[gforge]

Lovely article, as an orthopaedic surgeon I can tell you that most of us know this. Treating chronic pain with surgery is generally a bad idea, I spend a large share of my time explaining this. Some patients are grateful for this, but I think that many go and try to find "a real doctor".

An interesting development is that there is generally an increased acceptance for psychiatric diagnoses. More are accepting that just as the pancreas may stop delivering insulin, the brain may fail to uphold the proper seretonin levels. Unfortunately it is not as simple as that, fixing seretonin or any other substance is like pouring oil over an engine and hope that it reaches the target. Still, I'm sure that we will see a huge change as true targeted treatments are no longer just sci-fi. Getting people to the right specialist is until then a good start.

[curun1r]

The problem with viewing pain the way you're viewing it is that pain is an entirely subjective concept and there's no way to objectively measure it. Looking for physiological symptoms, like serotonin imbalances, can never adequately explain the perception of pain because there's no way to tell the difference between a symptom and a cause.

I've seen through meditation how simply learning to experience pain in a more productive fashion eliminates the vast majority of it. So much of the pain that I used to experience was the result of feeling a small amount of physical pain and my mind blowing it completely out of proportion. Learning to experience pain with equanimity rather than distress causes pain to recede into the background.

In addition to using disciplined thinking to control pain, I've also used it to increase the amount of time I can hold my breath from just over a minute to over six minutes. Like pain, the urge to breath is a little bit physical and a lot mental. Learning to experience it with calmness and acceptance dramatically reduced its power.

The tendency of modern medicine to look for a pill to cure everything is very dangerous when the problem you're dealing with cannot be objectively measured. The mind is a very powerful thing and it's measurements will always be at least partially the result of the patient's thought processes...there's no way to separate them. And with all the negative consequences of these drugs (both painkillers and drugs that target neurotransmitters have very serious side effects), there should be a lot more emphasis on patients exhausting all non-pharmaceutical approaches first.

[gforge]

I could not agree more. Our bodies have had millions of years of handling disease without drugs, we should tap into that resource. The problem I face daily is that many patients come to me and say they don't have the time for physiotherapy and want surgery. They often add that their neighbor had great experience with surgery for the exact same illness. It's actually amazing how illnesses cluster...

It is hard to convince people of taking the slow route. This is a similar to convincing people to write unit tests for their code, we understand that it is the right thing to do but we always have a deadline. Some threads here report that they started with physiotherapy after years of other solutions, I would love to know how to change years into months.

[edison85]

I feel like most chronic issues have to be viewed systematically. Often an injury or imbalance in one area over time causes dysfunction in another and although we have physiatrists, they jus don't have enough time to look at the body as a whole and PTs have the time but many just go through the motions.

For chronic pain, I've given the book Trigger Point Workbook by Davies which makes Travell and Simon's trigger point research easily understood by the layman tona few people and many have improved over time. I've seen carpel tunnel, back pain, scoliosis, SI dysfunction, TMJ all improve

[tcj_phx]

> An interesting development is that there is generally an increased acceptance for psychiatric diagnoses.

Psychiatry is the only medical specialty that has a resistance movement and survivors groups. I think psychiatrists do okay with diagnosis, but commonly-used treatments frequently make the patients' condition worse. Ref: Whitaker's Anatomy of an Epidemic

> More are accepting that just as the pancreas may stop delivering insulin, the brain may fail to uphold the proper seretonin levels.

The MAOIs were reasonably effective as anti-depressants, but fell out of favor as newer & less-effective patent medicines were approved. The SSRIs are slightly better than a placebo, for some patients. I think the Paxil hawkers recently lost a lawsuit over a lawyer who rapidly became suicidal after starting that drug. He threw himself in front of a train: https://www.madinamerica.com/2017/05/change-in-chicago-playi...

[gforge]

I agree, there are serious issues with many of the drug treatments and psychiatry has some dark history - but so does orthopaedics (e.g. the pseudotumors associated with hip resurfacing). Even if anti-depressants are no more effective than placebo, I still think a knife may be an even worse alternative and I've seen patients spiraling down into an abyss of pain after repeated failed surgeries. My hope is that if we are able to correctly identify the cause we can start getting somewhere with the treatment.

This said, there are indications that there is a subset of cases where the pain actually is triggered by the spine. The SweSpine register has some interesting numbers that show the results after surgery over time (http://4s.nu/pdf/Report_2014_Swespine_Engl_ver_141204.pdf page 37, DDD). There is also the very fascinating study by Arlbert et al (https://www.ncbi.nlm.nih.gov/pubmed/23404353) that show that antibiotics may help. As always LBP is most likely a mix of diagnoses where we need to identify the correct subgroups before we even start to test treatments.

[tcj_phx]

Thanks for responding, and for the links.

