What Do You Bring to the Table?

I recently had to appear before the Industrial Accident Board in my home state (Delaware) to describe my care of a patient. He had suffered a well-documented injury and all of the data supported a chronic diagnosis. The opposing counsel even presented information that he had already been deemed permanently disabled. I was being asked to defend my continued care, as another doctor who worked for the insurance company claimed that my care was of "no benefit."

As a background, my patient had been working at a job site almost five years ago when he stumbled backward and hit his head, losing consciousness. Since that trauma, he experienced ongoing headache pains and vertigo. He also reported neck pain into his scalp, and readily demonstrated severely restricted neck motion. Neurologically, he had been diagnosed with a post-concussion syndrome. Functional capacity and disability exams had already tagged him at better than 60 percent disability.

He had a history of substance abuse and did not respond well to the medications available, so he was referred to me for care. My treatment began with acupuncture, which did help to ease the pain and spasm. Manipulation was then incorporated to reduce fixation and improve motion. As he continued to improve, we also incorporated several sessions of active stretching exercises to further improve motion, and then released him to continue stretching at home.

Although the neck pain and spasm did improve, he continued to report recurring severe headaches. His neurologist referred him for psychiatric evaluation, as he was having a lot of anger and depression due to his chronic pain. My care continued on a less-frequent basis; we had been able to significantly reduce the pain and spasm in his neck, but the headaches did not respond to my or any other provider's care.

At a certain point, it was decided that he had reached a maximal level of improvement with the care I provided, and so I released him from my treatment in relation to the work injury. However, upon stopping my care, he quickly noted an increase in his neck and shoulder spasm, with referred pain up into the head. His dizziness also increased to a point that he was not able to drive. He ended up going back on three narcotic medications he had been able to stop taking while under my care.

Due to this flare-up, his neurologist referred him back to my care. The entire reason for my being asked to come explain my case to the Industrial Accident Board was that the carrier did not feel my continued care was warranted. The argument was that the patient clearly had a defined condition that had been deemed permanent. It was argued that my care did not make him better, but only gave him temporary relief of his symptoms.

Now into the treacherous waters. I explained that I did not expect my care to address all of his complaints. I showed from the records that my care had been very effective in reducing his neck and back pain and spasm. The neurologist had been treating his headaches and the psychologist had been addressing the emotional component of the case. The moderator of the panel then dropped the big question: "How do you know your care is helping the patient when it is mixed in with all the other types of care? Doesn't it seem more logical to pursue one therapy at a time so you can define what techniques provide the most benefit?"

At a quick glance, that is a great question - but only if you view the body so mechanistically that you believe you can only fix one piece of a problem at a time. The reason there are different facets of health care is that there are many different conditions requiring different care. Nowhere does it say that a patient can only have one problem at a time. In dealing with chronic pain patients, it would be a very rare case that did not require a multifaceted approach to treatment.

This is not a new concept - recall back to the concept of treating the "whole" patient: body, mind and spirit. You can define those components many different ways, but the application is the same: Different patients need different types of care, and that may not always be the care you provide. The more current understanding of treating chronic pain embraces this concept - chronic pain conditions are often complex and require a variety of therapy options simultaneously to achieve the best possible outcome.¹ These can include (but are not limited to) chiropractic, acupuncture, therapy, medications, counseling and active rehab.

In this particular case, the patient had come to me almost a year and a half after the injury - clearly chronic, his body used to being in a reactive inflammatory state. He had already been taking many medications to address this injury; whether I liked it or not, that was part of his treatment at the time. With such a long history of spasm and limitation, he had a great loss of muscle tone and function in his neck and upper back; he needed active exercise and stretching. His counselor also recognized that as we decreased his pain and spasm, his function improved and his mood improved, as he was no longer grossly disabled by his pain and was able to get out and provide for his family.

When my part of the overall care plan stopped, there was a rapid decline in his overall condition - increased pain and spasm, decreased motion and an increased use of medications. My argument was not that my care was the "end-all" of his treatment, but part of a synergistic approach to the patient that produced a much better outcome.

So, what is to be learned from this? Simply put, don't discount the value of the care you provide, but at the same time do not get so caught up in your own bubble that you fail to recognize that your patient may need more than you have to offer. There is no shame in that. If anything, being able to recognize when your ability to treat a patient stops and the need for other care begins shows you have a much better perspective on the actual needs of your patient. Coordinating care with other providers - medical, psychology, rehab - will only serve to improve your quality of care and your treatment outcomes.

As a health care professional, you are responsible for the care you provide your patient. Align yourself with quality practitioners in other disciplines so you have a network of options available to meet your patient's varied needs. As always, document your findings, your treatment plan and the response to care. If you take the time to fully evaluate the patient so your diagnosis is correct, your treatment will be appropriate and your patient will thank you for your quality care.

Reference

1. Boswell MV, Cole BE (editors). Weiner's Pain Management: A Practical Guide for Clinicians. American Academy of Pain Management.