Escaping the Medical Merry-Go-Round of Chronic Pain

Many patients don't realize they're stuck in a cycle until you help them zoom out. They're doing something about their pain, seeing the chiropractor, getting regular massage, booking, dry needling sessions, and on the surface it looks proactive. Week after week, they're still not living the way they want. They're stuck in a loop of temporary relief without real forward movement. As clinicians, part of our role isn't just to treat, it's to help them step back and ask, is this care actually helping me move forward to what matters most? In today's episode, I want to unpack how to facilitate that kind of reflection, and if you stick with me until the end, I'll share a free tool you can use in your very next session to start that conversation with clarity and structure. Now, on to the episode.

This is the Modern Pain Podcast with Mark Kargela.

So this all started, and you've all probably had these patients I've had just quite a few lately where patient came in with a lot going on. It wasn't just pain, it was widespread. They had sleep disruptions, they had GI distress, they had just multi-system effects of chronic pain. As we know more about pain, we understand that pain doesn't just seclude itself to the musculoskeletal system where it just hangs out in a muscle or joint. It permeates our whole being, our whole body, our whole lives. So to try to bucket it into one little simple musculoskeletal problem really misses the mark of what we know about pain. So what does that result with, with patients? What results with patients who go on what I like to call the medical merry go round. So they've been to every ologist under the sun. And when they look at their calendar, their calendar has little to nothing to do with anything that brings'em joy, happiness, or leisure. It's all medical appointments and oftentimes these folks really have to muster up a lot of energy and it's a struggle to get ready to make these journeys to these medical appointments. Sometimes they're well far away from where the patient lives, so it's a journey, but even if it's close, a lot of patients just get in The energy to get up and get out and get prepared to, get to appointment is, is very taxing on them. All these medical appointments really are a reflection of where we are as a healthcare system and understanding pain as well. And I think we have a medical training that tends to really hyperspecialized often where these patients are seeing immunologists, endocrinologists, rheumatologists, neurologists, neurosurgeons, pain physicians, you name it. I'm probably missing ologists, but there's many ologists and the. The big issue with this is it becomes like a forest problem, which what we know pain is, it's a much more multi-system, psychosocial, bio-psychosocial issue. It doesn't hang out in just our physiology, although our physiology is ma massively affected by our psychology and the lives that we're living around our pain and the distress that it's put us under. But when we have a bunch of people who are looking at specific trees in a forest problem, so we have your immunologist looking at an immunologist tree. We have a endocrinologist looking at an endocrine tree, which again, aren't necessarily bad, but what does that leave a patient with? A absolute laundry list of all these things that are wrong with them, that I would argue, and if we look at what we know about pain that it's likely one big emergence of the massive distress and life altering problems that pain has put this person under emerging in different trees in the forest. So what do we do in healthcare? Nobody tells them the story of the forest and how these things all relate to each other, and how pain is much more than just messages from your tissue. Though they're important and definitely can be part of the problem, of course, it's much more than that when those messages hit the central nervous system, and brain and are impacted by hormone levels and all these different things that the neuroendocrine immune system and, and much more systems are impacting. What system does that enter? And it often enters a system where this person has lost a lot and has really had a significant amount of stress, distress, depression, all normal emotions that humans would experience. But when our body is trucked full of those emotions 24 7 365, it creates an ecosystem that has massively dysregulated for a person. And again, healthcare puts these folks in a bucket. I have had the occasional person who's come across a physician who tries to really put this in a big picture story and I. I wanna step back a little bit too,'cause I'm not trying to dog physicians, primary care physicians are way overworked, have way too much on their plate, are trying to balance so much and their, their productivity is getting pushed harder. They have to do more and have less resources. It's a massive system problem. So I'm not dogging primary care physicians, but if you talk to primary physicians, and I'll link some research in the show notes. Most primary care physicians in the US receive less than 10 hours of formal pain management training during medical school. And the training that it is is more diagnostic and pharmacologic. It's not really, well, how do I manage somebody with a complex illness or a complex pain condition? And when you ask the physicians what they feel, they feel unprepared to manage chronic pain, which is a common issue, especially in primary care. Primary care is probably where we'd love to have physicians acting as the quarterback and telling the forest story of, you're gonna see all these specialists. We're gonna talk about one tree, but recognize person with this horrible journey that you've been on, that it's much more than that one piece. And we need to understand that you're gonna probably get labels of that tree, but we have to bring those labels to make sense of the big picture and not get stuck into really hyper pathologizing and hyper labeling, somebody who's got a very difficult condition nonetheless, but it's probably not helpful for them to just accumulate diagnosis after diagnosis after diagnosis. I think we could probably do people a better service by recognizing which diagnoses are absolutely important that we need to have and which ones are just probably. Same ways of naming the problem in the forest, but it's just looking at it through one tree, right? It's like different ways to say the same word in different languages. It's still the same thing we're trying to express. The other problem is, is there's training available for physicians after they graduate, but it's not mandatory, which I think we should make it mandatory, not just for physicians, for physios, for any healthcare person that's touching on anybody who deals with pain, I think we should have mandatory pain training to help us stay up to date and make sure we're doing the best we can for our patients. It's a difficult discussion and it's a very gentle, delicate discussion to have, to have people challenge their approach with healthcare. It's not to say the people that they're encountering in healthcare have any bad motives. it's just when they're not prepared to understand the situation that's in front of them, then we're, when they're only trained to understand it under their little categorical bucket of whatever ologists they are. They miss the big picture. And most importantly, they often miss the humanity of the experience. I can't tell you I've had, again, three or four patients just this past week where they felt massively invalidated by a physician who I, I know has no malice or ill will intended, but because I think they don't see the big picture, that person's condition, and it doesn't necessarily make sense.'cause chronic pain often doesn't make perfect algorithmic sense of how we're trained in healthcare. That the physician gets frustrated and some of their coping mechanisms, I think is just to push it off on the patient and make them feel like, oh, you're making a big deal of this. It's just your stress or your anxiety, and you probably need to just move on with things. And I. That obviously doesn't sit well with patients, and I think I've