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The Medical Blind Spot for Aches, Pains & Injuries

Most physicians are unqualified to care for many common pain and injury problems, especially the more stubborn and tricky ones

Paul Ingraham • 6m read
Blue caduceus symbol.

Medical training is unquestionably better than the competition — the chiropractors and naturopaths who insist their training is similar — but nobody is under any illusions that any kind of medical training is perfect. Family doctors can be superb generalists, but they tend to underestimate the complexity of even common aches and pains, never mind the more stubborn rehab challenges or strange chronic pain problems that plague humanity.

And so they aren’t even particularly good at triaging cases and referring appropriately.1 They routinely scare patients unnecessarily, miss significant red flags, and make extremely naive treatment recommendations. But no one particularly expects general practitioners to be good in this area, however. So what about specialists?

Who is qualified to treat chronic pain and injury?

The unfortunate reality is that medical care in this field is poor on average across the board. The least-bad answers are: physiotherapists, physiatrists, and occupational therapists for most rehab challenges; sports medicine specialists and orthopaedic surgeons for more traumatic injuries and advanced pathology (e.g. knee replacement); and neurologists, rheumatologists, and pain specialists for a wide variety of painful diseases.

There are major caveats with all of these, however. For instance, while there are some exceptional physical therapists, massage therapists, chiropractors, and osteopaths, these professions (yes, even physio) are littered with quackery — much of it impossible for patients to detect.2

Medical incompetence in this area is unfortunate but understandable

Please cut doctors some slack on this. It’s not an insult to physicians.3 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).4

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.

Too specialized for pain

The medical specialists are often too specialized, and they excel at ethically dismissing any patient that isn’t obviously in their wheelhouse — and “that’s not what I’m good at” is actually a legitimate excuse for not treating someone! The problem is that literally no one easily findable is “good at” whatever ails many kinds of chronic pain patients, and so they still struggle to find good care and fall through the cracks, especially without a clear diagnosis.

For instance, there is no medical specialty where fibromyalgia patients actually “belong.”

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”:

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. This late in history, 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:

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

Headshot of Paul Ingraham, short hair, neat beard, suit jacket.

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:

What’s new in this article?

Dec 2, 2023 — Fairly extensive modernization of the article, reflecting substantial evolution in my views over the last decade.

2023 — Added a section: “Patients are part of the medical incompetence equation.”

2012 — Publication.

Notes

  1. Most doctors are well aware of these limitation, 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.

  2. Not all quackery is obvious — not even to skeptics. Many forms pass as mainstream. Pseudo-quackery is unusually rampant in physical therapy. Because it hides right in the mainstream, it may do much more harm than more overt quackery, which is marginalized and relatively rare. For more information, see Pseudo-Quackery in Physical Therapy: The large, dangerous grey zone between evidence-based care and overt quackery in treatment for sprain and injury.
  3. Criticism, yes. Chiding, even. But not an insult!
  4. Ingraham. A Historical Perspective On Aches ‘n’ Pains: Why is healthcare for chronic pain and injury so bad? PainScience.com. 4042 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”).
  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.”

Permalinks

https://www.painscience.com/articles/medical-incompetence-pain-injury.php

PainScience.com/dr_competence
PainScience.com/musculoskeletal_medicine_incompetence

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