> I've seen patients spiraling down into an abyss of pain after repeated failed surgeries.

I think surgery is commonly seen as better than doing nothing. Someone I know has some deterioration from cortisone medications. He just heard that his neck implant didn't fail, now the next joint down is gone. He'd rather not have surgery again, but is rather miserable currently, and some doctors make their money by doing surgery...

Do you have any comments on Inertia in Medicine? Doctors try to stay up to date, but... well, cardiologists seem to resist acknowledging that statins don't actually help many patients, and psychiatrists are very resistant to admitting that antipsychotics prevent their patients from recovering from their psychotic episodes...

What does medicine do well, and how can use of practices and procedures with limited benefit be curtailed?

[gforge]

There is an inertia but I would say that it is often of benefit to the patients. The problem is that I as a surgeon love to operate (note that we don't even have a monetary incentive) and I truly want to help my patients. This makes me biased and the inertia has saved me quite a few times for starting performing new cool procedures.

The biggest problem is that we often have a big problem with discontinuing treatment s, see my post on clavicle fractures http://gforge.se/2017/08/clavicle-gate/ I am not a cardiologist so I don't know the full details on the statins, but I would be careful not to skip them. Cardiovascular mortality has decreased hugely the last decades and this one of the major treatments - they must be doing something right.

Also be careful of flat-earth arguments, there are plenty of people who want to disprove medicine - some of us are researchers but others are just writing blog posts after finding a single article contradicting a treatment. It is incredibly hard to do medical research, it takes years to recruit patients and collect data. You always think that there is a ton of patients with this condition and then you find that the inclusion and exclusion criteria that you believed to be so brilliant (others had forgotten about them in their studies) actually get in your way of being able to finish the study. If this wasn't enough, once you are done with disproving the treatment, you will find that the person that a few years ago popularized it is no longer doing it... They would never do that, now they're doing treatment B, a completely different thing. It's a game of whack-a-mole.

[tcj_phx]

Hi, thanks again for your comments. I am trying to better understand the mindset behind the medical status quo, and you've given some good insights.

> I am not a cardiologist so I don't know the full details on the statins, but I would be careful not to skip them. Cardiovascular mortality has decreased hugely the last decades and this one of the major treatments - they must be doing something right.

Statins cause massive numbers of side effects: http://www.skepticalob.com/2009/06/doctor-listen-to-your-pat... - this doctor figured out that an elderly patient's "progressive muscle weakness" was caused by the statin that he'd been on for years.

> Also be careful of flat-earth arguments, there are plenty of people who want to disprove medicine - some of us are researchers but others are just writing blog posts after finding a single article contradicting a treatment.

My girlfriend was grievously harmed with the injection of Depot-Provera ~10 years before she met me. This drug is known to be defective - usually it just makes women fat, but sometimes it makes them suicidal - but doctors inject it anyways. One theory is that depot provera was approved by the U.S. FDA because that agency's job is to approve drugs, and was long ago captured by the industry it supposedly regulates.

Medical apologists could say that Provera is very effective at preventing babies, so "they must be doing something right". But you have to ignore the carnage: https://www.youtube.com/results?search_query=depot+provera - "Depo Provera has destroyed me" has a compelling title.

Assuming there is good basis for common medical practices is a great impediment to medical progress.

[gforge]

A common problem that we have is that there is no such thing as the perfect drug. Any drug that is stronger than placebo will inevitably have side-effects (note that even placebo has side effects). It is always a cost-benefit and this is a tricky thing to fully convey to patients - what does 10% risk of side-effect mean? For the patient that gets the side-effect they usually have it a 100%.

I wish that we doctors were immune to the industry's influence but unfortunately we also sometimes fall prey to the cunning tricks. I think the OxyContin scandal says it all http://theweek.com/articles/541564/how-american-opiate-epide... Mind-blowing that doctors actually believed that there is a free lunch - a morphine product without addiction...

There is hope though, here in Sweden doctors during the 90:s were frequently taken to nice dinners and other events in the name of drug companies representative costs. In early 00 this basically disappeared and today we get a sandwich during lunch break in order to hear about the new thing that they want to sell us. I think the awareness of the "no free lunch" concept (see http://www.nofreelunch.org/) is much higher today than 20 years ago when I started med-school.

One cost that you have to be prepared for is that the system becomes "communistic": if we prescribe any drug that is outside the recommended set of drugs our clinic has to cover the costs. The adoption of new drugs is generally slower (although not for important drugs e.g. cancer treatments) and we are no longer allowed to make local deals with suppliers, everything has to go through centralized deals (even if we can get a better deal). In my mind it's a small price to pay if it keeps our patients safe and we get to spend the money on our health-care where it matters, but I think this system would never pass the American legislative system...

[gsmethells]

Shameless plug: have you tried our orthopedic PACS?

http://www.medstrat.com