Empathy in Medicine

Empathy - When the Doctor Becomes the Patient.

The need to be empathetic is something we have been taught since not only medical school, but for many of us, since we were children. I have always embraced that goal and I thought I had achieved it. I was wrong. Sure, I had been a patient before, after a high school or college football injury. That is American football for my ISPN friends. I had also been a patient after trail running trauma and crashing my triathlon bike.

Despite this, my early bounce back from those events gave me the false perception that being a patient was easy. The sequence was the following: have a feeling of being amazing and great, get injured, feel acutely bad, recover, and then feel amazing and great again, then back to the old grind. I saw little issues with being on the other side of the hospital gown. My yearly physicals went fantastically well, and my doctor always told me I was the picture of health.

In July of 23, that facade of invisibility was initially cracked. During the buildup to the Badwater 135-mile road race, I was injured, and then pushing through on race day, I had a full thickness hamstring rupture, rhabdo, and acute kidney and liver failure. Despite this, I was still somewhat invincible, refusing hospitalization and being treated as an outpatient. This led to a 4-month long recovery, which led me to the cusp of being back to normal.

In May of 24, I never saw it coming. Feeling better, I ran the Key West Ultra 50 miler, a race I had won overall in the men’s division in 2017 and one that seemed, if anything, too short. It was 110 degrees on the heat index, and the sun was baking. I calculated my water to sodium balance poorly, and by mile 40, I was getting into very bad shape. Cramping, falling, suffering, my mind was going into strange places, and I started to hallucinate. This is when my crew told me I was in first place in my age group. Snap out of it, Tim; you can do this, I told myself, and do it I did. I could and would suffer through anything to get top 20 ultra finish and an age group win. Winning my age group, 11th place overall and still something was wrong. I asked the race director, “Did I finish?” three times, and then it went black.

A few hours later, I was awakened by the placement of a Foley catheter (not a good experience) and a new IV stick. The doctor in the ER, Dr. Barry, told me that my sodium and potassium were critically low, and my myoglobin was critically high. He also told me if I wasn’t airlifted to Miami right away, I may die. I consented, and my first helicopter ride was underway. I must admit that was surreal, and seeing the Keys coastline was fantastic. Once in Miami, I woke up again in the Brain CT scanner. Apparently, my sodium had been elevated too quickly, and I was at risk for brain edema.

Later, the ICU monitors went off every 5 minutes because my baseline heart rate was 50, and the nurse told me I was bradycardic and may have done heart damage. The real answer was quite the opposite; my heart was strong, and the slow heart rate was great conditioning, but still I had repeat ECGs and a cardiac consult. My IV infiltrated, I had bloody urine after my catheter pull, and I was getting 2-hour checks of my electrolytes.

Thankfully, I recovered very quickly, and at 48 hours, I declared myself ready to be discharged from the ICU. The doctor initially disagreed, but after discussion, agreed to let me go home, although I am not sure this was the right medical decision—VIPs always get suspect care. I drove 9 hours to Northern Florida, flew back to West Virginia, and went back to work 3 days after the event. I was doing great.

Then after working on Friday, I noticed the area of IV filtration was inflamed, red, and swollen. This required drainage twice and broad-spectrum antibiotics. Being ill, at this point, I took a week of vacation. During that week, I noticed my hands and feet felt “on fire” and appeared sunburned despite no sun exposure. This is when I learned of sulfa-induced vasculitis. This condition required me to switch antibiotics and go on oral steroids. This switch led to peripheral edema. Does this everend?

I found some relief by taking the steroids and propping my feet up after work, which led to sciatic nerve compression and a fall on getting up from the couch. That fall led to a biceps hematoma, ligament strain in the thumb, and back injury. I am now suffering from a facet injury to the lumbar spine from the fall. I am getting exhausted living and telling the story, but I did learn some major points.

• Being a patient gives one a feeling of helplessness and loss of control.

• Being a patient is expensive. Copays and deductibles add up.

• Being a patient can lead to new comorbidities and iatrogenic injuries.

• Being a patient is not easy, and sometimes, despite good care, one thing leads to another.

• Laying on the pain procedure table instead of standing over it leads to an all-new perspective. Anxiety washes over you, and you are not sure it is the right move, but when it is over, you are happy you had the block.

• Having great doctors, APPs, and nurses is worth its weight in gold.

• Prayer worked for me.

So, to summarize, I have been the physician for 34 years, and I have been the patient for three months. Having to choose, I will pick being a physician every single time. I don’t think I am tough enough to be a patient for much longer. Hopefully, all of you can find empathy without undergoing a similar experience.

