This tragic—yet intriguing—topic has captured non-stop media attention for the past 10 years.  Sadly, the same tragedy befalls everyday people but their stories aren’t sensational enough to make the news.

When I met Arianna Huffington on an airplane last weekend, she insisted that I share my insight with the Huffington Post about this topical issue I am so passionate about.

As a skilled and experienced Pain Management physician, I frequently see people with narcotic addictions that masquerade as physical pain. In fact, it is physical pain because withdrawal from narcotic medications and illicit substances causes an extremely painful cascade of physical phenomenon. More often than we doctors realize, patients end up in the emergency room with symptoms of nausea, vomiting, abdominal pain and chills because they are in the throes of acute narcotic withdrawal. They are not suffering from an unidentified gastrointestinal infection or abnormality.

In the E.R., they undergo a lengthy and expensive evaluation, often without insurance coverage, that doesn’t reveal any abnormal physical process. They are given intravenous Dilaudid for the abdominal pain and, should the symptoms return, a prescription for Vicodin to go home. In actuality, they’ve just been given the treatment for narcotic withdrawal and a nice little supply of more “medicine” to feed the addiction.

The often heard question during the Anna Nicole Smith trial is ”Was she addicted to pain killers or not?”. It really doesn’t matter whether she was being treated for chronic pain or being given narcotics to quell an addiction. She’s dead now and there are no more opportunities to help her. The question should be, “Why were those two doctors, a psychiatrist and a geriatric/internal medicine specialist, prescribing large quantities of highly potent narcotics to Anna Nicole Smith?”.

Unfortunately, both of Anna’s doctors were treating her outside of the limits of their medical expertise. It’s now an all too common phenomenon for physicians to treat problems that are outside of their primary field of training and board certified qualifications. The major risks taken in assuming the role of a pain management physician are:

• Poor patient selection for treatment with narcotics
• Worsening addiction
• Diversion of narcotics to the street or at risk friends and family members
• Overdose and death

Why would any physician want to take on that task and risk without proper insight and training? The worst possible outcome isn’t a botched boob job—it’s death.

Prescription medicine is now the highest abused substance in the United States. We doctors are primarily to blame for this. We’re prescribing the drugs to patients at much higher rates than before.

Most physicians don’t have adequate training or knowledge of these controlled substances and the patient population that regularly requests them. In California, a Pain Management initiative went into effect in 2003 due to the law case of Chin v. Eden Hospital. A 1.5M dollar settlement was paid out to the family of a patient for Elder Abuse from inadequate pain management. Since then physicians from every specialty have been encouraged—even feel pressured—to treat all patients’ pain complaints. The California Medical Board mandated completion of 13 hours of continuing education credits in pain management to renew all physicians’ state medical licenses. 13 hours of pain management continuing education is enough information to know when to refer a patient to a pain management specialist. It’s certainly not enough training to act as a pain management specialist.

Pain Management is a one year fellowship training program after a four-year anesthesiology residency. Anesthesiologists have in-depth knowledge of pharmacology, physiology, pharmacokinetics, pharmacodynamics and drug-drug interactions. This information allows us to safely anesthetize patients for surgery with minimal pain. No other residency devotes as much time to understanding how drugs work in the body and how drugs interact with other medications during the painful perioperative period.

Pain Management specialists then transfer that knowledge to an outpatient setting to treat chronic pain. During the extra year of training, we develop an acute understanding of how a person’s psychological state affects pain perception and treatment; how to effectively use controlled substances and non-controlled substances to treat pain with as little risk possible; how to identify patients who are not good candidates for controlled substances and ,maybe most importantly, how to say “NO” to prescribing more controlled substances to patients who are not benefitting from them or who show signs of addiction or other adverse side effects.

Dr. Perry Fine testified in the Anna Nicole Smith case that her use of 1,500 pills per month of controlled substances was not a definition for addiction. He’s right—it’s not enough evidence to prove she was addicted. To diagnose addiction, a constellation of psychosocial behaviors and physical symptoms need to be identified and documented. Some of the factors that we use to diagnose addiction are:

• Excessive use of medication
• Obtaining controlled substances from more than one physician
• Continued use despite harm of a controlled substance.

Anna Nicole exhibited all of those “red flags”. The question that should have been asked of Dr. Fine is “Would 1,500 pills per month be a reasonable amount of medication given Anna Nicole’s documented pain diagnosis, response to treatment and functional level on the medications?”.

