In Greek mythology, Sisypheus was a deceitful king whose punishment was to roll a huge boulder up a hill, supervised closely by Persephone, only to have the boulder roll down again and he would have to keep doing this for eternity. The endless repetition of some tasks which eventually stop becoming helpful is known as a Sisyphean task.
What is the connection you may ask in relation to Pain medicine?
I would argue that sometimes the various interventions we do in modern medicine especially in long term orthopaedic and pain management could very well constitute some form of Sisyphean model. A patient comes in with knee pain or back pain, We examine her and then do a scan if needed . More than 50% of the time, the scan of the knee or the back is going to show some age related changes in the joint or in the discs or joints of the back.
We then proceed to tell patients that they could be pain generators. I am more careful these days but most of my colleagues especially my surgical colleagues will convince themselves and the patient that the pain can only be because of those changes and then suggest an intervention, ranging from a simple steroid injection to key hole surgery to major invasive options. Often when these don’t work, then they get referred to a pain clinic/service and then we have to unwrap all the false beliefs that the patient would have been gathered by then .
Because each time we want to inject/operate on an area which we think is generating pain, we have to convince ourselves and the patient that it is a pursuit worth undertaking.
Then when the injection or surgery doesn't work, we don’t have a plan for how to handle that. We haven’t given ourselves a “get out clause” so instead we tell them ‘we don’t know where your pain is coming from so off you go to the pain clinic and they will sort it’.
Undoing that kind of model and asking them to embrace the belief that the pain may never have come from that structure is a whole other battle. The term Cognitive dissonance is so strong that sometimes neither the patient nor we can shake it off and then we wonder why patients don’t engage with a pain management programme!
Our basic interventional model of managing pain by all specialties can be a form of Sisyphean logic. We do something; it lasts for three or four months. We then want to do it again. Patients feel they are getting benefit, but it then again has to cycle and repeat again. Then the scientific evidence or the insurance reviewer comes along and says “It can’t be done because the evidence is not great”. We see patients who get the benefit, but we can’t translate patient satisfaction or outcome into anything that’s worth commissioning and more importantly, worth paying for.
I think trying to break that Sisyphean model is paramount and crushing that belief needs to be done at the beginning because if patients go through the whole 2–3 year cycle point, they feel like victims of that Sisyphean model.
They go to a doctor, they get a diagnosis and then a steroid injection into a joint. The lucky ones might get a relief lasting a few years but for most, it works for eight to 12 weeks then it comes back.
The issue is no one is sure where all the pain is coming from.
We know the evidence would dictate that a structure alone is never responsible for all of the pain. But when it works very little or doesn’t work after the 2nd or 3rd time, then patients may start to assume “Yes, I’m stuck with it, I’ve got rheumatoid or osteoarthritis, I’ve got this. I can’t change anything”.
This has been called in psychological terms as learned helplessness. This is a very important psychological construct to be aware of and as pain doctors and specialists, we should try hard to prevent patients from feeling that.
Our main role as pain management physicians is to improve education and empower patients, to set the scene to bring about behavior change, give patients opportunity to recognize how they can live their life differently with less pain or maybe even pain-free — What do they have to do? How do they have to change? And I think that’s where asking ourselves and thinking about more importantly what value we bring to the consultation.
What value do we bring to the commissioners and what value could we bring to society ?
This is important; because in any negotiation/transaction we are encouraged to think win-win, but its “Win Win Win” as Christine Clifford has said. We are trying to tell patients what we can offer — there is no doubt about that but it has to be a “Win Win Win”, and if we can give something to the patient, something to the commissioners and something to the society — then that makes us valuable and relevant and I think that allows us to break away from the Sisyphean model that we are part of now;
To me that means adopting a systems-based approach with us at the beginningof a patients healthcare journey. Pain Physicians, especially those with training as anesthetists, are often familiar with lots of treatments and conditions from diverse medical and surgical specialties.
We do not have to know all the medical aspects of gynecology or urology, but we do know a lot about the physiology of the patients undergoing a variety of surgical procedures and the anticipated preoperative care and post-operative complications.
So we have the opportunity to take that model into primary care to provide value, to provide lifestyle and behavior change and to also bring about that same behavior change during their time when they come into hospital for a surgery, because that is a teachable moment.
A teachable moment is a changeable moment for behaviour modification and nudges and we need to be there to take advantage. The pain management programme model that we offer as outpatient therapy has allowed my colleagues in the primary and intermediate care to deliver that kind of teaching and behavior interventions.
Let’s face it — A patient and a member of the public has to hear the same message every time at least 7 times — so called multiple touch points. He or she or the child has to hear a common message, a similar theme and everybody singing from the same ‘behavioral’ hymn sheet as it were.
For any change to be meaningful, any change to be valid and for that change to be actually implemented means that we need to offer that repetition.
The noted cardiologist Dr Aseem Malhotra mentions in one of his online talks about lifestyle intervention an example where he performs this lifesaving, stent insertion at night into the heart vessels to save the life of a forty-five year old gentleman who’d come into his cardiology department. Next morning when he’s talking to the patient and teaching him about “Stop Smoking” and “Healthy diet”, along comes the hospital staff with a burger and chips! And the patient says — “Look doc! What’s the point in you giving me all this lifestyle advice if you’re going to send me the same crap that actually brought me here!”I think that’s a very powerful argument for system change!
We need to be changing multiple things at multiple levels, and this is the first step to stop this Sisyphean model. We are in a prime position to do it and we need to able to do it.
Most of the UK is moving to an integrated care partnership model where the budgets for the health and social care are being brought together.
This is the time for the interested anaesthetists and pain physicians to step up and offer a much needed and valuable integrative pathway. We need to be able to influence the commissioners to take us up on this and start chipping away at this boulder.
We cant keep rolling it up the hill all the time. There just isn't the time for this anymore nor the funding. Sisyphus didn't have an option and became a parable. We have options!
Dr Deepak Ravindran