Using Doctors

The first and perhaps most surprising thing you need to know about using doctors is that most receive very little if any formal training in the management of pain. While excellent training programs in pain management exist, they are relatively few in number and usually attended by doctors who have already completed their training.  However, any doctor can legally call himself/herself a pain specialist regardless of the training they’ve received.

Because adequate physician training is lacking, access to care is limited. Despite increasing recognition in the medical literature of the high human and economic cost of chronic pain, getting appropriate treatment remains a struggle for far too many patients.

When seeking help, you must be armed with an understanding of the above. There are limits to the amount of care you can get from doctors, depending on their experience and/or area of expertise. Knowing this, you can avoid feeling you have to beg for or demand a kind of care from a doctor unequipped to provide it.  It is far more productive to regard a doctor as a source of information or possessor of skills that can be of use to you, even if only in a limited way.

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. Medical and surgical specialties focus on diseases affecting specific body systems or surgery on specific areas of the body. In the surgical specialties, greater emphasis is placed on developing the physical and mental skills required to perform surgery than on investigative skills and non-surgical treatments.

Here is a survey of specialists who often see patients with chronic pain. As of 2015 there was no officially recognized specialty in pain medicine. This means that for most chronic pain patients the main purpose in seeing a specialist is to rule out a specific disease or need for surgery, not provide care.

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.

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 (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 by trauma. The treatment they provide often focuses on physical 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 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 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 orthopedic surgeons, 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) and the use of drugs to control pain. Anesthesiology is the only medical specialty that has significant formal training in the treatment of pain. 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. This is what all specialists are trained for.

Most specialists are not trained to provide comprehensive long-term care required for many chronic pain patients. However, when the role of each specialist is understood and used appropriately by a chronic pain patient, their services can be used wisely.

While the reality of chronic pain is a grim one, it is also a changing one. Chronic pain is far more widely recognized as a serious medical condition than it was even 20 years ago. Chronic pain specialty programs are on the horizon. Research has established the need for multidisciplinary approaches to treatment. There is good help available. It is just not perfect or found in every office, clinic and hospital. Even if the doctor you see can’t take away your pain, that same doctor may still be able to help in some fashion. If you want a doctor for an ally you must learn what he or she can actually do for you and be willing to learn about it.