Overcoming Pain

Why people experience chronic pain, and the power they have to de-intensify it

The Guardian Angel in the Waiting Room

Ms. DuBois had it right: “I have always depended on the kindness of strangers."

Maybe the reason for the existence of chronic illness and chronic pain is not such a complex thing: Research has shown that approximately 50% of Americans with chronic disease do not receive the care supported by the results from all those clinical trials that you and I pay for in the form of taxes and expensive medications. This could be due to limited access to care, or maybe a health care environment that rewards “care” by how many conditions a doctor bills the insurance company for, while ignoring the actual results of whatever treatment is being rendered. Patients with chronic pain and other chronic illness are just not being treated.

Or are patients not treating themselves? Is the failure in chronic illness treatment the result of lapses on either side of the doorway to the waiting room?

An article published last week in the journal “Annals of Internal Medicine” described a research study whose authors embraced the consensus that chronic disease can best be managed by a team that works to involve patients and provides feedback to health care providers about the quality of care provided to those patients. The existence of such teams is nothing new; they have usually been led by an experienced nurse. However, most physicians these days do not have the money to support a nurse’s salary for such activities.

Enter the lay “care guide.” Who are these guides? Well, maybe one was working at Best Buy last week. Or you might have passed another in the unemployment benefits queue at the state building the month before. For this study, the laypersons hired to be guides had at least two years of college education and interpersonal skills; they were additionally provided with basic information about particular chronic illnesses. Their task: Facilitate the achieving of health care goals by interacting with the patient and the patient’s health care provider.

The result: A group of patients with chronic disease reduced unmet goals by over 30% in one year with care guide support, whereas a group of patients in the same clinic who were randomly assigned to usual care reduced unmet goals by approximately 12%. Further, the patients with assigned care guides experienced an improvement in the perception of the quality of their care, and had fewer hospitalizations.

How did these care guides do it? Sad to say, they interacted with the patient in a manner that every doctor should:

• Took the time to explain the benefit of meeting treatment goals in lay language.

• Created an environment where patients felt comfortable asking questions.

• Called patients after office visits to ensure that instructions given during the course of the last appointment were understood.

• Assisted in the development of action plans (such as losing weight).

But these guides also worked on the doctors, by reminding them about unmet goals, and informing them if there were financial obstacles to carrying out the care plan formulated at the last appointment. This is meaningful feedback, something some distant reviewer of the medical record cannot provide.

The power of face-to-face relationships gives new life to behavior change therapy. The utilization of a lay person, “one of us,” may put doctor and patient at ease. Maybe Blanche DuBois had it right: “I have always depended on the kindness of strangers.”

It might be the case that a stranger now and then sitting next to you in the doctor’s office is not so bad. You might live a little longer, and it certainly appears you will be the healthier for it.

Mark Borigini, M.D., is a board-certified rheumatologist who has devoted his career to treating illnesses that cause chronic pain and disability.

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