When patients with chronic pain want a procedure, but doctors do not recommend it
Updated: Jan 11, 2022
Patients with chronic pain want their life back
They want to be who they were before the pain became the center of their life, be able to work, sleep, take care of their family, and enjoy life, among others. For too many patients presenting to a pain clinic, medications, physical therapy, and other non-invasive treatments offer only partial solutions. So, what is next?
Treatment of the site of pain is the preferred option for most patients
Clinicians frequently hear from patients: "if my back is treated, I will be able to work again and get rid of my depression". This is a straightforward thought. However, when addressing this wish, we are frequently confronted with challenges. The source of pain may not be identified, even using advanced procedures. For patients with a known source of pain, evidence-based treatments to eliminate the cause of pain may not be available. For instance, no treatment capable to revert knee osteoarthritis exists.
Pain procedures can help even if the cause of pain cannot be solved
For instance, ablation of nerves that supply a joint of the spine can provide excellent pain relief, restoration of function, and reduction in psychological distress, although the cause of pain (such as arthritis of the joint) is not solved. When an herniated disc causes inflammation of a nerve with consequent sciatica, injection of a steroid to the nerve can dramatically reduce the pain, although it cannot resolve the herniation.
Regrettably, procedures cannot be offered to many patients with chronic pain
For instance, ablations cannot be performed if the nerve controls important functions, such as movement. For certain types of pain, the nerves cannot be ablated because they are close to sensitive structures, and injuries of such structures would lead to severe complications. This is the case of upper cervical joints that are close to arteries that bring blood to the brain or feed the spinal cord. Many patients have multiple potential sources of pain, rendering ablations impossible or associated with high risk of failure.
How do I behave, when I cannot meet patient's expectation?
I frequently see patients coming to clinic with the expectation of receiving a procedure that will "fix" their pain. This expectation comes from different sources, not uncommonly from referring clinicians. If a referring doctor tells patients that they can get a nerve ablation to make a body part insensitive to pain, this creates a huge expectation. Sometimes I can meet this expectation, sometimes I can't.
When I believe that procedures are not promising, unfeasible, or potentially dangerous, I am aware that I disappoint patients. Some of them express understanding. Other patients express disappointment and anger, or even display aggressive behavior.
I try not to take these reactions personally. Patients with chronic pain presenting to a tertiary pain clinic have been through many treatments, mostly with disappointing results, have a very poor quality of live, and are very frequently under substantial psychosocial distress. They come to my practice with a hope, sometimes believing that this is their last chance. My message is another disappointment of a long chain. It is ok to be angry.
Tips for clinicians
Do not judge patients.
Tell yourself that providing responsible care is your priority, and this may be incompatible with patient's expectation.
Discuss alternative treatments, even if the patient has already tried them and is not primarily open to have anything else than a procedure.
Offer a follow-up visit if the patient is not open to discuss further options at this time.
If you had trainees involved, debrief and discuss the case after the patient has left the office.
Tips for patients and caregivers
Consider that your clinician wants to offer you the best available treatment and is disappointed for not meeting your expectation.
Be reluctant to contact multiple clinicians. Providing procedures is a large financial incentive and you may eventually find someone willing to "try".
Be open to consider the alternative treatments that your clinician proposes, even if they seem little promising to you. You have been suffering for long time and deserve further chances.