Connecting The Medical Dots

/ Thomas Cohn, MD

Medicine today has become fractured. Primary care does basic analysis of a problem and basic care of that problem, while specialists have become such experts that they often can not see past their own rabbit hole. Few doctors are willing to look at the whole picture, analyze the patient as a person and all the problems presented. When someone takes the time and connects the dots, something special happens, and a path to the future can be found. For many patients, finding the doctor that has the experience to listen, to ask the right questions and to find the source of the problem can take years.

One Patient’s Dots Become Connected

Being a patient can be very frustrating. The other day I had a new patient with back pain, which is a pretty normal complaint for a referral. The patient was referred from an orthopedic spine surgeon who felt the patient was not a candidate for surgery. She was in her mid-30’s and had neck and upper back pain. She also has had longstanding scoliosis, a prominent curvature of the spine, and she had been to a number of previous providers for the problems and wants answers and a solution.

I usually work with a scribe. When I started my visit with the woman with scoliosis, she was fascinated. Within in a couple minutes and a few choice questions, my scribe saw a light in my brain go on and the discovery of the unifying diagnosis that no one in the past had a clue about. The patient had scoliosis, but had been double jointed, had shoulder and knee joint issues, had heartburn, and cardiac problems. She also had siblings that were double jointed. The unifying theme was a genetic-based connective tissue disorder, probably a form of Ehlers Danlos syndrome or Marfan’s disease. This will need to be confirmed by further testing and probably genetic testing.

Finding a diagnosis that connects the dots changes the whole picture of a problem. It no longer is a set of random of events causing pain. Now there is a reason and a pathway to follow to manage the problems. There is also knowledge about the course of the disease and a way to anticipate future medical issues.

Unfortunately, most patients never can connect the dots. Primary care physicians often do not have the time to address more than one problem at a visit. Specialists are only interested in their small corner of the world. My world often consists of looking at odd medical issues. Many times helping a patient means having to analyze the past, ask a few questions, closely listen to what a patient says, and bringing together the story to develop a pathway to the future.

The best patient care is provided by those providers who can see the big picture. Medicine has been fractured by the pressures to see as many patients as possible if providing primary care, or staying in your specialty only for others. Seeing the big picture and connecting the dots is a lost art. Changing lives for a patient means being able to go beyond the ordinary and really trying to answer the all their questions to uncover a long-term solution.

Headaches, Daith Piercings, and the Vagus Nerve

/ Thomas Cohn, MD

42212395_lOn November 28th, Science News published an interesting article on the science of the vagus nerve in the human body. It is the tenth cranial nerve in the body traveling from the brain to multiple organs in the body. It has thousand of fibers, and it influences functions throughout the body from the stomach and intestines to the heart and brain. The nerve has fibers that travel relatively superficially through the neck and in the skin of the ear. Stimulation of the vagus nerve in the neck has been used for a variety of disorders including many stomach and gastrointestinal problems as well as depression and seizures. Now the ear is the focus of treatment of number of problems by stimulating the vagus nerve as it travels in the region of the tragus of the ear.

The Vagus Nerve and Headaches

Headaches are extremely common. Many people struggle with the management of chronic daily headaches. Drugs are often not the answer, and can oftentimes make headaches worse. A lot of people also do not want to be putting more chemicals into their body. Finding suitable alternatives is difficult. Treatments for headaches run the gamut from diets to all kinds of supplements to stress management. Alternative medicine also has a number of treatments from chiropractic adjustment to acupuncture. Now there may be link to why these therapies work in terms of traditional medical knowledge, it is not just a coincidence they are effective.

Daith piercings and regionalized acupuncture for headache relief may now have a scientific root in the vagus nerve. This nerve has sensory branches that travel in the ear in the region of where the targets for acupuncture are and where a Daith piercing is placed. Electrical stimulation of the ear and vagus nerve has been done to treat headaches, depression, memory loss, and seizures. The vagus nerve has control over a variety of the body’s hormones, including acetylcholine and norepinephrine. The balance of these hormones can be affected by stimulating branches of the vagus nerve. Electrical or mechanical stimulation in the ear can accomplish changes to the branch of the vagus nerve and thus affect any process influenced by this nerve. Headaches have been known to be affected by vagal stimulation, and some have found pain relief through nerve stimulation.

