Ideas for improving pain care

Last fall I published a three-part series to answer the question, “Why is it so hard to get good help for pain?” I laid out the grim realities, from the disaster of the opioid war to the sneaky quackery of technology to a whole new way of mind-blaming; from the systemic biases and prejudices, to the institutional glitches: fifteen depressing reasons.

That was good stuff, valuable for patients especially: I wanted to represent and validate their frustration and despair. And I wanted to help clinicians understand why so many patients are so very pissed off, disengaged, and even scared of “care.”

But it was also rather bleak and “negative,” and I promised some nicer follow-up. So what’s the constructive version? Do I have anything encouraging to say, or is it all just problems, problems, problems? Where do we go from here? It’s time for that positive post!

There is always hope, of course. Patients can at least improve their odds of finding better help and relief. And professionals — no matter how humble or advanced their training — can always do better, and become that breath of fresh air for their patients.

So here’s my best crack at an antidote to all the bad news. This is shorter and sketchier than the original series describing all the problems. There just aren’t as many solutions as there are problems, many of the problems have no obvious solutions, and some of the solutions are extremely obvious — just mirror images of their corresponding problems. Not enough education? Well, gosh, I guess we need more education! Duh.

But it’s worth trying to reframe many of them in a more constructive way. So … what are some of the possible pathways to better pain care?

I usually use this image sarcastically, to represent snake oil of one kind or another. But today it is sincere, because these are my earnest prescriptions for hope.

