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Addressing The Problem Of Physician Burnout

/ Thomas Cohn, MD

One of the front page articles this week in the StarTribune explored the subject of doctor burnout. Every job comes with stress; Medicine is not immune to stress and burnout is becoming a more recognized phenomenon. Many jobs have the pressure to perform, but many doctors try harder to push through the stress and daily duties. Recently, we began to realize we are no different than everyone else.

Medicine has for a long time been a very strenuous career. The academic requirements and training are very difficult. Most of us started our careers with residency training involving workweeks that exceeded 80 hours, and we continued working 50-60 hours each week after residency was complete. The time spent seeing patients is only a fraction of the time spent – many more hours involve paperwork, patient preparation, administrative tasks, and continuing education. Family and fun time become eclipsed by work requirements, and sleep is an afterthought.

Tired Doctor

Daily Doctor Stresses

Stress becomes a lifestyle. Seeing patients and being able to identify the correct diagnosis and treatment is always a challenge. Many physicians also perform complex procedures that could easily cause significant damage if something goes wrong, adding to the stress. Then, if patient is at all unhappy, we may have to deal with administrators questioning the encounter or the possibility of being sued.

Preventing stress and burnout in any profession is necessary. One may be busy, but to prevent burnout, one needs to take time out from work. Physicians need to do this just like everyone else. Some physicians take extended breaks from practice, taking months off at a time. They do charity work and get away from their normal practice. Others limit their work hours. Many try to find outside interests to focus on to reduce stress. No one goes to their graves saying that they wished they spent more time at work.

Work is only a small part of life. Maintaining outside interests is essential. Stress comes as part of the profession. Ways to handle the stress include maintaining good fitness and having outside interests that you enjoy. Often, the outside interests of a physician can be seen readily at their offices. A physician with no outside life besides medicine may be more likely to become burned out. Stress reduction for everyone is necessary. It is summer time and now is a time to be outside and enjoy the world.

 

Insomniacs More Prone to Chronic Pain

/ Thomas Cohn, MD

Findings out of the Norwegian Institute of Public Health suggest that people who have trouble sleeping are more likely to have an increased sensitivity to pain.

Although the study didn’t show a cause-and-effect relationship, researchers said insomniacs were more likely to be sensitive to pain. For the study, researchers asked more than 10,000 adults to dip their hands in cold water for 1 minute and 46 seconds. If they felt the cold water was causing too much pain, participants could remove their hands from the water prior to the completion of the timer.

Insomnia

After their reading was recorded, researchers asked participants a bunch of questions about their sleeping habits, including how long they typically sleep, how long it takes them to fall asleep, and if they suffer from insomnia. Researchers also asked questions about related issues that can make it hard to fall asleep, like anxiety, stress and depression.

Study Results

After looking at the findings, researchers uncovered:

  • Nearly 1/3 of participants were able to keep their hands in the water for the entire test.
  • 42 percent of people with insomnia pulled their hands out of the water early.
  • 31 percent of people without the sleep disorder pulled their hands out of the water early.
  • Participants with frequent insomnia were more likely to remove their hands from the water than people who have insomnia once a month.
  • People with insomnia and chronic pain were twice as likely to have a reduced pain tolerance than participants without those conditions.

“While there is clearly a strong relationship between pain and sleep, such that insomnia increases both the likelihood and severity of clinical pain,” researchers wrote, “it is not clear exactly why this is the case.”

Dr. Cohn Comments

Although the findings are interesting, they are hardly revolutionary. In fact, it’s more of a chicken-and-the-egg type argument. People who have chronic pain are more likely to be plagued by nagging pain, which can make it difficult to fall asleep and stay asleep, and if you don’t get a full night’s sleep, your body can fully recover from the activities of the day, contributing to more pain. So what came first, the chronic pain or the insomnia?

Related source: Health.com

Dopamine May Be Key To Unlocking Chronic Pain

/ Thomas Cohn, MD

DopamineMedical researchers at the University of Texas say dopamine – the mechanism in your brain responsible for movement, memory and reward – could provide the key to unlocking the problem of chronic pain.

Dopamine is vital for several different brain functions, but its contributions to the problem of chronic pain are not well known. To better understand dopamine’s role in chronic pain transmission, researchers began studying its effect in mice. Researchers noted that removing a specific collection of neurons -known as A11 – helped diminish the perception of chronic pain. The cluster of A11 neurons contained high levels of dopamine.

“These findings demonstrate a novel role for how dopamine contributes to maintaining chronic pain states,” said associate professor Dr. Ted Price.

How it Works

When a person gets injured, neurons inside the body send pain signals to the brain. In someone with chronic pain, these neurons send pain signals to the brain even when an injury isn’t present. A physical medicine pain specialist’s job is to determine what is causing these neurons to fire, and how to stop them from incorrectly firing.