As noted above, some headaches respond to vagal stimulation and improve, while others don’t. There are multiple ways to stimulate the nerve – electrical stimulation, mechanical stimulation as well as medication stimulation. Acupuncture, massage and Daith piercings provide mechanical stimulation of the region and possibly the nerve. Some varieties may respond to different types of stimulation. If your headaches have a vagal component, probably ear massage, electrical stimulation or acupuncture trials will determine if this may be helpful. If those work, consideration of Daith piercing for headaches may be aligned with your treatment strategies. If the above is not helpful, working with a neurologist, a  headache specialist or pain specialist may also be helpful to find other solutions.

New Laws on Chronic Pain and Medical Marijuana in Minnesota

/ Thomas Cohn, MD

Medical Marijuana chronic pain minnesotaEarlier this month Minnesota added intractable pain to the list of conditions that qualify for medical marijuana. It was a decision made by the Commissioner of Health, Dr. Ehlinger, in accordance to provisions of the legislation passed. In August of next year patients will be able to obtain prescription cannabis through the state approved pharmacies if they have been qualified. The exact rules are not yet in place, but there are some clear indicators of restrictions will be present. It is also not homegrown marijuana or any other marijuana; it is just from approved dispensaries that are strictly controlled.

Intractable pain in the State of Minnesota is chronic pain that has failed to be adequately managed by traditional medical care. This means that one has to have tried to manage the pain, gone through what is considered acceptable and approved treatment regimens, likely medication, physical therapy and possibly invasive management, and these treatments have been unsuccessful. One cannot just say they have pain, not have a diagnosis, and not go through standard treatments and expect to be able to obtain medical cannabis. Lastly, it is likely that two qualified medical providers (not just one) will both have to evaluate you and approve, and that the pharmacist at the dispensary also will have to agree.

Intractable Pain and Medical Marijuana

If you have chronic, intractable pain, it will not be easy to obtain medical marijuana. There will be good providers who will consider it an option as part of treatment. However, it is likely to be a choice only after one has failed reasonable standard treatments. The patient will have to be psychologically stable, and for most practitioners, it is likely that they will want them to be well controlled if they do have depression. Many providers will also look into any potential past substance abuse, and receiving both opioids and medical marijuana is likely not to occur. The better pain providers will likely want to closely monitor the patient receiving the alternative treatment and be in touch with the dispensary and pharmacist to know what is exactly being prescribed.

Medical marijuana is not a panacea. It is another possible treatment that may have benefit for some patients. The science and effectiveness behind its use is just in its infancy. Like all other medications there are side effects and problems. It is not an FDA or DEA approved substance and is very much considered experimental. Therefore it is not approved at this time by any insurance. Expect all management and treatments associated with its use to require cash (not credit card or check) payment up front for any services including doctor as well as pharmacy visits. Treatment is likely not to be cheap and it very well may not be readily available. Many physicians may be reluctant to be involved with this treatment, and as a patient, if you are at all mean, abusive, obnoxious, inappropriate, or otherwise difficult with a provider or their staff, this would likely close the door for further management with that office.

The State of Minnesota over the next several months will likely clarify the rules and regulations of medical marijuana for patients in the state. There will likely be a number of hurdles to climb to obtain the high quality pharmaceutical cannaboid for pain management. If it is the correct management tool when all else has failed, it may be worth the effort. It is not a simple solution, and it is not going to be a legal way to just get street quality marijuana for personal recreational use.

Improving Care by Listening and Explaining

/ Thomas Cohn, MD

An article in Sunday’s Star Tribune discussed a new program at the University of Chicago where doctors work to better explain medical problems to patients in order to provide better care. It sounds perfectly obvious to patients that doctors should be doing this, but doctors do not often understand this issue. What is obvious and simple to a doctor is a mystery to the patient. Being able to understand and explain the complex situation to a patient is what old time medicine is all about, and has often been lost in our high tech world.

Why The Change?

Medicine has changed significantly in the last twenty to thirty years. Technology and computers have taken a leading role. In the past, time was spent with the patient taking a history, doing an exam, and then discussing with the patient a plan of care. Afterwards a couple minutes was spent dictating a short note and checking off a sheet for a bill, then you were done. Most of the time was spent interacting with the patient. Today time is spent staring at a computer, first searching medical records, then filling out pages of forms to create a new report for the visit, then typing out orders for tests and bills. More time is spent interacting with the computer than with the patient. Government regulations demanding electronic medical records and ridiculous details for billing are partly to blame. Unfortunately, for many doctors it is easier to be quick and done than to spend time and effort explaining the complexities of the problem.

