Inside chronic pain

OVERALL RATING Excellent

STRENGTHS Very well written; author maintains an excellent sense of humour despite difficult subject matter

WEAKNESSES Slant of the medical commentator reflects the American rather than Canadian situation

AUDIENCE Medical students, residents, and practising physicians who see patients with chronic pain; patients with chronic pain

I would like to buy 100 copies of this book and make it required reading for every medical professional I meet—from the greenest clinical clerk to the most grizzled consultant in any and every specialty.

Lous Heshusius is among the 20% of adult Canadians who suffer from chronic noncancer pain. She is also a Professor of Education at York University in Toronto, Ont, whose world was turned upside down by a car accident that “shattered her life and her identity” in 1996. Her chronicle of moving from the optimistic belief that her “soft tissue injury” and pain would resolve in a few weeks to the dark world of daily debilitating chronic pain is eloquent and tragic, yet spirited and infused with her singular intelligence and wit.

Dr Heshusius lists the contradictory advice that she received from the 22 doctors and more than 60 consultants she visited in her attempt to gain relief: “Exercise, Yes! Exercise, No! Traction, Yes! Traction, No! Botox Here! No There!” The 8-page list of mumbo-jumbo diagnoses and advice is enough to make even the most pain-free heads spin. Her categorization of the doctors she met—the fine ones (thank goodness there were a few!), the “do I have a cure for you” ones, the bad-mannered ones, and the science-obsessed ones—casts an all too embarrassingly bright light on our profession and the failure of the reductionist biomedical model: If I can’t see the damage then the damage doesn’t exist, and it’s all in your head. That Canadian medical students receive only 16 hours of pain education compared with 87 hours received by veterinarians is a feeble excuse for the brushoff many pain patients receive.1

In the end, Dr Heshusius did meet a few physicians who believed and supported her as she made her way through her nightmare, giving up her home and job in the process. The evidence now proves (via dynamic kine magnetic resonance imaging) that whiplash indeed involves damage to cervical ligaments.2 Prolotherapy (injection of saline or glucose directly into damaged ligaments) as well as mindfulness meditation, yoga, music, a healthy diet, and the support of her daughters allowed Dr Heshusius substantial pain relief and the ability to write and engage with the world again.

Aside from the good quality of the writing and the many references to pain research and literature, this book teaches the physician what is needed by a patient suffering an invisible malady: “My fine doctors heal by their kindness, grace, their genuine regret that they can’t cure me, by touch, attentiveness, their welcoming of dialogue—even by their gentle sense of humour …. [B]etween visits you know that you have someone who cares, who will help in any way he or she can. You feel no tension, no increase in pain before an appointment, no question is seen as unimportant …. This is the gift of healing.”

We family physicians have to “be” the fine doctors that Dr Heshusius describes, because we are the ones who will coordinate, explain, and persist when our patients suffer from chronic noncancer pain. Indeed, family practice care that involves listening, understanding, and shared management was found to be the greatest factor in reducing global disability in occupationally injured patients in both Canada and Australia.3

The clinical commentary by Dr Scott Fishman, a noted American pain physician, provides my only gripe with this volume. His comment that “the primary care physician is the first stop …, but moving on to other clinicians with more to offer is … often necessary for making timely progress.” Given that Canadian pain clinics have wait times of 1 to 4 years,4 this hardly seems realistic. All the more reason for me to keep good on my threat to hand out copies of this book to all comers wearing white coats, short or long.

• Copyright© the College of Family Physicians of Canada