May 1998
Volume 62 |
Number 5
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| The 'Art' of Healing |
Kenneth C. Liao, M.D.
I saw her through my wire-rimmed glasses from across the patient
waiting room.
She appeared to be about my mother's age. I introduced
myself and asked her to follow me. She ambulated with an ungraceful
gait. Her left eyelid and dry lips flinched with every small
step. Her back was slightly hunched over toward her left side
as though she was carrying something heavy, but she was not.
Her head stood on her shoulders crookedly.
It was obvious that her body had memorized these movements
after years of practice. I wondered what could be causing her
to walk with such agony. I opened her chart. I was prepared
for anything. After all, I had finished four grueling years
of medical school, endured through an internal medicine internship
at a presumably prestigious institution and completed my anesthesiology
residency at another Ivy League institution. I could handle
anything.
But I was wrong. I was unprepared.
It was the first day of my pain management fellowship at the Hospital
of the University of Pennsylvania in Philadelphia. I was excited.
This was what I had wanted to do since my third year of medical
school when I was exposed to the pain service. I was asked once
why I wanted to be a physician. I answered that I wanted to ease
suffering and pain. To me, I was describing a pain medicine specialist.
It seemed natural that this would be my lifelong ambition.
Now I was faced with someone who was suffering and had
been evaluated by multiple specialists, undergone several laminectomies
and tried countless varieties of medications - all without effective
pain relief. She expected me to help her get better.
After all, I was the "Pain Specialist."
I was overwhelmed. Where should I begin? What should I
do? How could I help her when everyone else had failed? The answer
quickly came to me. My medical training did not abandon me. Start
from the beginning. Treat everyone with respect and with proper
decorum. Approach the problem systematically: obtain a detailed
medical history, perform a physical examination and formulate
a differential diagnosis. I may not know how to perform every
nerve block or be experienced with cryoanalgesia, radio frequency
ablation, implantable pumps or spinal cord stimulators, but I
know how to be a physician. Just as important or even more important
than knowing how to solve a problem is to know, "What is the problem?"
Once this is established, I can at least formulate a plan to reach
an answer.
When I was evaluating pain management fellowships, I examined
each program's offerings to determine if it would, first and foremost,
train me to be that forementioned problem-solving pain physician.
The questions that I needed answers to were simple: who, what,
where, why, and how was that fellowship going to accomplish my
goal?
Who was in charge of the program and who were the faculty?
Were they prominent, nationally recognized and reputable? Who
were past members of the fellowship program, and what are they
doing now? What were their backgrounds?
What was the vision for the program? What was the relationship
of the program to the pain management group, department and hospital?
Were they working as a cohesive unit toward a common goal, or
were they constantly fighting and not evolving? Was the program
striving to become better, or had it been deteriorating over the
years, losing faculty members and having trouble attracting qualified
applicants? Were there research opportunities with nationally
recognized researchers?
Where was the fellowship program? Was it in a hospital
known for providing excellent medical care with the necessary
breadth and depth of cases? What was the status of the other departments?
Why was there a pain management program? Was it simply
an extension of the residency program, or was it geared toward
teaching the physician how to become a pain specialist? Was it
supported by the other groups?
How was the program run? Was it a multidisciplinary pain center?
Did it have a good balance of medical and interventional modalities?
How were you taught, and what were you taught? Was there an environment
conducive to learning?
The most important lesson that a pain management fellowship can
teach you is not how to place a spinal cord stimulator lead or
an implantable intrathecal pump, or how to perform a radio frequency
neuroablation. The most important lesson that my pain fellowship
program has taught me is the art of being a doctor. My training
does not end on June 30, 1998, when my fellowship is over, but
rather it is a lifelong process. It is not what you know but how
to get to the answer that is the key. Each patient is an individual
first. The biopsychosocial model must be employed and adapted
to each person. The objective is not always to completely eliminate
the pain which may not be possible. The goal is to ease suffering
and pain in the most dignified manner in order to improve quality
of life. To achieve this is to become a pain medicine physician.
I walked into the patient waiting room.
He looked familiar. I thought he was my father's close friend,
but he was not. I had never met him. The wrinkles on his forehead
sunk deep into its furrow as he arose from his seat. His fragile
hand transferred to my arms after they bolstered him up. He did
not need me for support, but rather, I was his security blanket
in case he were to succumb to the lightening jolts that radiated
down his spiny legs.
As we walked in unison to the examination room, I felt
a sense of optimism. I may not know the answer to his problem,
but I knew how to attack the problem.
I was prepared.
Kenneth C. Liao, M.D., is a fellow in pain
medicine at the Hospital of the University of Pennsylvania, Philadelphia,
Pennsylvania.
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