More About Doctors

There is a saying in medicine that those who specialize learn more and more about less and less until they know everything about nothing.

As medical knowledge has increased so too has specialization. It is impossible for any one human being to know all that is being discovered even in only one area of medicine. Given the complex nature of chronic pain, it is common that different medical specialists will see and perhaps treat the same patient.

This longer than usual post describes the kinds of medical specialists that chronic pain patients are most likely to be referred to in Canada by a primary care physician. Use these descriptions as a reference. If you see one of these specialists it will help you be more realistic with your expectations.

While doctors may be taught to remember large quantities of information, more importantly, they are trained to use information appropriately to arrive at a diagnosis and prescribe or provide treatment. In the surgical specialties, greater emphasis is placed on developing the physical and mental skills required to perform surgery than on diagnostic and non-surgical management skills.

Medical and surgical specialties focus on diseases affecting specific body systems or surgery on specific areas of the body. As I’ve written before, there is no officially recognized specialty in pain medicine and depending on experience and/or interest, there can be great variation among doctors in a particular specialty with regard to their knowledge of treating the pain associated with some specific disease. For many chronic pain patients the role of the specialist is to rule out the presence of a particular condition that may be causing pain.

Rheumatologists are trained to investigate as well as treat osteoarthritis and diseases that lead to inflammation of the joints, muscles and other body tissues. Such diseases involve the immune system and musculoskeletal pain is one of the most prominent symptoms of these conditions. Specific skills required in rheumatology include questioning the patient about the nature of their pain (i.e. location, quality and associated symptoms), performing a physical examination, most often with a focus on the musculoskeletal system, ordering appropriate laboratory tests, determining appropriate treatment and performing procedures such as joint injections. All the different kinds of arthritis, systemic lupus erythematosis, vasculitis and inflammatory muscle disorders are examples of rheumatologic disease.

Neurologists assess and treat diseases of the brain and nervous system including headaches. In many neurological conditions, pain is not a primary feature although it may be an associated one. The skills of neurologists are similar to those of rheumatologists. They must question patients about their symptoms, examine them and order tests. On the basis of the information they gather they must then figure out what may be the cause of the problem and how best to treat it. Neurologists deal with such conditions as headaches, seizure disorders (epilepsy), multiple sclerosis, Parkinson’s disease and stroke.

Physiatrists (also known as specialists in physical medicine and rehabilitation) share some of the knowledge base of rheumatologists and neurologists. They evaluate patients whose ability to use their bodies have been impaired by neurological or rheumatologic disease as well as trauma. The treatment they provide focuses on mostly physical but also pharmacological methods of rehabilitation. They too are trained to ask questions, examine and order or perform tests related to musculoskeletal/neurological function. If pain results from poor function, physiatry may play an important role in treating pain.

Orthopedic surgeons (orthopods) assess and treat problems affecting the bones and joints caused by disease or trauma. Their primary training is in learning surgical techniques and developing skill in the use of a wide range of surgical instruments. Many will focus on a few surgical procedures only (e.g. “back doctors” are often surgeons who operate on the spine) while others learn to manage acute trauma. Some orthopods may also develop expertise in non-surgical management of injuries and become affiliated with sports teams. Their value to the chronic pain patient is most often in being able to either rule out the need for surgery or give a realistic picture of the potential benefits and risks of surgical treatment.

Neurosurgeons assess and treat trauma or disease related conditions of the brain and nerves. Their primary training is similar to that of orthopedic surgeons but with emphasis on microsurgical techniques required to operate on the brain. They too may sub-specialize and gain extra expertise in a particular kind of procedure or in the management of a particular kind of problem. Some have developed expertise in managing pain related to specific kinds of nerve injury. As with orthopods, their most common value to pain patients lies in providing information on the potential role of surgery for their condition.

Psychiatrists are trained to recognize and treat psychological disorders. Their training develops expertise in identifying the nature of the disorder through the use of questions and psychological tests. They are also taught to use psychotherapy and medications to manage psychiatric conditions. Like all specialists they may focus on particular disorders or treatments. Chronic pain is often accompanied by depression, anxiety and other related problems. Psychiatrists are therefore valuable for their knowledge of the treatment of these problems although their focus may not include specific treatment for pain.

Anesthesiologists have primary training in the management of patients undergoing surgery. Their role is to manage pain, consciousness and the physiological derangements caused by surgery and/or disease during an operation. Training includes technical/manual skills (e.g. injections of local anesthetics or placement of intravascular catheters) and the use of drugs to control pain, awareness and physiological function. Anesthesiology is the only medical specialty that has significant formal training in the treatment of pain. Although this training focuses mainly on acute pain, some anesthesiologists sub-specialize in chronic pain management because of their familiarity with pain medications and local anesthetic injections. North America’s first multidisciplinary pain clinic was founded by an anesthesiologist.

Other specialists such as gastroenterologists and gynecologists will see pain problems such as chronic abdominal or pelvic pain. But just like all the specialists listed above, their value is in their knowledge and skills in detecting and treating specific diseases with specific methods. This is what all specialists are trained for.

For chronic pain patients, specialists should be regarded as potential sources of information or skills that may be relevant to their pain. It has to be emphasized that most of these specialists are not trained to provide comprehensive long-term care required for many chronic pain patients. However, it must be equally emphasized that when the role of each specialist is understood and used appropriately by a chronic pain patient, this constitutes a solid base for multi-disciplinary treatment.

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