The rise of the upstreamist!

“There is no growth in the comfort zone!”

Isnt that a trite overused cliche? Well, anyway, that has been my defining statement to my inner self for the last 24 months. And it has led me to places that I would have never thought possible. To me, it has been a defining statement that I have now internalized and come to believe it wholeheartedly.

Well, Who am I?

I am practicing Pain physician (a trained medical doctor, not just a pill pusher!) leading a very busy department of Pain medicine in a big hospital in the South of England. I have a very portfolio week at work. I am an anaesthetist and still anaesthetise patients and spend time in preoperative assessment once a week. I spend a day in the community teaching and seeing patients with chronic pain alongside physiotherapists and psychologists and working in a multidisciplinary team. I spend the remaining week seeing patients in a specialist pain service. I do fancy awesome nerve blocks and injections to releive pain in some patients. I optimise pain medications including opioids for complex pain patients. I do ward rounds seeing other complex pain patients throughout the hospital. I see patients in the outpatient clinic and advise on pain management.

I have been doing pain management for the last 20 years. For me it has become my PIE — my Passion, my Interest and my Energy — and it has kept me satisfied. BUT these last few years have been tough. It has been an awakening and it has led me to evaluate my entire way of doing things and what treatments I offer my patients and what they ACTUALLY want.

the long walk of complex chronic pain — lonely

What do I mean by that?

Pain is very, very complex. The whole thing of pain always indicating that something is wrong and it only is a matter of time and the right knife or investigation will reveal it all and then the pain can be taken away, IS COMPLETELY FLAWED.

It has always been a biopsychosocial phenomenon meaning that all pain has a biological dimension and then psychological and social dimensions also exist. In medical school and during my pain training, this was drummed into my head but what hasnt been really panned out is how this gets reimbursed and supported in general life.

The biological aspect, whether this is injections or investigations or surgery is heavily reimbursed and then the other dimensions are an afterthought, never properly supported nor recognized. I know that injections do make a difference. I have done 2 extra degrees in musculoskeletal medicine and then in Interventional Pain practice and so I knew where and how injection therapy made a difference. But I realize that when you move patients especially through the slow NHS system then a lot of helplessness sets in about their pain which means that by the time they reach me in the pain clinic, it becomes a challenging task and almost an impossible one to get them back to function and pain free living. That is just unacceptable when there is a better way.

Everything we were taught about pain has to be unlearnt and then started afresh especially with the explosion of new robust knowledge thanks to some really eminent neuroscience researchers. What it does show is that we need to go UPSTREAM in order to manage pain better and get control of it before it controls us.

If the data is true, then more than 100 million Americans suffer from chronic pain, more than 28 million Britons suffer the same fate and similarly 20% of the European population are the same way. The number of patients with chronic widespread pain (of which fibromyalgia is part of) is more than all the diabetics and stroke victims put together in the UK!

I listened to a story by Rishi Manchanda, an upstreamist a little while ago and I tell it slightly differently. Right now, I tell a story often in my talks to other healthcare professionals about 4 doctors who are strong swimmers and arrive at the base of a tall torrential waterfall to see hordes of men and women and children falling over to their almost certain deaths. One of them jumps in and starts to rescue and pull out the living, the few that are. The other three climb to the top of the waterfall and jump in and try to prevent the people from going over the waterfall. They are strong swimmers and do a good job but they are getting tired and they certainly cant get everyone. 2 of them look around and realize that their third friend isn't with them and instead spot him swimming further up. They call out and ask him to come back to help pull out the people from the river. He tells them, “ I am going upstream because I want to know who is throwing these people in!”

Photo by Eric Muhr on Unsplash

That has become my mission, to go upstream. I am right now at the bottom of the waterfall picking up the few survivors and taking them to shore. I just have to let the remaining bodies go because there isn't the funding or support to do anything more, not even a decent burial. My friends at the top are like my surgeons, my GP/medical colleagues and my emergency department. What I want to be is that friend who swims up shore against the current to find out how it all started and why and what can be done about it.

Along this path, I have already learnt not just about pain management but about the business of health and social care not just in UK but worldwide. I have a better understanding about human behaviors and why people behave the way they do. I am reading about change management at the organizational level and behaviour change at the social level and where they intersect.

I have come to learn so much about nutrition, diet, the microbiome, the mirror neurons, epigenetics, the evidence around antidepressants, opioids and statins and how everything can sometimes feel like an illusion.

I have realized that if I needed to change and have an impact, I cant do that just by talking to a few GPs at a time in a lunch break or talking to patients on an one to one basis. I cant just whisper to my medical colleagues in the hope that that they would change their beliefs.

I have to go to where the people are. I have to change minds at a much larger level with a bigger audience and come out of my comfort zone and into the big bad and good world of social media. This is my first blog post and there will be many more covering a lot of the topics that have intrigued me about healthcare, human behavior, pain management and relationships.

1. I want people to have accurate information. There is so much that is good and useful that lies undiscovered and not talked about.
2. Already in my forays into twitter (@deepakravindra5) I have learnt about patient views, new studies and feel a better, more informed doctor.
3. With social media, I want to reach more than just the patients I see in the clinic. I want to show that Pain medicine is actually vitally important and needs to be at the top of most commissioning and reimbursement decision making, not just the biological aspect but the full monty of the package.
4. That stigma and taboo around mental health and pain as something to be endured needs to reduce and we need to talk about the big overlap between persistent pain and mental health and trauma-informed care.
5. I aim to provide evidence-based knowledge, the same level that I offer to my patients in clinic or in support groups.
6. I want people to learn to be fierce self-advocates on their chronic pain journey as they will meet healthcare professionals on various aspects of the knowledge spectrum and it is up to patients to know what to fight for.
7. I hope to inspire and motivate others to lead healthier lifestyles in order to prevent/mitigate/manage not just their chronic pain but also any other chronic long term condition.
8. I think, especially with chronic pain, there is so much false information and hype to sometimes promote surgeries and newer drugs. I am all for trying new drugs but we need to help patients to choose wisely.
9. Patients believe much of what they read and they come to various platforms to educate themselves on their conditions. I feel that we need to be able to educate our patients not only in our clinics and ward rounds but also on social media as well. After all in marketing, it is very well understood that we need to have multiple touch points to say the same things so that behaviour change can occur. After all, pain management is not just about drugs and interventions. Using a holistic, integrative approach is a surer guarantee to healthier lifestyle
10. I hope to use this platform and other aspects to share pain knowledge, mind and body fitness tips, hopeful content to uplifting patients, exchanging ideas with colleagues, educating patients, and diet and wellness information and other healthy practices. And possibly about the business of pain management and healthcare!
11. My own health has changed for the better by implementing some of those dietary and wellness practices over the last 18 months and I would like to think that my patients benefit from being cared for a doctor who is passionate, interested in them, and enthusiastic to come up with the best plan for them.

SO there you have it. I am on a mission to make everyone trauma informed! I want to show that implementing compassionate pain practice as early as possible is more useful for the patient and the economy as well. It will involve changing beliefs and crushing false ones. It will involve embracing new thoughts, new ways of doing things and stepping out of one’s comfort zones and going upstream. Will you walk with me?

Photo by Marc Schaefer on Unsplash

Dr Deepak Ravindran