lower average and may need more “therapy” than those of us who have just come out of our group therapy session. See you there.

A special thanks to Dr. Olson for his incredible body of work and his ability and willingness to share it with us in an understandable way that makes it easy to implement.