Without hesitation, the answer is, “Absolutely not“.

http://www.prweb.com/releases/social_security/disability_insurance_pain/prweb4471524.htm

Well, actually, if you want the best medical care, your personal information is your doctor’s business.  I was stunned last week when a new patient in my office told me that his psychiatric history ”isn’t any of your business!”  This person was visibly agitated and raised his voice in response to  my audacious question about his personal mental history and any treatment he received.   I then spent the next 10 minutes of our precious evaluation time calming him down and  explaining the rationale behind my offensive behavior.

This led me to reflect that it isn’t an uncommon belief that patients can withhold specific information from their doctors.  Apparently, they don’t understand how important all information is to us  in guiding our safest treatment plan for them.  I believe that patients also don’t realize how their exclusion of such information increases their chances of having an adverse event or complication from treatment.  Patients are more responsible for their medical complications that they realize, in this way.  Unfortunately, physicians are the “bad guys” when something goes wrong regardless of who really dropped the ball that caused the adverse outcome and all too often, a lawsuit ensues.

I have a list of specific psychiatric diagnoses that I ask all patients whether I believe it might pertain to them or not.  As I’ve explained in previous posts, in chronic pain syndromes the brain plays a crucial role in how pain is perceived, alleviated or worsened for all people.  Variations in genes and the brain connections also strongly influence how an individual will respond to specific medications.  For example, a recent study by Geisinger Health Center in Pennsylvania identifies increased risk factors for pain-killer addiction.  In order to assess if those risk factors exist in any patient undergoing treatment, the doctor needs to ask the right questions and the patient needs to give honest answers.

I understand that oftentimes the questions that doctors ask during an evaluation are embarrassing for patients.  To be honest, it’s sometimes uncomfortable for the doctor as well; however, we understand that we’re not giving good care if we avoid the tough questions.  Likewise, a patient can’t be given good care if he decides to omit pertinent information and thwarts the doctor’s effort by assuming that he knows which information is pertinent.  There’s a reason that medical school takes so many years and so much time of one’s life.  There’s a lot of information to learn that isn’t gleaned by doing a Google Search.  

This is why I believe it is crucial that we work on improving doctor- patient trust relationships.  I am happy that people are taking a more active role in their health issues and seeking medical information, but that will never take the place of trusting the advice of a medical doctor with many years of training and experience.  Doctors are similarly dependent on their patients for a successful medical practice.  We want to care for patients who are intelligent about their health issues and compliant with our recommendations so that it’s a win-win situation.  We doctors don’t look good if our patients aren’t doing well.

My endeavor to be a Pain Management specialist started in 1991. Although, I have been a board certified Interventional Pain Specialist treating patients since 1998, it never fails to surprise me that all this time that I’ve concentrated on becoming the best doctor I can be, there are many people who don’t understand what it is that I do.  The people who need Pain Management, don’t know that such help exists.

“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.” – Sir Albert Schweitzer, MD (1931)

Dr. Schweitzer, Nobel Laureate and humanitarian,  made that statement after practicing medicine for 20 years in the African jungle. Ironically, when I decided that my medical career would be devoted to the same it was because of a similarly impressionable moment.  I saw for the first time, a woman who had Chronic Regional Pain Syndrome.  CRPS is a crippling pain disorder that affects the arms and/or legs.  The slightest touch on her left leg caused screaming pain.  Her leg was thin, pale, cool and dry with shiny skin.  She couldn’t stand on it or walk.

An anesthesiologist performed a Lumbar Sympathetic Block to “quiet” the nerves that caused the vicious pain cycle to continue.  The injection was temporary;however, the patient was pain-free afterwards and was grateful for the reprieve.   The procedure was tedious and involved the injection of potentially dangerous medication.  The doctor taught me about the injection and how to avoid complications or identify them before they became disastrous while he was treating the suffering woman. 

I was in awe of the breadth of knowledge the doctor had in understanding the pain syndrome, the treatment and risks involved and the ability to perform the procedure safely while simultaneously preserving and expressing his compassion for this woman.  He never lost sight that she was the most important person in the room from every aspect of her care.  It left a heavy impression on me that patients deserve to be treated in a sympathetic and dignified way despite the seemingly more important mental task that a doctor is engaged in at the same time.

