The chronology is a familiar one. The individual is injured, sent to occupational medicine/panel physician, xrayed (if indicated) and medicated. If the patient returns, there is a high probability that they will see another physician. Persistent pain may result in the patient being referred for physical therapy. The occupational physician may feel that this has been sufficient care, and the patient is able to return to his/her job despite continued pain.
If the patient balks at a return to work, and the panel physician is empathetic, the patient may be referred to an orthopedist who may, or may not, enjoy seeing injured workers. Care will be conservative and often a repeat of physical therapy. Continued pain complaints may be treated with a variety of drug regimens, injections and eventually additional diagnostic studies are ordered. The studies may not be approved for an extended period.
Once approved, the completed studies may reveal degenerative changes and suggest additional and likely, but not definitely, related findings. Dependent upon a variety of factors that are often not exclusively clinical, surgery may or may not be recommended. Those recommendations may be more related to how the surgeon sees his role in treating injured workers. If surgery is to occur, it will not occur until the patient has had one or more independent opinions. Agreement among those rendering an opinion is often not consistent. Patients understand little about their pathology, why surgery would be indicated or what surgery would entail. The patient does know that his/her goal is complete elimination of all pain.
When this does not occur, nor does continued post-surgical conservative care, an additional surgery, often more extensive, may be recommended. In the interim, there have been delays in authorization for additional diagnostic studies, and the surgeon may have grown weary and distrustful of the patient. During the course of ensuing and inevitable second and third opinions, the patient often requests a change of provider. The way the patient believes that his continued pain is partially attributable to the indequate skills of the first surgeon.
However, the second surgery may also not produce the desired results. The surgeon may have little more to offer, does not want to be in the role of endlessly dispensing narcotics, does not want to deal clinically with the patient’s altered mood and sleep. The patient is referred to a pain center. The way treatment in the center is wide ranging with many options explored. However, a great deal of time has passed; not the weeks anticipated by the patient on the day of injury but, instead, years. The patient is in dire financial straits. The family is taxed.
The patient has developed maladaptive health habits. The patient is dependent upon his/her medication, fearful that it will be withdrawn, and has been looked at with jaundiced eye when asking for increases or even refills. And, yet, in this way the patient is still unprepared for what will likely be chronic residual and refractory pain. While it is not my preferred timeframe, this is most often the point at which the patient is referred to me. Initially, the patient restates that it is mandatory that all pain be ameliorated and that there is no other possible or acceptable outcome.
I ask the patient if s/he feels that the pain has improved since the time of injury, whether it has improved as a result of conservative care, whether it has improved as a result of invasive procedures. The answer is invariably: “No, my pain is worse than ever.” It is at this point that the patient must be directed to create a life that includes pain, not a life contingent upon pain resolution.