The A11 cluster might be causing some of these neurons to fire. In fact, when removed, mice were still able to feel acute pain (an actual physical injury), but they exhibited a lesser response to chronic pain.

“We used a toxin that affected A11 neurons, and that’s when we found that acute pain signals were still normal, but chronic pain was absent,” said Dr. Price. “This may open up new opportunities to target medicines that could reverse chronic pain,” said Dr. Price.

Dr. Price and colleagues want to continue studying dopamine receptors in relation to chronic pain perception.

“In future studies, we would like to gain a better understanding of how stress interacts with A11. And we’d like to know more about the interaction between molecular mechanisms that promote chronic pain and dopamine.”

What Virtual Reality Can Teach Us About Chronic Pain

/ Thomas Cohn, MD

Virtual reality may be the next innovation in the gaming world, but it also may offer real world benefits for chronic pain sufferers.

According to research published in Psychological Science, virtual reality is being used to see how physical and physiological factors impact chronic pain. Researchers say that misrepresenting physical positions through virtual reality can change how someone experiences pain. For example, researchers would outfit patients with a virtual reality device that appeared to show their neck torqued in a position of discomfort to determine how a perceived position impacts brain signals.

Virtual Reality

“Our findings show that the brain does not need danger messages coming from the tissues of the body in order to generate pain in that body part — sensible and reliable cues that predict impending pain are enough to produce the experience of pain,” said researcher G. Moseley of the University of South Australia. “These results suggest a new approach to developing treatments for pain that are based on separating the non-danger messages from the danger messages associated with a movement.”

The Virtual Study

To see how virtual movements impacted chronic pain perception in your brain, researchers recruited 24 chronic pain sufferers whose pain stemmed from several different conditions, including poor posture, tension, repeated strain, trauma and scoliosis. Participants were equipped with a virtual reality head-mounted display and were positioned to prevent excessive torso movement.

Once the headsets were in place, researchers asked participants to rotate their head until they experienced pain. What the participants didn’t know is that their virtual reality devices either:

  • Projected an over-rotated representation of the person’s neck.
  • Projected an under-rotated representation of the person’s neck.

After looking at the data, researchers uncovered that the feedback display had a significant impact on when the participant reported pain. Researchers found:

  • When head rotation was understated, participants rotated their heads about 6 percent farther than normal before reporting pain.
  • When head rotation was overstated, pain-free range of motion was reduced by an average of 7 percent.
  • Intensity of pain did not differ across the various representations.

“We were surprised at how robust and predictable this pattern of results was,” said Moseley. “If cues signaling danger amplify or indeed trigger pain, then these cues present a novel target for therapy.”

How Friends With Pain Affects Your Pain

/ Thomas Cohn, MD

A recent article in the journal Current Biology found that humans and mice exhibit more pain when with friends with pain than with strangers without pain issues. Those who are with friends with pain will report more severe symptoms than when they are with strangers. Furthermore, people exhibited more pain related behavior in these situations. The researchers hypothesized that when friends had pain, we make a bigger deal about it than when our companions are pain free. As a pain practitioner, it should be a shame on the researchers for jumping to such conclusions.

All pain patients find living with chronic pain is extremely difficult. Pain is mentally fatiguing and depressing. It is a constant battle to control symptoms. Most of the time the battle to control pain is fought alone. People who do not have the problem usually do not want to hear about other people’s medical issues. Others also do not want to be brought down emotionally by the struggles of someone else since they have their own problems.

Pain With Friends

When one meets another who shares the same problems you have, one may tend to be more honest in the portrayal of your own issues. It is not that you are making your pain sound worse than it is, you just are actually reporting how bad are the symptoms. A person with the same problem is likely to better understand what the other is saying. The communication is more honest and more clear cut. There is also no fear of shame that pain is a significant problem.

Pain Support Groups

The concept of a support group hinges on the fact of a common understanding of a problem. Chronic pain severely affects many people, impacting all aspects of their lives. In normal relationships, one often tries to hide medical problems. We all figure few people understand the problem and we do not need to be shamed by disbelief. Meeting someone who understands the problem of pain and the impact allows the person with pain to be honest about their concerns. To the outsider, this is likely to be seen as embellishment of the pain.

The researchers who wrote this study about pain patients being more open and “feeling worse” when with others who have pain may not be looking at the responses correctly. It is likely that those with pain were just being on honest with how they were feeling when they were with friends who had similar problems. When with strangers, people with pain will often just bite the bullet and act as if everything is okay. No one wants to be known as a complainer. The bottom line in this story is that 40% of the population suffers pain, so maybe we need to show a little more compassion for those with this problem.