Mentions of and treatments for chronic pain have been recorded since Babylonian times.  Over many centuries, many pain theories were formulated and revised.  In the 1950′s, Dr. John Bonica, Professor of Anesthesiology at the University of Washington wrote the first edition of “The Management of Pain”, thus legitimizing an entirely new field of medical specialty.  He then founded the International Association for The Study of Pain (IASP) in 1973 by bringing together scientists and physicians from 13 countries who were all dedicated to improving the knowledge of pain, education of health care providers and improving care of patients with chronic pain.  The IASP is now composed of 123 countries and 6500 members that provides the bulk of the pain research and information today.

Pain Management is for anyone who has a pain that just won’t go away.  Essentially, sooner or later, all of us will have a chronic pain that we will need help managing.  As generations continue to live longer than the previous ones, we are more susceptible to the consequences of bodily degeneration.  Nearly daily, I hear the sentiment that “getting old is not for the faint of heart”.  We don’t die at the age of 35 due to tuberculosis or other maladies that modern medicine has learned to treat and cure.  However, there’s no cure yet for osteoarthritis or degenerative spine disease or cancer– all of which are more prevalent as we age.   The real key is not to live longer but to live livelier. 

Managing pain means learning how to tolerate it and keep the intensity to a low-level so as not to affect the rest of a person’s well-being.  When crucial aspects of our lives are affected, such as independence, social relationships and emotional state, we should take action and seek treatment. If a person’s pain problem is lasting longer than the time it takes for an injury to heal and/or she has seen her primary care physician with sub-optimal results, then it is time to seek the opinion of someone who is specifically trained in the diagnosis and treatment of chronic pain.

http://www.medpagetoday.com/PainManagement/PainManagement/21758

America is a Drug Nation.  We want a quick fix and we believe that the “fix” exists in a pill. We believe this because the television tells us this everyday, every hour of the day,  in the form of commercial advertisements.   When pharmaceutical companies advertise medications directly to the consumer or  ”patient” without using a physician as the middle man to ensure the correct patient-medicine match, they become drug dealers.  Without a doctor, a medication is just a drug.  It might be helpful but it might do harm.  Pharmaceutical companies don’t care which it is, they just want to profit from the “deal”.

Prior to 1997 it was extremely difficult  for pharmaceutical companies to advertise their products on television.  At that time, FDA statutes required that companies give full disclosure of the medication, its uses and side effects within the allotted 90 second commercial time slot.  Logistically, this wasn’t possible, however; new legislation in 1997 allowed an abbreviated comment on the medication along with “ask your doctor” as the prerequisite, thus allowing drug companies to peddle their drugs directly to the consumer.    Interestingly, Michael J. Friedman, M.D. who was the lead deputy commissioner of the FDA and the major force behind changing the legislation, resigned shortly thereafter and accepted the position of Vice President of Searle pharmaceuticals.

Billions of dollars are made within the pharmaceutical industry.   Big Pharma is coaxing us to use every possible concoction available to fix what isn’t even wrong with us.  There’s a pill for any symptom we have or think we have.  Every other commercial on the television promises us a better life if only we could get that pill…They’ve even stooped to advertising pills to children:  acne medicine will put an end to all of that adolescent angst… just ask your doctor. 

To make matters worse, we’re paying for these commercials.  The price of pharmaceuticals has skyrocketed over the past ten plus years. Some medications are more expensive now than they were fifteen years ago.  Big Pharma will say that it’s because of Research and Development, but the real reason is that television advertising is pricey.  There’s no better way to maintain those profit margins than by making the consumer pay for the cost of advertising.  Afterall, we’re the ones who are Jonesing to take the pills.

Americans  need to stop looking for  passive ways to solve our problems. We need to get back to the basics of health and actively participate in our well-being.  We know that proper exercise, diet and sleep are the cornerstones of good health, yet we would rather take a pill that does all the work for us– even if it might kill us.   Pharmaceutical grade medication is a major advancement in modern medicine, however; we should not prefer it over following a healthy lifestyle when we can.  Big Pharma is the only benefactor if we do and then they will  make us pay them to sell it to us.

One of the greater concerns in pain management is the use of narcotics and their potential side effects.  Narcotics are morphine-like medicines and are extremely helpful in treating pain.  Over time, physicians have learned to be more judicious in our reliance upon them as the primary pain relieving therapy.   We have come to realize that their powerful effects, unrelated to the original intention, can lead to negative behaviors and tragic outcomes for patients and their families.