shared it on the podcast. I remember my wife when she had a micro embolic stroke, which didn't light up a CT scan or, brain testing that, immediately it was pushed, oh, well, are you sure this isn't just your anxiety yet? She's got hemiplegia. She's got, almost a little bit of a facial droop, definite definitive weakness on her right side of her body. Yet, they're jumping to that. And I think there's obviously times functional neurologic disorders and things where I think we need to have some ways to have discussions. But I don't think when somebody's under massive distress and you throw them the anxiety thing, and again, with pain anxiety's just one piece of a massive, complex puzzle. We have to consider how our words are landing with somebody and be a little bit more understanding of the humanity that goes into that experience. I'm just frustrated that oftentimes healthcare and physicians are struggling to even maintain their humanity'cause they're so pushed and spread thin. I. So when we have these discussions with patients about their medical merry go round that they're on, there's some helpful key questions you might be able to ask that patient to see if they can maybe consider, and again, this is a guided discovery type approach. We're not, I know this, I'm lecturing you. Why are you doing this? You should do that. This is, hey, if we look at your care, let's take a look at what you're doing. Does this care feel like it's helping you move towards what matters to you? Or are we just trying to make the pain go away? What's your focus with these treatments so you can get, again, an understanding of if the patient's on the pain eradication approach, or are they saying, I need these symptoms to help me get back to my job. So it's helpful for us to have skills, to have these difficult conversations with people because again, as me a physio, I'm not looked at as the higher echelon of a neurosurgeon or a high level neurologist and things. And they have their different training, different skillset. I would never claim to have their skillset, but I do think as physios and some of the other ancillary healthcare folks. Really can understand this big picture, especially as in physio when we get an hour with people sometimes, and that's usually how much time I'm fortunate enough to have with my chronic pain patients. We can start hearing their story and their humanity coming through. And it's hard not to just want to say, what are we doing as a healthcare system? When you hear all the stuff that's surrounding somebody's symptoms. Yet we are still bucketing people off into little separate pieces of a machine, which people aren't. We aren't just parts of a car that we can have one person look at one part of the car, one person look at the other part of the car, one person look at the other car and fix it, and it's all gonna end up well. Would be nice I guess if that worked.'cause then healthcare would be knocking it outta the park. But of course that's not what's happening. So we need to have skills to be able to have difficult conversations in ways where we can help the patient explore their own journey and explore how their approaching things. So one of the first things we wanna understand with them is to say, are we trying to use treatments for, what are we using'em to? Get back to what matters or are we just trying to get pain down? Like sometimes I should say, a lot of times patients are on a very, I just need to get my pain down so then I can, I need my pain to go away, so then I can, it's not usually used in treatments often where I. I'm using it so I can, I can get to golf tomorrow or I can pick up my grandkid tomorrow. It's, those things are all on hold. I'm, those things aren't even my, in my thought process. I need to get pain to go away first, which again, can be a delicate topic to touch on, and that's where you have to have skills such as creative hopelessness and things to help people explore that pain eradication approach and how it's went, and is it really truly moving them towards where they want to be? Other questions you can ask the person is, Hey, are you becoming more confident and capable, or do you feel like you're becoming more dependent? I. And are these treatments giving you more of life or are they giving you more appointments? And I think as you get rapport people, you can have some frank questions that maybe hit hard a little bit, but as again, as you've developed some rapport with somebody, you and you've shown that you care and that you're on the same team, and that you want to guide them to a better life and better way that they're interacting with their pain, that some of these questions can be some. Tough ways for them to like have to look at their approach and maybe sometimes when we're patients are just on autopilot with just trying to survive and keep their head above water, they don't even recognize some of their thought processes behind their approach. So very helpful to have some strategies to dig into that approach and see if they can explore it. Then as a guided discovery, well, what do you make of that? Do you feel like it's really moving you to where you want to be, or do you feel like this is, an approach that's really giving you the results that you want to have? Not we're, we're telling them what it's giving them. You're letting them explore what they feel they're getting out of it. So as a clinician, we facilitate these conversations by having one conversational skills, motivational interviewing, guided discovery methods, understanding some root of roots of acceptance and commitment therapy, and other psychologically informed approaches. As a clinician, we are the guide. We are not the fixer, we are the facilitator. We are trying to help facilitate change by helping the patient recognize some of the strengths and skills they have within them that have been left behind with the tough journey that they've been on. We're gonna reposition the focus from symptom reduction to life engagement and values-based direction. So trying to ensure that. Again, we've hopefully had some discussions where patients have seen that this constant pursuit of symptoms to go away hasn't really given them the results they want. Not that they haven't tried hard, and as I said earlier, none of this is to say patients aren't busting their tails to make this thing go away and working very hard and filling their schedule full of a lot of appointments. But that's hopefully the journey you help people step back and look at what have you been doing, how's it been helpful? A lot of people will line up a line in the short term. It does great things. And then when we look at long term, it doesn't really fill up much of anything in the long term benefits column or very minimal. and again, the things we wanna see patients get back to are the things in life that they value that matter to them, that oftentimes they really struggle to say they've had any pursuit of in the recent past. But again, if we. can help people zoom out on their care using simple frameworks that can be massively helpful for a patient. We also need to make sure, this is just we're changing our course. We're just taking a little bit of a different direction or course correction. We're not blaming anybody. We're not blaming healthcare systems. I usually try to empathize with the how physicians are trained and how the lack of training they get with pain. I share exactly what I shared with you all in the podcast. With my patients to say this isn't necessarily their fault. I know we'd wish they maybe had better interactions, but when they don't have a good founding or understanding of what they're dealing with with pain and how much more complex it is than maybe what they've been trained to understand that unfortunately we're left with some interactions that, aren't really the most ideal. So instead of blaming the healthcare system or physicians, although I get frustrated and probably blame the healthcare system a bit because I think we need to do better, and that's what we're trying to do at modern pain care. But let's just control what we control and looking back in the past and blaming things doesn't move us anywhere in the future as it is.