• More education for everyone is the critical prerequisite for solving most of the problems. We can’t fix everything that’s wrong with education, but individuals can always do better — a theme throughout this list. For clinicians, “continuing education” should be about acquiring knowledge and thinking skills, rather than certifications and hands-on skills, modalities, techniques, which tend to target simplistic notions of what drives pain. All the industry’s problems will be harder to solve if pros are preoccupied with being “body mechanics” and profitably doing things to patients to “fix” their flesh — and as long as patients keep driving strong commercial demand for all that with unrealistic and naive expectations. The general antidote to reducing both supply and demand for simplistic solutions is more knowledge.
• Patients should become biology nerds, and have fun doing it. General literacy in the life sciences should be a higher life priority than, say, learning how to do your own plumbing (handy as that might be). In a perfect world, we’d outsource our healthcare just like we outsource legal advice or car repairs. But it’s so hard for patients to find good help that you have to take matters into your own hands. And so I want pain patients to consider making a major hobby of learning about this stuff. I’m not talking about taking night classes (though you could); just read good books for general audiences about this stuff, like Bryson's The Body: A Guide for Occupants, or Mary Roach's Gulp: Adventures on the Alimentary Canal.
• Your first educational priority should be scientific skepticism — it’s achievable, liberating, and the payoff is huge. It’s the most important thing you can learn, because it supercharges your future learning. But skepticism is a unique skill set that isn’t a part of any curriculum, and you have tackle it yourself: start with a book (The Skeptics' Guide to the Universe) and a video course (Your Deceptive Mind). Your investment will pay off in many ways, but the most direct benefit is that bullshit detector upgrades will save you real time and money when you start spotting and avoiding the non-obvious quackery — whether you're a patient declining a dubious therapeutic option, or a clinician refusing to go to a weekend workshop about it.
• Cultivate higher awareness of vulnerable people, red flags, and contraindications — another specific educational goal with good bang for your reading buck. Patients need deeper insight into their own potential vulnerabilities and fragilities; and clinicians need to lean less on “no pain, no gain,” because it is going to backfire for many (even if it works for some, which is doubtful). The less formal training you have, the more important this is. Are you a bodyworker who only went to night school for 6 months, but you find yourself with clients who are asking for your help with their ominously worsening back pain? You can be a part of the solution by learning your red flags, and learning not to “go deep” with someone who could have one of the many pathologies that cause soft-tissue fragility. Do you know what they are? Do you know how common they are? No? Fix it! Stat!
• Manual therapy should be a pleasant and reassuring sensory experience. That’s what pros should deliver, and what patients should expect. Primates groom each other, and the job is to do it artfully, to make it nice — because “nice” has a better chance of doing the most good with the least harm. By all means continue to get manual therapy you like (mostly massage, probably), but never tolerate more intensity than you can enjoy. If you’re going to pay more than a buck a minute for hands-on care, you should get pleasure and relaxation from it, to balance the pain in your life with something positive. See: The Pressure Question in Massage Therapy.
• Patients should cheerfully seek second opinions … and twenty-second opinions. Self-education can only get you so far: patients still do need good help, but many lose heart and give up too soon. It is hard to find good help, but it’s not impossible. Treat it like dating: expect it to be demoralizing, but do keep going! Rule out more options than a vegan at an all-meat buffet. “Shopping around” for the right professional help isn’t a disappointing and desperate plan B, it’s plan A. The sooner you embrace that reality, the sooner you can get on with it, and find the right helper.
• Don’t embrace either the bio or the psychosocial at the expense of the other — it all matters. The “biopsychosocial” model can be a wise way to approach pain care in theory, but in practice it has largely failed. It needs more sophisticated and mature ideas about what constitutes “bio” and “psychosocial” factors, and a more sincere balance between them. In this list, I’ve been avoiding constructive suggestions that are just don’t do the bad thing, but I couldn’t avoid it in this case: please stop paying lip service to one of these while overemphasizing the other! And don’t oversimplify either! More specifically…
• Bio means actual biology, not just biomechanics. Stop worrying about posture and kinesiology, in other words! Stop worrying about barely detectable defects and movement dysfunctions. Metabolism matters more than mechanics. Focus on messy physiology, neurology, pathology. Another hopeful implication of this is that we should never give up on diagnosis. Assume that nine times out of ten “mysterious” pain actually does have an explanation, very hard to find, but possible in principle. Many people can eventually be diagnosed, but only if everyone keeps the faith that something biological is probably wrong.
• “Psychosocial” means actual psychological and social factors in care, not just psychosomatic pain. In practice, the “psychosocial” has mainly been about minimizing and even disparaging the role of biology and pathology as “overmedicalization,” and replacing them with psychological explanations and treatments for pain, gaslighting patients with the notion that their mental state causes their pain. Don’t do that! So what should the psychosocial perspective be about? Compassion and empathy! Communication and respect! Seeing past racist, sexist, and homophobic blind spots! It’s about bedside manner, patient-centred care, and patient-reported outcomes, the pursuit of relevant functional and life goals, and easing pain-related suffering wherever possible! That’s a whole bunch that has nothing to do with psychosomatic pain.
• Prioritize general health and fitness. Patients: invest in your fitness however you possibly can. Improve your odds of recovery someday. The only thing worse than whatever’s already wrong with you is that plus other health issues. For instance, you might eventually discover that you need a surgical solution — and the sooner you start “prehab” the better — even years in advance! Because it can take years. And clinicians? Help people with this! Help people with the boring basics. Help people live as well as possible with and in spite of pain, to be as active and functional as possible — be more like occupational therapists, basically. (And if you’re an occupational therapist already … good career choice. 🙂)
• One more just for clinicians: move away from fee-for-service practice models, and towards value-based care! Whether you’re a self-employed “freelance” manual therapist without a billing code in sight, or you’re a physio in a big clinic and everything you do had better have a billing code, you are immersed in the perverse economic incentives that have undermined good care for pain for decades. Value-based care rewards results and efficiency, not the number of visits or procedures delivered. Even if you can’t be paid that way (yet), you can still benefit from shifting your focus to what patients experience and what they can actually do (patient-reported outcome measures). This is a way bigger sub-topic than I can manage in a bullet point, so I refer you to the Future-Proof PT podcast for advice on how to cross the chasm between these practice models.

I could keep tuning and adding to this list for a month. For the sake of my sanity, I will stop revising it now — it has already taken hours, and I really need to start treating blog posts more like works-in-progress on the road to more polished articles and books. So I’ll stop there, knowing it’s not the end. Got suggestions? Let’s hear it!

Most patients will continue to be disappointed and frustrated with the quality of the care they get for unusually intense and/or chronic pain. The problems I’ve reported are so serious that there’s no realistic hope for most patients in the foreseeable future. At a time when many countries are attacking known good solutions for serious health risks — vaccines, fluoride, abortion rights! — it’s hard to believe we stand much of a chance with much harder problems that have never been anywhere close to solved.

If you’re not cynical, you’re not paying attention. But that doesn’t mean we just give up, and there are many good goals to work towards.