Addiction is a risk of using narcotic pain medicines regularly.  The quantitative risk may be significant or minimal depending on the person or problem for which it is used.   Addiction occurs as a result of the properties of narcotics outside of their pain relieving effects.  Specifically, narcotics can cause euphoria and a state of well-being and tranquility as a side effect.  Most of us would agree that these are desirable or positive side effects, however, when a person uses narcotic medications to obtain these mental states, as opposed to using them  to reduce pain, the chance of addiction is high.   Addiction is a psychological and behavioral syndrome characterized by: 1.  Loss of control of use 2.  Use despite harm to user or family 3. Preoccupation with obtaining the drug.   These behaviors will spiral out of control, if no intervention takes place, until the person becomes completely dysfunctional and/ or dies due to drug overdose in trying to prolong the psychological state they are seeking .

 Oftentimes people confuse addiction with physical dependence.  Physical dependence is a natural physical syndrome that occurs when the body is exposed to certain medications regularly.  The medication molecules attach to “receptors” in tissues in order for the active substances to take effect.  When the medicine is taken regularly,the body builds more receptors to make sure the extra medicine has a place to go.  This is analogous to a parking lot at a mall.  When the mall becomes more popular, more parking spaces “receptors” are needed to accommodate the extra people.  The problems start when the  medication is abruptly discontinued.  Now there are too many empty receptors or parking spaces that the body is used to having full.  This discrepancy causes withdrawal symptoms, which are specific symptoms from different organs as a result of having an empty parking lot.  Withdrawal symptoms aren’t synonymous with addiction and can also occur when many non-addictive medications have been quickly stopped.  These symptoms can be prevented by slowly weaning off of the particular medicine so the body has time to adjust to the change and remove the excess parking spaces.

As physicians, it’s our job to weigh and balance both the positive and negative effects of narcotic medications when deciding to use them or not.  We tailor the medication to the specific patient and problem that we are treating.  Much of the balancing act is first determined by considering factors related to the individual’s medical and social history.  For example, a patient with a strong personal or  family history of substance abuse, physical abuse, emotional trauma, depression and psychological disorders may be at a much higher risk.  Also, studies have shown that an active smoking history has a strong correlation to potential narcotic addiction.  This information doesn’t mean that people who have more addiction risk factors should not be treated with narcotic pain medications, but that the utmost care should be taken in deciding the best pain treatment plan and proper surveillance should be done to identify any issues should they begin to occur.

Interestingly, for some types of pain, narcotic medications may not be very helpful at all.  For example, muscle and nerve pains tend to be less responsive to morphine-like medicine.  I find it more useful to use muscle relaxants and anti-epileptic medications that target those specific tissues before using higher potency and addictive types.

I also use treatments outside of prescribing medicine to reduce the risk of addiction.  Rather than using any oral medication by itself, I incorporate steroid injections, nerve blocks, physical therapy and psychotherapy  into the patients’ treatment plans.  These modalities block the pain cycle and allow the patient to be more active in their recovery without the risk of taking pills.

During all the health care debates and discussions, one item that I don’t hear much mention of is how  the quality of health care is being affected.  What good is having health insurance if the kind of care you get is analogous to shopping at Walmart rather than having a thoughtful, sit-down doctor visit?  Actually, I wouldn’t be surprised if Walmart started hiring doctors and put them in a corner with a big red banner sign that read “Wal-Care”.   Everyone deserves health insurance and medical treatment, but this privilege shouldn’t come at the expense of a lower quality of service.  Unfortunately, this is the trend that I am seeing and my colleagues agree.

It’s no secret that insurance companies are dictating and directing the  medical care given  by physicians.  They don’t necessarily tell us what to do, but if a patient can’t afford the treatment plan or medication therapy that we recommend, and opts for the treatment that the insurance company will pay for,  then it’s  the insurance company that  is making the medical treatment decisions.   Insurance companies don’t go to medical school, they don’t pay malpractice, they don’t take mandatory continuing education classes, and they don’t work endless hours, but they do make decisions that continue to keep their pot-o-gold full.

Business people are making medical decisions.  Their decisions are made to ensure company survival and profit.  Conversely, physicians make medical decisions based on what the patient needs to survive a health adversity or to stay healthy.  A patient’s welfare takes second place to company profit in the eyes of health insurers.  Sadly, this is the  conflict of interest that presidential  administrations either do not consider or do not care about when debating and negotiating health care reform.

