The Medical Blind Spot for Aches, Pains & Injuries

Medical training is better than the competition, but family doctors lack the skills and knowledge to treat most common aches, pains and injury problems, especially stubborn cases. Even the best general practitioners of medicine are poor substitutes for specialists,1 physical therapists, and some exceptional chiropractors and massage therapists. Most doctors are well aware of this, but some seem to be disconcertingly oblivious. Dr. Jonathon Tomlinson, an instructor at St. Leonards Hospital in Hoxton:

Undergraduate training is focused on hospital orthopedics (broken bones and anything else that’s amenable to surgery) or rheumatology (nasty inflammatory diseases) which comprise a minority of the aches/pains/strains and injuries that people actually suffer from.

Medical incompetence in this area is unfortunate but understandable

Please cut doctors some slack on this. It’s not an insult to physicians.2 Doctors have to work with an astonishing array of conditions, and pain is often too subjective, slippery, and minor compared to other pathologies — it doesn’t get on their radar. Musculoskeletal pain is a bit of a backwater, simply because medicine had bigger fish to fry (e.g. curing major infectious diseases and so on).3

Nevertheless, the severity and importance of a lot of body pain was also underestimated — or even disbelieved — by too many doctors for too long. Medicine should now be taking pain more seriously.4

Medicine gives itself a failing grade in pain management

Medical researchers have done many studies showing that most doctors still do not understand aches and pains or heed expert recommendations. At the 2014 World Congress on Pain, Dr Andreas Kopf presented “3 Sad Realities”:

• Poor pain management education in medical schools
• 90% of postgraduate physicians report no adequate training in pain
• Essential medical deficits (inaccurate education)

A paper in Archives of Internal Medicine showed that family doctors frequently ignore guidelines for the care of low back pain — see Williams et al. More generally, the Journal of Bone and Joint Surgery, and the Journal of the American Osteopathic Association, have both published papers showing that physicians simply do not have an adequate understanding of musculoskeletal medicine. In 2002, Freedman et al felt that “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.”5

Then again in 2005 in JBJS, Matzkin et al concluded that “training in musculoskeletal medicine is inadequate in both medical school and non-orthopaedic residency training programs.”6 In 2006, Stockard et al found that 82% of medical graduates “failed to demonstrate basic competency in musculoskeletal medicine.7

So that pretty much tears it. Medicine gives itself a failing grade in this area.

Patients are part of the medical incompetence equation

One of the best examples of medical incompetence in pain and musculoskeletal medicine is the notoriously excessive imaging for back pain, especially MRI. Why so much imaging?

It seems baffling. In 2023, why would primary care physicians continue to order way too much inappropriate spinal imaging when it’s blatantly at odds with every expert opinion and all the clinical guidelines? When it’s a very well-known problem? Are they feckin' stoopid?! Maybe a few. But mostly it’s this stuff, perfectly summarized by Adam Dobson:

• Time
• Patient pressure
• Lack of training
• Defensive medicine
• 'Fix it', societal mentality
• Beliefs around 'reassurograms'

Notice that a few of those fall right in the lap of the patient. 😬

So here's an ugly truth: “medical incompetence” is often collaborative. Doctor and patient can and do work together to achieve a lousy outcome. We all bring a lot of biases into medical appointments … and often misinformation too. Doctors and patients alike.

About Paul Ingraham

I am a science writer in Vancouver, Canada. I was a Registered Massage Therapist for a decade and the assistant editor of ScienceBasedMedicine.org for several years. I’ve had many injuries as a runner and ultimate player, and I’ve been a chronic pain patient myself since 2015. Full bio. See you on Facebook or Twitter., or subscribe:

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Notes

1. The medical specializations relevant to most common musculoskeletal pain and injury problems are physiatry, sports medicine, neurology. There are even pain specialists.
2. Criticism, yes. Chiding, even. But not an insult!
3. Ingraham. A Historical Perspective On Aches ‘n’ Pains: We are living in a golden age of pain science and musculoskeletal medicine … sorta.  ❐ PainScience.com. 3066 words. We can put a man on the moon, but we can’t fix most chronic pain. The science and treatment of pain was neglected for decades while medicine had bigger fish to fry, and it remains a backwater to this day. The seemingly simpler “mechanical” problems of musculoskeletal health care have proven to be surprisingly weird and messy. The field is dominated by obsolete conventional wisdom and the speculations of desperate patients and opportunistic cure purveyors. Ignorance is widespread thanks to professional pride and tribalism, ideological momentum, screwed up incentives, and poor critical thinking skills. But the worst single offender? The pernicious oversimplification of treating the body too much like it’s a complex mechanical device that breaks down: (“structuralism”).
4. It’s presumptuous of me to prescribe medical priorities, but it’s not hard to make a case for it, and many doctors have done so.
5. Freedman KB, Bernstein J. Educational deficiencies in musculoskeletal medicine. J Bone Joint Surg Am. 2002 Apr;84-A(4):604–608. PubMed 11940622 ❐

   From the abstract: “It is ... reasonable to conclude that medical school preparation in musculoskeletal medicine is inadequate.”

6. Matzkin E, Smith EL, Freccero D, Richardson AB. Adequacy of education in musculoskeletal medicine. J Bone Joint Surg Am. 2005 Feb;87(2):310–314. PubMed 15687152 ❐

   From the abstract: “ … training in musculoskeletal medicine is inadequate in both medical school and nonorthopaedic residency training programs.”

7. Stockard AR, Allen TW. Competence levels in musculoskeletal medicine: comparison of osteopathic and allopathic medical graduates. J Am Osteopath Assoc. 2006 Jun;106(6):350–355. PainSci Bibliography 56560 ❐

   From the abstract: “82% of allopathic graduates ... failed to demonstrate basic competency in musculoskeletal medicine.”