Check out my Linkedln post (opens in new tab) about this experience.

Safety and Efficacy of AXON Therapy (SEAT)

This abstract highlights the groundbreaking research on magnetic peripheral nerve stimulation (mPNS) and its significant impact on patient care. The study showed a remarkable 95% responder rate in patients with various types of neuropathic pain, as well as a 93% improvement in patient quality of life.

These results demonstrate the potential of mPNS to provide lasting results and effective, cost-efficient treatment options for patients suffering from chronic neuropathic pain.

This research not only contributes to the existing literature on neuromodulation techniques but also has the potential to revolutionize pain management practices in the future. Considerations should be made to introduce this therapy early in the treatment of neuropathic pain.

Overall, the findings presented in this abstract represent a major advancement in the field of pain management and have the potential to significantly benefit patients worldwide.

Congratulations to all three Top Abstract Award Winners: Dr. Kapural, Dr. Beall, and Dr. Levy. We look forward to reviewing the abstracts in future editions of the newsletter.

It is such an exciting time to be in pain medicine! As a community, we continue to embrace the value that diversity brings to a healthcare team. We are witnessing a historical time in our field, where pain medicine fellowship programs are embracing diversity and welcoming candidates from a variety of specialties to train as the next generation of pain physicians. Diversity in pain medicine is crucial for providing equitable and effective care to a diverse patient population.

We have seen a tremendous growth in diversity in gender, race, medical training, and specialty representation in our field. ASPN fosters an inclusive environment that promotes a sense of unity in our field, despite various interdisciplinary backgrounds and levels of training. ASPN fiercely advocates for promoting equitable opportunities for its members to become leaders in education, innovation, community, and research.

The recent Annual Meeting showcased a commendable increase in diversity and inclusion across various dimensions, including background, stage in career, gender, age, and specialty. Notably, this event featured members from all stages in careers—from seasoned physicians with extensive practice experience to fellows still in training, all sharing their valuable expertise in panels, breakout sessions, podium presentations, and Master’s cadaver lab.

A significant milestone was the inclusion of women representation in approximately half of the presentations during the meeting, highlighting a progressive shift toward gender equality in the field. Additionally, there was a marked increase in faculty from diverse backgrounds, including experts in practice management, private equity, law, industry, and advanced practice providers. This diverse representation underscores ASPN’s commitment to fostering an inclusive environment that values the contributions of professionals from various backgrounds and stages of their careers.

Participating as faculty at the recent ASPN conference was a transformative experience for me. It was incredibly rewarding to discuss my journey, exchange ideas, and learn from my peers as a panelist in the Young Innovators session. As a member of the Poster to Podium program, I had the opportunity to present my collaborative research project, which not only facilitated significant professional growth but also inspired me deeply. These unique opportunities continue to reinforce my commitment to advancing in our field.

We are so excited to learn, collaborate, and gain perspectives from international colleagues in pain medicine at the annual ISPN meeting in London. This will be an engaging opportunity for members to gain fresh perspectives on disease processes, novel therapies, and understanding ways to create more culturally sensitive treatment approaches for our patients.

ASPN is committed to making equitable inclusivity a priority, which will continue to advance our field for years to come.

Looking forward to seeing you all at the ASPN mid-year next meeting in Nashville!

ASPN Advocacy & Policy Committee continues to advocate for all its members and the subspeciality of interventional pain and neuroscience.

• DEA controlled substance delivery regulation update affecting intrathecal compounded medication:

DEA law and federal regulation require pharmacies to dispense controlled substances to the “ultimate user,” meaning directly to patients at their home address. However, the DEA has historically permitted pharmacies to implement the industry standard practice of shipping these medications to physician prescribers instead of directly to patients. There is an obvious health and safety risk associated with shipping highly concentrated opioids directly to patients at their homes.

DEA will issue guidance to explain the current law in the near future and allow continued delivery to clinics, one of the options is that both the patient and treating physician sign a Power of Attorney (“POA”) form to cover the risk. This form will only need to be signed once per patient. While we eagerly await the final guidance from DEA, ASPN will continue to advocate on behalf of its members. We encourage our members who procure their intrathecal medications from compounding pharmacies to reach their respective pharmacies for further guidance and instructions to comply with the law written in its current form.

• ASPN is working with CMS to reconsider coverage of SI Joint radiofrequency ablation.

ASPN is a part of the multispecialty initiative working closely with the Federation for Pain Care Access. We met with CMS leadership and their medical directors of respective MAC”s to discuss strategies for reconsideration of SI joint LCD. We were joined by numerous other state and national pain societies for this meeting. The reconsideration request will be submitted soon.