Insurance companies are dumbing down doctors by encouraging us  to be less thoughtful and innovative about your health care.  They accomplish this by refusing to pay for proper treatment and more state of the art therapies.  Doctors are no longer thinking “outside the box” in treating medical problems.  We are pressured to choose treatment options within an algorithm or flow chart of “acceptable” treatment for a particular ailment.  These algorithms are generic and can’t possibly take into consideration every unique patient and their particular circumstances.  Thinking outside the box is considered “experimental or investigational” by business people because it might involve “non-generic” or “non-formulary” medicines and innovative procedures that would cut into their bottom line.  

As a result, doctors are devising medical treatment plans based on what the patient can afford, which is determined by what the insurance agrees to pay for.   This treatment option list continues to shrink to the point that doctors are refusing to accept patients who have certain types of insurance.  What good are you doing if  you can’t treat people using your best knowledge and ideas? 

For example, I no longer treat injured employees who are using Workers’ Compensation insurance (WCI).  Ironically, these are some of the patients who need my services the most.  Previously, WCI was incredibly difficult to deal with regarding these specific issues: 

1.   Refused any treatment plan that I formulated unless it was reviewed and authorized  by another physician (who never saw the patient in person) first.

2.  Refused any treatment plan except prescribing medications.  More helpful therapies such as steroid injections or nerve blocks which provided pain relief without pill medicines, were frequently denied.

3.  Refused to continue to pay for the patients’ medications after a variable amount of time.   Patients who were using narcotic pain medications were forced to go through dangerous withdrawal symptoms until I made a phone calls to supervisors who admittedly had no good reason for the medication use disruption.

 4.  Refused  to pay for my  evaluation services in a timely manner (they would pay 3 months or more after or even never).  Excuse me, but I don’t like working for free any more than the next person.

My opinion is that universal health care is a wonderful objective, but not at the expense of the quality of the care that is accessible to people who need it.  Individuals become doctors because they genuinely care about people and are intelligent, ambitious and interested enough to endure the years of sacrifice and training that it takes to obtain the honor of the M.D. degree. If we want those types of people to continue to enter the medical field and take care of us as we age, we better not condone big business interfering with our health.  Physicians are systematically turning into pawns for the insurance companies to direct medical care for their own benefit.  This is the reason that more physicians are saying no and leaving their practices for other occupations.  It’s just not what we signed on for.

Acute (short-term) and chronic pain (long-term)  are both influenced by the mind-body relationship.  Acute pain may persist and become chronic because of dysfunction in this normal interaction.

Acute pain is a warning signal that the body is being injured.  It’s a protective measure that tells a person to stop doing the activity that is causing harm.  Pain signals from the skin and tissues are transmitted by nerves  to the spinal cord and then to the brain.  The brain sends information via different nerves,  back down to the body to make the hand move away from a hot stove, for example.  All of this happens within seconds; however, it is very complex and involves many nerves and nerve pathways in the spinal cord and brain.

Chronic pain is not necessarily a sign that an injury or dangerous situation is present.  Chronic pain is a disease and not a signal, in most cases.  The common exceptions to this would include pain related to Rheumatoid Arthritis, Osteoarthritis and Cancer pains, to name a few.

Pain is called “chronic” when it lasts longer than expected for the normal healing process to occur after an injury.  Chronic pain doesn’t have a protective function and may lead to severe emotional, physical, social and economic dysfunction if untreated.   It is important to not only treat the abnormal process, but also to treat associated symptoms that can reinforce pain and make treatment more difficult.

There are areas in the brain, the midbrain and frontal lobe,  that can actually determine our perception of pain.  In other words, our brains can decide whether it is a good pain or a bad pain and how we will respond to it.  “Good” pain is something that we’re not frightened by and we expect it to go away.  Something good will be the result despite the fact that it hurts.  “Bad” pain is something that we shun to avoid further injury, it scares us and if untreated can cause physical and emotional impairment.

Pain perception is how we feel about pain at the emotional level.  This perception can be altered by many factors, both external and internal.  For example, external factors would include family and job stress.   Internal ones would be insomnia, depression and anxiety.  Those negative factors can decrease our pain tolerance and make the pain more severe than if we didn’t have those influences.  On the other hand, positive factors such as  listening to music, getting restful sleep, relaxation techniques,  spending time with family and friends and proper exercise can increase pain tolerance and decrease pain severity.

Acute pain can become chronic if the negative factors remain present despite the fact that there is no more trauma causing the pain.  I think of this as “What the brain remembers, the body can  feel” and “What the body feels, the brain can  remember.”  You simply cannot separate the experiences of the mind and body. 

