You may have gone through something similar yourself. But let’s think it through again from a doctor’s point of view to understand why we can’t simply tweak the system a little bit to solve the problem of chronic pain.
As a whole, we doctors are well-trained and dedicated to making you well. That’s what drives us: We love to heal! What we didn’t realize back in medical school is that there are many pressures on physicians that make it difficult to stay focused on the patient’s best interests. No matter how hard we try, we cannot dodge these pressures, because we’re forced to work within a broken system And the dysfunction is present at many levels. To begin with, the system rarely covers the type of integrated care needed to treat pain adequately, which usually means doctors are not allowed to provide the best treatment for chronic pain. As a result, we struggle every day to work with patients who have very challenging pain problems, but do not have the best tools at our disposal. In addition, the pressure to see patients quickly and do something now, pushes us to prescribe medicines and order tests, rather than dig deep into what’s happening with our patients. Our current healthcare system, then, presents doctors with a multifactorial dilemma. Let’s take a look at some of the key problems and pressures.
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There are time pressures. While most doctors would prefer to spend as much time as necessary with each patient, and then spend more time thinking about the situation and perhaps discussing it with colleagues, they can’t. With the costs of running a medical practice spiraling upward, while reimbursements from insurance companies and the government shrink, doctors are forced to see too many patients per day. I could write a whole book on the subject, but let me simply point out that Medicare (the federal government’s program for senior citizens) pays the primary care doctor about $70 for a follow-up visit. Ideally, the doctor and patient should have a lengthy conversation during follow-up visits, with the patient describing how he has fared, how and why his pain has gotten better or worse, how it has affected his ability to get through the day, whether his emotional state has been worsened, how the various medicines are working, and more. Then, the doctor would spend time educating the patient about things like the “pain brain” and lifestyle changes, while working through a plan. But how often does that really happen? It’s simply not cost-effective.
Think back to Kate’s case: Her primary care physician didn’t look into her lifestyle or personal history, ask how her work ergonomics might be causing or contributing to her pain, or ask whether or not she was under stress. He went straight to tests and medicines, and when the X-rays showed an anomaly in her back, passed her on to the next doctor. That’s not unusual, for there is minimal reimbursement for educating patients about things like spinal anatomy, lifestyle changes, work ergonomics, controlling stress, or reframing how they look at their pain. It can take many hours— hours doctors don’t have—to educate patients about stretches, exercises for the back, breathing exercises, lifestyle coaching, and so on. But the system simply doesn’t support it. This means the doctor is forced to become a symptom manager rather than a healer and educator, prescribing medicines for pain, sleep, depression, and more, hoping that it will all somehow work out.
Even doctors who work for large groups—the current trend in healthcare—are under pressure to see more patients each day. These salaried doctors are encouraged to meet quotas and are chastised if they don’t see enough patients. There is no focus on the quality of the time spent with patients. But such “assembly line medicine” is not very effective when treating complex chronic problems and diseases.
The bottom line is that the system for treating pain doesn’t work well because the insurance model doesn’t work well. More Americans suffer from chronic pain than from heart disease, cancer, and diabetes combined, yet our insurance system is set up to treat those diseases, not pain. Clearly, the system needs to be changed so doctors can provide better treatment, more meaningful change, and better outcomes for pain patients.
And even if a doctor does somehow manage to find the time necessary to educate patients, he or she is still pressured to prescribe medicines for pain, sleep, depression, and other problems, or to offer injections, because that’s what most patients want. Seized by pain, their relationships falling apart, finances shredded, and entire lives running down the drain, people want instant results. And they’ve been told, over and over again by pharmaceutical company advertisements, that relief is spelled “m-e-d-i-c-a-t-i-o-n.” Many medicines are advertised on TV, radio, in popular magazines and on the Internet—it seems as if people are exposed to more advertising about treatment on the Internet than anywhere else. Concerned spouses, family members, or friends who are caring for the patient also push for more medications. (I recently had a spouse come to my clinic with his intimidating two dogs in tow to make sure I understood that his wife needed stronger pain killers to get through the week!) This means that doctors, even those who would rather try different approaches, are under tremendous pressure from multiple sources to offer pain medicines.
Naturally, doctors want to be nice and give people what they want; that’s human nature. But many of them also prescribe out of fear of the surveys patients fill out to rate their satisfaction. In the not-too-distant past, dissatisfied patients could not do much except vent their unhappy feelings about a doctor to family and friends. That might cost the doctor a patient or two, but no more. Today, unhappy patients can post negative remarks and ratings on various websites and, if the doctor works for a healthcare company, give an unsatisfactory rating on a customer satisfaction survey. Too many unsatisfactory ratings may cost the doctor her job, so she’s under a lot of pressure to keep her patients happy, even if it means writing prescriptions she believes are not necessary—or even harmful, if the patient misuses them.
This same pressure from patients ofen pushes doctors to order MRIs and other tests they may think are unnecessary. Every patient that comes to my office seems to have an MRI or want one. It’s as if you’re not American unless you’ve had an MRI. You would think that the more tests the better, but if you perform enough of them you’ll eventually find something “wrong,” some anomaly that doctors and patients can seize upon. Then they say, “Ah ha! This is it!” and focus all of their attention on it. Unfortunately, the anomaly doesn’t explain the whole pain picture. It can even turn into a red herring that diverts attention from real problems like neuroplastic changes in the brain.
The truth is, most doctors don’t approach chronic pain as a brain/body phenomenon. General practitioners and primary care physicians learn little to nothing about pain management in medical school. Most doctors get zero training in managing pain unless they take a pain fellowship. So they rely on the information they get from the pharmaceutical or surgical hardware sales representatives who visit their offices, sponsor educational presentations, and charm them at medical conferences, where fancy booths filled with slick displays and brochures trumpet the benefits of their products. Sometimes the border between physician education and salesmanship is very gray. And let’s face it, there are no companies peddling products to doctors that make pain patients healthier; there is no financial incentive to do so. It’s all about managing symptoms, trying to fix something that’s anatomically wrong, or treating the side effects of medications.