David Ring, MD, PhD
The Pain Special Interest Group (Pain SIG) recently interviewed Dr. David Ring, Associate Dean for Comprehensive Care and Professor of Surgery and Psychiatry at Dell Medical School at The University of Texas at Austin about his perspectives on addressing mental and social health in musculoskeletal specialty care.
My long-time psychology collaborator, Dr. Ana-Maria Vranceanu put together a team was awarded a U01 from NCCIH to do a multicenter, multi-year investigation expanding on work we did to develop and test the “Toolkit for Optimal recovery after injury”, a 4-session live video program aimed at optimizing recovery and preventing transition to persistent pain and disability. We’ve known for a long time that psychosocial factors such as anxiety about pain and catastrophic thinking about pain at the time of the injury are associated with persistent pain and disability months after the injury. The Toolkit is the first program design specifically for the 20-50% individuals who endorse high levels of catastrophic thinking or pain anxiety. We have done some preliminary work in the Orthopedic Trauma at the Massachusetts General Hospital (MGH) and showed the program is feasible and associated with improvement in pain, disability, depression and post-traumatic stress. We now have the opportunity to evaluate the program at 2 additional level 1 trauma centers, Kentucky Medical Center and Dell Medical Center.
There is an understanding that we need to care for injured people within the biopsychosocial framework and yet there is, to date, little implementation of this knowledge. This work can evolve long-standing separations between the physically oriented clinician (e.g. the surgeon that puts a rod in your femur), and the cognitive, social and emotional health experts (psychologists). Mind-body approaches like the Toolkit work for patients because they use simple concepts and strategies like mindfulness meditation that are common in the public media and not stigmatizing for patients. However, there has been some resistance from surgeons which we think has a lot to do with challenges around communicating psychosocial factors with their patients and making referrals. As such, one of the first steps in our U01 trial is to do qualitative work with orthopedic surgeons and staff to understand the nuanced barriers and facilitators for integrating the Toolkit into the care of orthopedic patients within trauma centers. We will use this information to develop training materials (brief videos, etc.) for surgeons and the rest of the orthopedic staff to help them understand the benefit of incorporating mind-body approaches in the care of their patients, as well as help them better communicate with the patients and thus make referrals to the Toolkit. Our hope is that the centers where the trial is performed will use this as a catalyst to transform how they care for people with musculoskeletal injury. Next, this work can be disseminated to other trauma centers across USA.
What we know so far is that surgeons are discouraged early in their training from leaning into the emotional aspects of recovery, connecting with patients on the disruptions in their lives, or checking in on psychosocial functioning and common misconceptions about pain. Both injured people and surgeons tend to operate under this false belief that the only thing needed is technical and biomedical treatment of the fracture and the rest of it will occur spontaneously and without any specific intervention. Surgeons like me also tend to be blunt, matter-of-fact, and goal oriented. We may also stumble when we try to reorient common misconceptions about pain. For instance, we might admonish the person who needs to do stretches to regain motion, “no pain, no gain.” While that may or may not work in the sports coaching world, a person recovering from injury just hears, “The problem is you. You’re not trying hard enough.” It’s not the best thing to say.
My point is that, surgeons who try to discuss psychosocial factors with their patients may only need to have a few bad experiences and then they avoid those topics. That’s in spite of the fact that the vast majority of people would like to talk about the emotion and stress of recovery. It’s a shame. We can also consider the lack of resources (few psychologists interested, trained and available) and limited reimbursement, which are likely related.
Psychologists can help surgeons recognize the verbal and non-verbal signs of stress, distress, and coping difficulties. More importantly psychologists teach surgeons the importance of empathy, compassion, and relationship-building. The surgeon’s natural tendency is to teach and direct. What psychologists can help surgeons’ understand is that those are relatively ineffective techniques compared to meeting people where they are and guiding them to healthier ways of moving through the recovery journey. Motivational interviewing techniques are one example of skills that surgeons can learn from their psychology colleagues.
We are the early adopters both in the sense of being familiar with the evidence, having a taste of implementation, and being innovators and academics ready to take to the next level. It’s difficult to put into words how much I appreciate these relationships and collaborations. Culture change and innovation need this foundation.
Diversity is always a strength. If I look back at my career, I believe what defines it is curiosity and humility, wondering about things I felt might be opportunities for improvement, and then reaching outside orthopedics and medicine into expertise from psychology, sociology, communications, anthropology, religious studies, and all of the humanities. It is always the case that smart, thoughtful people had already thought through some of the issues, and there was a foundation to build on. One example is, cognitive bias. I noticed that nearly every person seeking my care had at least one misconception about their symptoms. When I discovered the work of Kahneman and Taversky, it was a quantum leap forward for me. Their Nobel prize winning career’s worth of research just needs to be implemented in orthopedic and medical practice.
Within orthopedic surgery, we did some pre-pandemic work on this, both qualitative and qualitative so I can tell you that both patients and clinicians had concerns about the warmth and effectiveness of remote video visits. I think now that most clinicians and many patients have had some experience, we are unlearning that bias, and realizing how it can often be easier to form a good relationship when we meet people in their homes at their convenience and there seems to be less of a time crunch with future care readily accessible. We are studying clinician attitudes to remove video visits in the pandemic and we have found that enthusiasm for telemedicine tends to hinge on your confidence that the interview gives you the diagnosis more than 90% of the time and that the exam is confirmatory and you can usually get enough by video. Also, we are finding that people that prefer in-person meetings also prefer in-person visits. People like me who love Zoom meetings for everything because of the convenience among other advantages are also big fans of telemedicine. Our psychology colleagues are mostly way ahead on telemedicine because they were able to get paid for it prior to the pandemic. The Toolkit was very successful in engaging orthopedic injury patients in mind-body virtual care. I’ve enjoyed the quantum leap forward in telemedicine and I don’t think we can go back.
It’s a fun place to work! I remember when the media was reporting “one in 5 people in the US has chronic pain.” I thought to myself, everyone over age 50 has pain every day. Yes, we can usually keep it in the background, but the pathology/nociception is unavoidable. We see this in the population-based studies, where most of the people with severe arthritis on an X-ray don’t experience it as a problem. I’m becoming more and more averse to the term “chronic” pain because it sets up a false dichotomy (categories tend to do more harm than good) and because it suggests a unique pathophysiological process (biomedical paradigm) when the evidence points more towards the biopsychosocial paradigm. If you like people and want to make a real difference in the world, there is no better space to work in. I should also say that, our work has the aim of reducing or limiting persistent troubling pain as an illness. If we work in the biopsychosocial paradigm from the moment a symptom becomes a concern, I think we can make a big impact.