How Pain Doctors Think – One More Time

How Pain Doctors Think – One More Time

Editor’s Note: When Dr. Richard Radnovich wrote a provocative column for The National Pain Report entitled “10 Things Never To Say To Your Doctor”, it engendered interesting and passionate response. It prompted Kurt W.G. Matthies to write a response. Both of these men made great points. The idea of the original column was to help patients understand what the doctor might be thinking. Dr. Radnovich explains in this follow-up commentary:


Dr. Richard Radnovich D.O.

Thanks for posting the thoughtful and reasoned commentary on “10 things never to say to your pain doctor”.

It is obvious that I have simultaneously over-estimated my ability to write on this topic, while underestimating the frustration chronic pain patients have with their care.

I do not want to belabor this, but sadly the point of the article has beenOK grossly misunderstood.  And the point of the piece is VERY IMPORTANT; misunderstanding the point of “10 things” is detrimental to all pain patients. So, let me clear it up.

Unfortunately, Mr. Matthias, your response perpetuates and expands the misunderstanding. Here are just a few examples: “we’re missing an entire group of patients when we follow the thought process of Dr. Radnovich” and “Let’s look at Dr. Radnovich’s ideas” and “Dr. Radnovich, please consider the fact that some pain patients who present in your office may know a hell of a lot about medicine”.

You, and others, have made this about me.

Let me be abundantly clear: the items on the ‘10 things’ list are not a valid basis for formulating an opinion about a pain patient, much less a treatment plan. They are not treatment guidelines. They are not suggestions that pain docs ought to follow in evaluating patients.

And they are certainly not “my ideas” nor how I treat my pain patients.

The ‘top 10’ list reflects the assumptions, biases, stereotypes, short cuts, categories, pigeon holes, first impressions, presumptions, and pre-judgements that just about every physician may make during an office visit. These impressions color how they feel about you and how they treat you.

Again, this is not my idea. I did not create this process. I am not to blame for its existence. Research has been done and books have been written on this phenomenon. Probably the most popular is “How Doctors Think” by Jerome Groopman, I would encourage all pain patients to read it.

Here is another way to look this. Patients talk about doctors, right? Well, doctors are human and we talk about patients. Or more accurately, types of patients. Docs share the things that patients say and do that rankles them; the things that trigger their pre-judgements.  That ‘top 10’ list is based on the things that I hear repeatedly mentioned from other doctors.

Again, I did not make those up. THEY ARE VERY LIKELY WHAT YOUR DOCTOR ALREADY THINKS when you say the things on the list.  Let me repeat that: I did not create that list; those are the things that your doctor already thinks. More importantly, your doctor is likely basing decisions on those assumptions, whether or not they are valid.  Mr. Matthies, you provided an example of this from your own experience: “My pain doctor asked me during my first visit – who’s your lawyer? Is this a work-comp case? When I replied I had no lawyer, he was surprised.” Your doctor had already made a judgment and assumptions about you.

The point of the article was not to marginalize patients nor justify poor treatment; it was not to make the pain patient even more depressed about the state of pain management.

The point was to empower pain patients by making them aware of theses biases. And if they choose to, use the biases in their favor by adjusting how they present to the doctor.

Of course, you can choose to ignore all of the ‘top 10’, and you can pillory me in the process for bringing them up. The plain facts are that 1) these biases exist and 2) the relationship with your physician is a 2 -way street. You will not be able to change the doctors’ biases, but you do have complete control over how you present.  If you are repeatedly unhappy with how you are treated, you might consider the latter.

I wish you, and all pain patients, good fortune in finding a pain doctor that really listens and cares. They may be hard to find, but we are out there.

Editor’s Note #2: I’m happy to report that both Dr. Radnovich and Kurt W.G. Matthies are going to continue writing for the National Pain Report.


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Sandy A S

Read them and could only think ‘ok so what is next?’

How can we do something to change communication?

For example, how can we tell a new doctor after a move perhaps another state that the current medications are working?

How can that be discussed so it’s not a frustration discussion w coworkers over coffee?

If managed and with good history along with medical history and prescription history why not listen to us?

If these medications work how do we convey it properly to a new doctor? What are the trigger words in that scenario?

Trying to keep it managed how can our words help or hinder?

Ultimately it’s a mercy plea for – don’t turn my life upside down. Movingly is hard enough.

Because even good changes too fast can throw one of us patients into a tailspin. Never any fun.

Remember, Every BODY is different. And getting managed even barely is better than trying all the medications again.

Plus CP doctors shouldn’t prescribe the amount of these types of medications – SSRIs have huge issues and should stick with psychiatric doctors, psychiatrists don’t generally prescribe opiates and they work well for some mood disorders.

SSRIs for me I have a terrible side effect of increasing the depression to suicidal. One works a little for me. On/off others can give me a terrible reaction.lethal even.