So I created a resource to help you have some discussions with patients around this topic, as I mentioned, can be a difficult one. So this resource is mainly just aimed for you to frame your discussions with a patient, but you can also use it as a homework activity for patients. They can take it home and evaluate what they're doing. Ideally, it's something where you've talked a little bit about their care and is it really getting'em what they want? And it might be a nice little follow up homework activity you can have them go home with to, to do.

To download the resource, go to modernpaincare.com/reflect

It's a little bit of a reflective sheet that they can look at their reproach thus far and to see if it's moving'em to where they want. It identifies how passive care can be very well intended, but sometimes can be left with some short-term gains with little long-term benefits. that also talks about when passive care can become a problem, especially when it's filling up our appointments with appointments that aren't really necessarily showing us that we're moving more towards our life and that our life is getting full of being a full-time pain patient. It helps people reflect on specific passive methods of care they've used, which again, not necessary or bad. I provide some myself, especially if it's something that I see patients are moving towards their values with. It's something that's a supportive measure, not a corrective measure, as I've always said. Then at the end of the document we talk about what should you look at in your care plan if you're dealing with some complex pain situations and gives patients some suggestions of having things that are moving them towards their values. Somebody that can serve as a guide, somebody that can coach them up. it's been a helpful guide for me. I pretty much do this verbally with patients, but I wanted to put it on paper. So if those of you who are trying to learn how to have these discussions on your own. Could use it as a resource for yourself and also, again, hand'em out to your patients. So let me know in the comments how those work, and if there's anything else we can create for you or any other resources, I'd love to be able to help you all out. So just let me know. I'm gonna leave it there this week for all you who are listening. We'd love if you could share this episode for somebody else who might be having some difficulties managing some people in pain, and we will see you all next week.

This has been another episode of The Modern Pain Podcast with Dr. Mark Kargela. Join us next time as we continue our journey to help change the story around pain. For more information on the show, visit modern pain care.com. This podcast is for educational and informational purposes only. It is not a substitute for medical advice or treatment. Please consult a licensed professional for your specific medical needs, changing the story around pain. This is the Modern Pain Podcast.