Successful treatment of pain requires treatment of both mind and body  because the two are intertwined.  I urge my patients to relax and not become anxious about the pain while they are receiving treatment.  Oftentimes, I treat patients with antidepressants, sleep-aids and anti-anxiety medications  to control the negative internal influences.   When a patient becomes fearful or anxious about pain, there is a vicious feedback loop that can be activated to reinforce pain and actually make it last longer.   

Previously, physicians would say that “it’s in your head” if they couldn’t find a physical abnormality causing the pain.   The truth is, it is in your head, but it’s also in your body.  The brain can activate nerve pathways to cause changes in the body that create physical pain and in return,  the body can activate nerve pathways to the brain to make us feel pain, even without a physical injury.

The brain is a powerful organ and both negative and positive environmental factors and internal emotions can go a long way to influence recovery from a physical problem.

“My doctor doesn’t listen”.  This must be the most common complaint that I hear from new patients about other doctors.  Sometimes it’s true and sometimes it’s the result of unmet expectations at the doctor’s office.

I believe that part of the problem is a misunderstanding of how doctors approach patients and problems.   For example, the Initial Visit is mostly about obtaining as many objective facts as possible in an orderly fashion.  The doctor listens, but it is also the doctor’s job to get a lot of information within a small amount of time.  It may seem like we’re not listening, but we are actually just trying to be as efficient as possible.

I’ll explain the  outline of  a typical first time office visit with a doctor.  Hopefully this information will help  set reasonable expectations and allow other patient-doctor relationships to get off to the right start.

The first office visit when you meet your new doctor is the most crucial.  It is the longest  block of time that we’ve set aside to get all the information we need to make a good diagnosis and devise a treatment plan to help you get better.   It is the most important visit because all others will be based on information gleaned from this one.

In general, most doctors follow a particular format when we see a new patient.  I think if more patients understand the format, then there will be less time wasted and less misunderstanding.

Chief Complaint:  This is the reason for the visit in the patient’s words.

History of Present Illness:  Doctors ask you about the problem that you’ve come to discuss.  We don’t want to hear about anything except what your pain feels like, for example.  This is not the time to talk about what other doctors have said or done, or what tests you’ve had or any of that.  That information will be heard later.  This time is devoted to how you are  feeling and other symptoms you may be having.  We ask specific questions in a particular order so we can get your story in a very concise form to help us figure out what is going on.

Past Medical History:  Now we ask you about what other health problems or diagnoses you have that could be related to your current problem, but might not.  It’s important that we know what your other health issues might be so we can treat the current issue without causing problems.  For example, if I know that you’ve had bleeding stomach ulcers in the past, I won’t prescribe high doses of anti-inflammatory pain medication that would potentially cause a repeat bleeding ulcer.

Past Surgical History:  We want to know all the surgeries you’ve had even if it’s not related to your current issue.

Medications:  We need to know the exact names, doses and frequency of the medications that you are taking.  If you have trouble remembering the names of them, write a  list and keep it  in your wallet.

Allergies:  We need to know what types of medicines could be dangerous for you.

Review of Systems:  This is a review of all the organ systems to see what other symptoms might be occurring that could be related to your primary complaint.  For example, if you are complaining of abdominal pain then the gastrointestinal review is detailed and thorough in order to find out what other related issues are present.

Family History:  Many medical problems are hereditary or the result of similar environmental factors.

Social History:  How much a person smokes or  drinks alcohol and type of work they do can affect health.

Physical Exam:   If a new doctor that you’re seeing does not give you a physical exam, don’t go back. Unfortunately, some pain management doctors will simply talk to the patient and prescribe medication without an exam. The exam allows us to corroborate your story and symptoms with objective physical findings to either support or refute the diagnosis.

Review of supporting Data: Lab test results, referring doctor notes, x-rays, etc.

Assessment and Plan: This is the diagnosis of the problem and the treatment plan.  I spend most of the this part of the appointment educating my patients about their particular problem and how we will treat it.  This is the time of the exam when interactive conversation should occur so both the patient and the doctor understand each other’s goal, which should be mutual.   I like to make  sure that whatever plan I think is best is also a plan that will work for the patient’s lifestyle, treatment expectations and understanding.  I believe that a physician should devise a plan that will be relatively easy for the patient to carry out and stick with for a successful outcome.  It’s crucial for the patient to have all questions answered at this time.  This is also the time to make sure that your doctor understands your concerns and issues so you can be sure you’re both on the same page as far as the treatment plan.