Howcan we present it and ourselves with little interruption.

Why ask about allergies or reactions? If not hospitalized it didn’t happen?

Is it any wonder why so many patients get a form of PTSD from doctors? I dread seeing and shake before appointments. Not just with new doctors even my current one. Not his fault I have it already had anxiety when I had a horrific experience of sexual abuse and blackmailing. Reported it to my doctor who then called him. The guy faxed a dummy script. My purpose at the other office was a test independent of primary doc for disability.

And when my lawyer requested paperwork I was never there? ! Lol. Still was held and everything searched after I told my doctor and he called the other then police.

As a woman ee have even less power tho!

Terri Lewis

Heuristics. Things we believe are true, even if they are not exactly or entirely true. These are the cognitive filters we utilize because it makes us more efficient. That does not mean it makes us more competent in our thinking, choices or actions.
Biases. The individual filters and algorithms derived from our heuristics. Hardened thinking patterns that efficiently and automatically direct our choices or actions.
Both of these very real cognitive behaviors negatively affect the working alliance that must be developed between physicians and and the people they treat. Both parties to the process must acknowledge that these things exist and fight the very natural tendency to apply unchecked heuristics and biases to the process of medicine. To be viewed as a person first and a collection of symptoms second is important for both parties to this equation. Drive through medicine only makes this more difficult.

OK – here’s one! 10 things a doctor should not to say to pain patient: 1. “I’m the doctor, you’re the patient, what the hell do you know about your disease?” We probably know more than them and everyone they know combined. We usually are stuck in front of a computer with a lot of time on our hands. And that thing about the internet and bad information? It’s bad and good information. It’s all information including what my dad thinks about my disease. We are professional patients. We know how to spot bad info. How about letting us study for you? You know, like a partner in healing? 2. “So, are you saying that you’re fed up with everything and no longer see a future or a happy life anymore?” Quit doing that passive aggressive, “Let me saddle you with a suicide attempt and then i can treat you by referring you to a shrink,” thing. Again, if only you understood how much you can screw up a person’s whole life. 3. “You’re a drug addict who came to me to get your fix, that’s all! Well, you’re not gonna do that in my office!” You either pulled the wrong file or are frustrated that nothing is working. We’re frustrated too but we don’t yell at you and call you “a 2 bit hack – trying to not work who is making 5 times what we make a year.” Although we’d like to. 4. “OK – sit here, I’ll be right back.” Then throw the patient’s file against the wall and storm off because they told you something you don’t agree with or you don’t understand why the steroid injections didn’t work. You know you’re not coming back, leaving us sitting in our underwear and again, you should see the frustration pain causes us. I was a single dad, working nights at jobs I could get because they had no Worker’s Comp insurance. I used to cook on my knees when my back was “out.” My poor kids, the things they saw. They have both been to counseling. I am a pain advocate because of them. God forbid pain is still treated this way when they grow up! 5. Tell the primary doctor that the patient threatened you and your family because they’re just a drug addict out of control, when the exact opposite is true, especially if you’re doing it to cover up a mistake you made. We would NEVER harm your family. (That’s truthfully why my doctor believed me. He knew I would never threaten the family! And the exact opposite WAS true. I was a very kind and thoughtful patient. I actually read books about “How to be a professional patient by JFK’s doctor! and he did leave me in my underwear until his nurse came in and wondered where the doctor went.) 6. Falsify any documents to cover your ass and cause the complete financial and social demise of the patient. Again, if only you… Read more »


I pretty much agreed with the top 10 things not to say to your doctor. In some of the chat groups I am horrified by the way the talk about doctor’s and treat them. And many do doctor shop when they don’t hear what they want to hear. Unfortunately doctor
s are human too. Not God’s.

I have a pain management Dr. I see once a month. I get my pain medication from her with no problems. She takes my blood pressure and a urine sample every 3 months.

Well said Dr. Radnovich. One can tell from the previous article that you clearly don’t use those 10 rules because you have a successful pain practice with lots of patients who believe in you.

I appreciate how strongly you have listened.
It seems to me that there are many unwritten rules in the interactions between patients and doctors. These unwritten rules definitely need to be distinguished.
This conversation is a great start. I appreciate your willingness to engage, and also the kindness that can be found reading between the lines.
Mr. Matthies was acknowledging your success and kindness as well.
Given that patients are beginning to wake up to their resentment about how they’ve been treated, and doctors are beginning to wake up to the resentment of how THEY have been treated,
We could all unify over the Pain issue and invent new ways of being.
I’m now an “accidental” pain doctor, and the natives are Restless.
This can be good news, if we can all begin to use empowering techniques to claim our power back as physicians, while patients claim theirs back.
Clearly you and I both believe that the physician patient relationship is sacrosanct.
Let’s use that.