Dell Medical School’s Carrie Barron, MD, and David Ring, MD, PhD, collaborated with Alton Barron, MD, clinical associate professor of orthopaedic surgery at NYU Langone Medical Center, to author the following commentary. Alton, a Texas native and UT Austin alumnus, is a hand and shoulder surgeon and has been treating members of the New York Philharmonic Orchestra and Metropolitan Opera for the past 17 years.
Pain is the most common symptom that brings a person to an orthopaedic surgeon. Most pains appear suddenly, and injury is a common assumption. Patients sometimes get their hopes up that a test (like an MRI) will find the problem immediately, and then surgery will fix it.
But many aches and pains are aspects of normal aging, like arthritis, or reflect a long-standing benign problem that has begun to cause symptoms. Often the pain comes out of the blue, with no readily discernable cause and no identifiable problem, which can be a source of frustration and loss of hope.
Screenings That Provoke Anxiety
Since almost no one has a normal MRI, incidental findings that may never lead to symptoms can suddenly become standouts that draw attention. Screenings often give rise to anxiety instead of relief, regardless of the findings: cancer screening can provoke thoughts, emotions and an altered sense of self that linger even when the test comes back negative.
We find that tests to determine the cause of musculoskeletal pain bring up similar feelings: will an MRI reading of “tear” or “tumor” change you? Will you feel pressured to undergo surgery even if the findings are likely incidental to your symptoms? What if the findings are just the details of your aging body? Unless there is a clear question that the test can answer with relative certainty, it may be better not to get the test.
Pain is an everyday experience, more so as we age, and particularly so with de-conditioning or disuse. Add job, financial and family stressors to the mix (stress is thought to be the key factor in as many as two-thirds of doctor visits), and you have a recipe for low resilience, more pain and greater limitations. There’s risk of redefining oneself as a “partial thickness rotator cuff tear” or “meniscal tear” when an MRI is obtained. And an additional risk of thinking that one must be “fixed” to carry on. When the problem is rotator cuff tendinopathy or knee arthritis — the “gray hair” of the shoulder and knee, respectively — these thoughts are neither accurate, helpful or healthy. The appropriate self-definition is often “I’m right where I should be, and right on track for my age.”
But it may dash hope to say there isn’t a surgical solution. A loss of hope can lead to anger, resentment, bitterness and even aggression (vitriolic reviews, complaints to insurers and licensing bodies, lawsuits and even physical threats or violence. One doctor in Boston was murdered.). If a patient becomes angry, he may strike out by yelling and telling others he thinks poorly of his doctors, which makes those of us on the care team feel bad and in no way helps the patient feel cared for.
More Listening, Less Explaining
So what can we do? How can we help create hope and resiliency? First, we have to find out who the patients truly are. We can listen to their stories. Maybe we’ll hear about the job they hate, their sick mother, the brother who was arrested, the husband who drinks too much and stays out too late, or the baby with a disability that makes intimacy between the spouses difficult at best.
But in order to do this, we have to step out of our hard-earned role as surgeon-healer to be a “healer-healer”: a confidant, a comforter. We may have to spend a little extra time in the moment, but we’ll save time by avoiding long explanations of pathophysiology. Our job is to determine the very best treatment for the patient, even if (especially if) it is not surgical.
Potentially angry patients are low on resilience and high on hope (often false hope, but hope nonetheless). That’s why they come to see us. And we mustn’t squander their last bit of hope. Rather, we must instill a different hope: one bred of true human connection, listening to their story, going where they need to go emotionally and finding a way to make them better. It may be through renewed exercise regimens, regular walks in nature or rekindling an ailing friendship. Or, in very rare cases, we may simply not have a solution for the pain. But if we listen, connect and empathize, those rare patients will often still be appreciative and remain hopeful — not because we solved their problem, but because we cared enough and took the time to listen.