Mentors and Models

One great thing about OHSU is that we have very early clinical experience, starting with the first year of medical school. Traditionally, most medical schools split up the education - two years of science, then two years of clinicals (having direct patient contact). As the times have changed, there has been a shift away from the know it all doctor to one that actually has some bedside manner, and having early clinical experience helps with this. We don't have to wait until our third year rotations to practice taking a history from a patient, or do a physical exam. With this early experience we can hit the ground running.

You may have remembered that last year I spent one afternoon a week with a primary care provider. At OHSU you spend one year with a primary care doctor (internist, general practioner, or a pediatrician), and then the other year is split up between three specialties. I was fortunate to choose the specialities I wanted, and to choose the doctors, since I had heard through the grapevine who was good to work with, and who to stay away from.

So the first term of this year I spent every Wednesday afternoon with a Physical Medicine and Rehabilitation doctor, who focuses on Sports and Orthopedic medicine. From the very first afternoon I was enthralled. It's like I found my home. Patients came in describing pain in different places in their body, and it was our job to figure out where the pain was coming from - muscle strain? tendon tear? bulging disk? nerve impingement? My years of massage therapy came flooding back as I remembered the countless clients I had with similar complaints. The difference now though is that I have more knowledge and tools at hand to determine the cause of pain.

Usually we start with an X-ray to determine if there are any bony abnormalities. We move to the more expensive MRI or CT only if we need to clarify the x-ray findings. So I am learning how to read all these images - how to create a story out of shades of white and gray. Daunting at first to be sure, but as time goes by, my eyes open, and I can more quickly see the secrets the image is trying to unveil.

Once we determine the cause of the pain, we return to the patient and give them the news, plus the options for treatment. There is non-invasive treatment of intensive physical therapy, a minimally invasive treatment of corticosteriod injections (that only have short term effects but can sometimes cure the pain, or at least bring it down a few notches so physical therapy can begin), or we send them to a surgeon for a consult. Most patients start with the conservative approach, physical therapy, and the doctor sends them to the very best PT he knows for their particular body complaint. He has PTs he recommends for each different body area - neck, mid back, low back, knee, or hip pain. He lets the patient know what to expect - at first the pain will most likely get worse - as the weak muscles are trained; flexiblity should improve in the first month (which he measures with a device that shows the angles of flexion or extension); next comes an improvement in strength in the second and third month; and finally, the pain should resolve in the third to fourth month. He lets them know that resolving their pain is not a quick fix, but that studies show the more flexible and strong you are, the less pain you experience. (You see all the pressure we have to move our bodies and exercise more is not just for heart health; did you know it can help with muscular pain?)

I have learned more in my short time with this doctor than I did the whole year with the primary care provider. Maybe it's because I have a passion for the muscles and bones, maybe it's because I have a better teacher; for whatever reason, I am totally inspired and motivated to learn as much as I can about rehabiliation, and it's confirming my suspicion that I want to move in this direction as a career choice.

While I am continuing to work with this doctor on my own time, (because I love it so much), I have been switched to a new physician for this term, and luckily got a Chronic Pain doctor. He was trained as an anesthesiologist, but no longer does surgical cases devoting all his time instead to taking care of patients that are often at the end of their ropes. They often come to the Comprehensive Pain Clinic at OHSU after being shuffled through so many other physcians - primary care doctors, neurologists, and others who have tried to control their pain, but to no avail.

It's only been two weeks with this new specialist and I am once again enthralled. It's similar to the patients I have seen with the rehabiliation doctor, in terms of them having pain, but these new patients have out of control pain. Many timesthis pain is not due to an actual injury to their soft tissues (muscles, tendons, etc..), but because their nervous system has gone awry, and the pain nerves are firing out of control. This type of pain is called neurogenic pain, meaning the pain comes from some sort of lesion or dysfunction of the peripheral nerves (the ones that run through your limbs), or the central nerves (the ones that run up and down your spinal cord and synapse in the brain).

The patients with neurogenic pain are the most challenging, because there is not one treatment plan that will cure their pain. So it's a matter of trial and error; try one medication, then another or another, until the pain is under control. I have learned all the classes of drugs that are attempted - each one working on a different ion channel or receptor, in an effort to stop the nerve cells from firing. If medications cannot control the pain, then more invasive techniques are considered, like nerve blocks (numbing the nerves with injected drugs), or nerve ablation (burning the nerves), or even electrical stimulation (putting an electrode in the spine to send constant signals up to the brain - if you overload the "highway" of nerves with other sensations, then it's possible that the pain fibers won't have as many open tracts to send signals to the brain. This is similar to what happens when you hit your thumb with a hammer - you instinctly shake your hand back and forth - sending competing signals up to the brain so that you won't feel as much pain).

We also deal with patients with chronic headaches; one patient we saw yesterday was ready to commit suicide after 20 years of uncontrolled headaches, regular visits to the ER, the inability to keep a job due to the headaches, and a rapidly disintegrating marriage. It's unfortunate that there aren't many doctors here in Portland that specialize in headaches, and there isn't even a department or area at OHSU that specializes in headaches. Headache patients are also challenging to take care of, just as the neurogenic pain patients, but I have learned that there are options out there - whether it's medication, physical therapy, surgical interventions, biofeedback, or pain counseling.

To say that the pain doctor is skilled is a vast understatement. Yes he is knowledgeable, knowing all the recent studies on the different types of pain and the proven effective treatments, but more importantly for this patient population, he is astoundingly compassionate. I have seen him deal with the most difficult of patients, and get them to agree with his treatment plan. With the suicidal man he got a verbal agreement that the patient would check himself into the hospital if he had more concrete thoughts about ending his life. With the clearly drug seeking patient, who had bounced from doctor to doctor, and was just there to get a refill on her prescription, he gently turned down the prescription request and got the patient to agree to a new approach to managing her pain without opiates. And yesterday I saw him masterly convince another physician to take back a patient, who he had removed from his practice because of a breach in the patient's pain contract (they found THC, from marijuana, in the patients urine).

So now I am being pulled in the direction of wanting to be a chronic pain doctor, although I think my approach to that speciality most likely will come from being a rehabilitation doctor first. Pain Medicine is a fellowship that you apply for after your residency and you can come to a pain fellowship from many directions - rehabilitation, anesthesiology, and even psychiatry. No matter what happens to me in my career, I know that I am learning invaluable lessons with my weekly visits with these two doctors and I am so grateful for their willingness to take me under their wings. I can only hope that someday I will have the opportunity to do the same for just as eager medical students.