Editor’s Note: As we have broadened the reach of the National Pain Report we are meeting new and potentially important voices in the treatment of chronic pain. Dr. David Nagel is a New Hampshire specialist in physical medicine and rehabilitation, who been practicing pain management for 28 years in private practice in Concord, New Hampshire. His book Needless Suffering: How We Fail To Manage Chronic Pain will be released in 2016.
Dr. Nagel agreed to an interview with the National Pain Report to speak about his book, and the state of chronic pain today. From the patient point of view, he thinks an overhaul of how people are treated is long overdue.
National Pain Report: Dr. Nagel, how would you describe the state of pain management from the chronic pain patient’s point of view?
Dr. Nagel: “In a word, I would say “dismal.” I recently met with a group of patient advocacy group leaders, who, for the first time, are coming together as a unified voice to try to affect the way we, as a society, treat those who suffer. Their concerns mirror those of the patients I have talked to.
First, they want health care providers who will take their needs seriously and give them the time they need. One cannot assess and manage chronic pain in a 10 minute office visit. Second, and related, they would like to see a change in the way the medical profession and our culture perceive those with chronic pain; they would like to “de-stigmatize the stigmatized.”
Third, they would like to see a dramatic change in the training physicians receive in managing pain. Currently, the average training a medical student receives in four years is less than 7 hours; often the training is received from those with little expertise in the subject. Fourth, they would like to see more resources, public and private, devoted to a developing a better understanding of pain and its treatment.
Fifth, they want to see honesty from those who are providing the treatment. More specifically, they see treatments rendered more on the basis of what they offer to the patient than on the potential financial remuneration to the provider. We do not have a cure for chronic pain and that needs to be honestly conveyed. Cure is not the goal, management is. Finally, they would like to see more resources devoted to alternative ways to manage pain, such as massage, acupuncture, etc.
National Pain Report: Same question–except from the doctor point of view?
Dr. Nagel: The answer to this question depends on what type of doctor you are referring to. Pain physicians would answer the question differently. However, in a word, I would say “fear.” We do not have a cure for chronic pain. Physicians often fear those we do not have a cure for. They especially fear being in the presence of someone who suffers so. They respond by denying or minimizing the person’s pain by either abandoning the patient to another provider and/or referring to the pain as merely a patient’s personality flaw. They fear the time it takes to care for these patients. They fear the associated socio-economic consequences, especially when the physician is employed, something that is now true of more than 80% of doctors. These patients cost both time and money, something they are rarely compensated for, something which adversely affects their bottom line. They fear the regulatory scrutiny of state and federal agencies, especially with regard to opioid and now cannabinoid prescribing.
National Pain Report: “You are writing a book on pain. What inspired you to write it? What’s it about?”
Dr. Nagel: “I have been using writing as a tool to help me deal with strong emotion since the death of my brother 32 years ago. Typically I write short stories for nobody in particular, and that is how this project started. I experienced a “perfect storm” of medical-social-economic events about 11 years ago that are detailed in the book. I was very upset about how the system was treating one of my patients. I was upset at how my partners were responding to my patients as a whole. I was essentially forced to bow to socio-economic pressures, leading me to close my pain practice and devote my attention to “interventional pain management,” something I have struggled with ever since.”
“The epilogue of the book is entitled “Am I a Coward” in which I try to understand my own actions in managing this challenging social problem. In the midst of all of this, one of my colleagues, someone I had never met, challenged my objectivity in a written statement, claiming I was not seeing the “forest for the trees.” In the midst of all my emotions, I sat down and wrote a series of short stories as a means of trying to make sense of all of this as a means of self-analysis. When I had finished, I gave the manuscript to a patient who is also a writer. She replied that what I had written needed to be published, that I was writing for “us,” meaning those who suffer with chronic pain. It was apparent to me that the problem of treating those with chronic pain involved a much bigger social picture than is typically looked at. For example, how does the workplace treat those with pain? How do entitlement programs? Each of the stories I had written were designed to help outline how I came to see the problem with chronic pain management in America as the travesty it is. It was critical to me that the book be constructive. I proceeded to outline 18 social entities that have an effect on how a patient adapts to their disability. I analyzed what each does right, what they do wrong, and what they can do better.”
“The final chapter that I referred to above is my self-analysis. Myra Christopher, a member of the IOM panel that created the blue-print for changing the way we manage pain in America and the director of the Pain Action Alliance to Implement a National Strategy (PAINS) has referred to my book as a self-help book for society. That is what I intended it to be. ”
Questions for Dr. Nagel? Email them to us (firstname.lastname@example.org) and we’ll ask him to answer some of the best ones.