Good diagnosis takes persistent questioning and good analytical skills. It’s a bit like a detective piecing together a puzzle from seemingly unrelated bits of information.
So argues Dr. Hillel Finestone, a rehabilitation specialist who has treated countless numbers of patients complaining of pain-related problems, be it a backache or neck pain. The associate professor at the division of physical medicine and rehabilitation at the University of Ottawa says he needs to know about a patient’s personal life in depth to really get to the bottom of the problems, and that includes information about family relationships or even a patient’s sexual orientation.
Finestone, also director of stroke rehabilitation research at Elisabeth Bruyere Hospital in Ottawa, was in Japan late last month at the request of the faculty of rehabilitation medicine at Showa University School of Medicine, where he gave a talk to physicians and spent a day training resident doctors.
His message was simple and clear: Physical pain and emotional stress are inseparable, and therefore both doctors and patients need to pay more attention to emotional and social factors in dealing with pain-related issues.
“Canada is similar to Japan,” he tells The Japan Times. “In Canada, we are still looking more at the physical and not addressing (mental and social issues affecting patients) enough. We are trying to talk more about mental health. But we are not connecting it (physical health) enough. I want to connect these emotions to our health and get people to think about it themselves — be their own pain detective.”
In his 2009 book, “The Pain Detective: Every Ache Tells a Story,” Finestone shares stories from his clinical experience. Written for laypeople, the book explains the case of a 28-year-old female patient who was referred to him by her family doctor because of a persisting pain in her chest and lower back area. The woman’s X-rays showed some degenerative changes but the exact cause of her pain was unknown.
Finestone gets on the case like a detective, and asks her about everything from her marital status (divorced) and ages of her children (3 and 6) to whether she is on disability benefits. The patient, named Ann in the book, initially sounds perplexed.
“Well, to tell you the truth, I’m not really sure why I need to talk about my kids or marriage — after all, I’m here for my back pain,” she tells him.
Finestone, however, explains that such information is important to “understand the pain story.”
“(I)f someone had, for instance, a child with Down syndrome … and was required to regularly bathe the child, even when the child was older, back pain could ensue or just not heal well once it had begun,” he writes. “Similarly, marital status can explain some of life’s tensions. For example, going through a divorce is potentially quite stressful, and stress can have a negative impact on the healing and recovery of injured back structures as well.”
In fact, Finestone says, over the last decade, medical studies have shown that stress delays the healing of wounds.
“They sort of found it is pretty much due to the stress response,” he says. “When you are stressed, you have cortisol. (Cortisol is) a stress hormone, and it’s a very important hormone if you are running away from a bear in the forest or you are crossing a street and a car is coming at you. But if you have that system going on for days it decreases your immunity.”
But more communication with patients does not necessarily help fund doctors under the public-insurance scheme, which tends to reward prescriptions or procedures, not time spent on the patients.
Finestone, however, argues that arriving at a diagnosis through detailed questioning costs the medical system far less than automatically turning to expensive diagnostic procedures, such as MRIs or CT scans.
“If we integrate (these psychological and social factors) into our medical system a little better, and not make fun of it, I think we’ll avoid more tests, more needles and more procedures,” he says. “One of the reasons I came to Japan is to teach physicians and doctors in training how to do this.”
Not all doctors are personable and find it easy to ask personal questions. However, they do already ask questions on health-risk factors, such as “Do you have high blood pressure?” “Do you smoke?” and “Do you have high cholesterol?” Finestone believes they just need to approach stress in a similar systematic manner: “I want (doctors and patients) to start thinking (about stress-related) pain risk factors.”
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