Listening Best Doctors St. Cloud

Pain management is no different, as many doctors do not spend the time to explain complex medical problems. Chronic pain is usually quite complex. There are often multiple factors contributing to the sensation of pain, and multiple areas affected. A lot of doctors just want things to be simple, and are not considering the full picture and how many issues may be present and interacting. Furthermore, they want to only deal with one problem at a time. Many pain doctors want to do only procedures and do not want to manage patients. Other pain doctors want to only deal with certain problems; they do not want to deal with medications, or have limited beliefs and are against many types of treatments from interventions to surgery. Finding a pain management doctor who is comprehensive, who understands the multiple complexities of pain problems and who can work with a patient as a partner to explain the problem and possible management options is difficult.

The solution to finding a good doctor is no easy task. There is no one place to look for a good doctor. Insurance companies set up panels of preferred providers that patients must pick from that have no correlation to quality. Physicians often have limited knowledge about their colleagues and their skills, and are even more reluctant to say anything negative about any other practice. Internet rating sites often have limited value since there is no good standard method to evaluate quality of medical care. Word of mouth from patients can sometimes be the best source of information. As rule of thumb, 90% of all physicians will do a good job, the trick is really to find the 10% who provide that exceptional level of care. Those 10% who are special in their level of skill will always be tough to find. When you do find those special quality providers, no matter what the profession, spread the word.

Chronic Pain In College Part 4 – Pain and Your Social Life

/ Thomas Cohn, MD

Chronic pain Social College Minneapolis(Below is Part 4 of a four-part series on chronic pain in high school and college. It was penned by a college student who has dealt with chronic pain throughout her academic career. The four-part series will cover four important aspects of college life – Academics, Dating, Employment and Social Life.

Here’s Part 4 on how to manage chronic pain and your social life during an important stage of your life. Click these links for Part 1 and Part 2 and Part 3.

Chronic Pain and Your Social Life

Pain can dominate your life, or you can make it just something that is part of your life. It starts with how you interpret life. If you take charge, you can change the way you interpret your pain and take back the control of how you live your life. The key is to find what you enjoy in life and to never loose sight of it. Make that your motivation through the tough days and a perk to enjoy on the good days. Make social events/time with other people a regular part of your week. It is really easy to isolate yourself from society when you have health problems, but life is a lot more manageable if you don’t.

If you’re in college, consider joining a club you’re passionate about. Clubs are a great way to get involved with your university, gain leadership experience and meet new people. Clubs can be social, professional, community service driven, or a combination. Most universities are also open to students creating their own clubs, so if you have an idea and want to implement it, you can do that too. I’d suggest being involved in at least one student organization in college. If you have chronic pain or are in a tough major (or both), joining a club can help give you multiple things in your life to distract you from the unpleasant aspects.

Friends Are Key

Good friends are a lifesaver. Having buddies that live with and know you well can be extremely helpful as you cope with chronic pain. It’s important to have someone to be able to go to (physically or a phone call) and be able to connect with, vent, or just distract you from what is going on. If pain prevents you from doing “extreme sports” then plan fun activities that will be less strenuous: game nights (board or video), movie nights, watching a TV show with others, playing pool or going to an arcade, going to a bar or out to dinner, going to a movie or comedy show, doing open skating, going for a walk with a dog or just with your friends exploring the city. I’ve found being surrounded by good company is enough to take my mind off the pain for a few hours and allow my life to have some normalcy. Just because you have chronic pain doesn’t and shouldn’t mean that you shouldn’t have a social life if you want one. Yes, you might have to make some adjustments, but here again, if you put your mind to it, you can make it what you want to.

All in all, these are the things I’ve learned and I hope you consider. Firstly, humans are generally kind, considerate, helpful, and understanding. It’s in our nature to help each other out, so don’t be afraid to lend a hand or ask for a hand when you need one in return. We (especially people with pain) catastrophize present and future situations, often assuming much worse outcomes will happen than are realistic. Don’t let this prevent you from trying new or different things in life. Humor and distraction can make an awful day a good one. Surround yourself with people that know you well and make you happy, don’t waste your time and energy with people that bring you down or make you feel bad about yourself. Be there for others the way you want them to be there for you. And LIVE the life you want to, don’t try to restrict your life to “fit” what you think you have to because of your pain; instead, do the things in life you want to do, and make the adjustments you need to in order to make sure you can indeed do what you want. Don’t let pain and others define your life—define your life how YOU wish to.