The Social History

A  49 year old woman came to my office last week with 5 years of debilitating headaches.  Her neurological evaluation included an MRI which  revealed a pineal region cyst.  After several years getting interval MRIs focusing on this benign cyst until she took her care into her hands and sought the opinion of a neurosurgeon.  I looked through her extensive catalogue of MRIs and could confidently reassure her that this cyst was not a worry and not the source of her headaches.  She was relieved but asked the expected question, "Then what is causing my headaches?"  I think I know but before I answer let me divert for a moment...
Pain-in its many forms and expressions-is probably the greatest challenge for physicians.  You can't see it or touch it, there are no tests that reliably predict it or measure it (there are scales that are used but they remain completely subjective), and it is always a "symptom" rather than a diagnosis (think appendicitis as diagnosis/right lower abdominal pain as symptom OR brain tumor as diagnosis/headaches as symptom).  Despite all this, pain is always real-one might complain more than another or let it interfere with life more but anyone who comes to my office complaining of pain IS REALLY experiencing pain.  Because pain is the end product expression of many factors and modulations-both physical and psychological.  And to date, science has failed us miserably in understanding the real mechanics of pain.  Sure I could enumerate molecular knowledge about receptors, agonists, antagonists, signal transduction and the like but in the end, it wouldn't get any of us closer to understanding how and why patients suffer, how stress can bring on a headache or aggravate back pain, or how a wedding can temporarily halt longstanding cancer pain (as just a few examples of a myriad of pain enigmas).

Early in my career, I learned an invaluable lesson from an enormously gifted and talented plastic surgeon (who I count as both friend and mentor), Dr. Jane Petro.  We were jointly running a peripheral nerve clinic and had to evaluate a patient with RSD (Reflex Sympathetic Dystrophy as it was known then, now referred to as Complex Regional Pain Syndrone-CRPS).  After the patient left, she engaged the team in a discussion of a striking paper that demonstrated the very high correlation of RSD with abuse (both child and spousal abuse) (References below).  The clear implication was that our life events clearly impact our response to injury and disease in ways that remain unknown to us.  But while we may not understand the mechanism, it is evident that all health care providers have to more closely attend to understanding the lives of our patients in order to administer to their medical needs.
Which brings me to the Social History-probably the most under-rated component of a patient's history (beyond the perfunctory smoking, alcohol, and drug history).  Despite the pressures and my role as a sub-specialist, I always ask a few questions about home, employment and background.  At the least, I know a few things about my patient and it helps me view them as people (fathers, sisters, colleagues, etc.).  And sometimes the information turns out to be critical for successful outcomes or interventions.  For example, I recently performed a spinal fusion on a woman who was clearly in a threatening marriage and based on that information, I made sure she went to rehab post-op, even though she was likely medically well enough to go directly home.
So how does this all relate to my headache patient? Well, by just asking one simple question, she revealed a recent divorce after several years of a nasty separation.  Clearly, her headaches were temporally related to the onset of marital strife.   Trust me, this woman truly suffers from terrible headaches-they are real and life-altering, neither imagined nor exaggerated.  How? I don't know. Why headaches and not some other complaint? I don't know.  What is the best intervention now for this woman? I don't know.
But I do know, taking the Social History remains a critical component of understanding and providing the best care to our patients.

References:
Abuse-related injury and symptoms of posttraumatic stress disorder as mechanisms of chronic pain in survivors of intimate partner violence. - Wuest J - Pain Med - 01-MAY-2009; 10(4): 739-47

Prevalence of interpersonal abuse in primary care patients prescribed opioids for chronic pain. - Balousek S - J Gen Intern Med - 01-SEP-2007; 22(9): 1268-73

Sexual and physical abuse in women with fibromyalgia syndrome: a test of the trauma hypothesis. - Ciccone DS - Clin J Pain - 01-SEP-2005; 21(5): 378-86

Psychologic factors in the development of complex regional pain syndrome: history, myth, and evidence. - Feliu MH -Clin J Pain - 01-MAR-2010; 26(3): 258-63

Stern: Massachusetts General Hospital Comprehensive Clinical Psychiatry, 1st ed.; CHAPTER 82 - Domestic Violence

Katz: Comprehensive Gynecology, 5th ed.; Chapter 10 - Rape, Incest, and Domestic Violence

Quagmire: To Laugh or Cry

Jacob wrestling the angel (from which he acquired back pain)

During the last two years I have treated a young woman who personifies my perception of the challenges of America (and our health care system).  She has limited educational and economical opportunities, landed in a threatening marriage, was injured in a car accident, and is overweight and unhealthy, now with severe pain and a resultant narcotic dependence (doctor prescribed).  Her MRI scans demonstrated significant disc herniations in both her neck and back with severe nerve compression, etc.

Ancient treatment for back pain

Despite all the factors mitigating against success, I offered her surgery hoping it might help lift her up and allow her to move forward with her still young life (she was just 29).  I was thrilled at her post-op visit after her second surgery to see a better dressed, slimmer, and much more animated woman greeting me.  She had thrown out her abusive husband, returned to work part time and lost 15 pounds.  Her progress was outstanding and encouraging.
Fast forward 12 months-she is back and the sight she cuts is not nice.  Now her skin is gray and droopy-an obvious reflection of poor nutrition, her weight has rebounded plus some, her narcotic use is higher than ever, and her back pain has returned. And then she relates a particularly distressing tale, motivated, I think, by her own guilt.
After her second surgery, her insurance company sent my professional fees to her (this is a local practice when the doctor does not work within the insurance network) a check of several thousands of dollars for this complex spine procedure.  She tells me she deposited the check in her bank with plans (when it cleared) to write me a check to cover her fiduciary responsibility.  However, because of unrelated financial problems, the money was "seized" or "frozen" by some creditor and taken to pay off some other debt she owed.
I admit, I am gravely disappointed-nothing worked the way it should.  This woman has potential that I fear she will never realize.  I have performed surgery that I have not received compensation for because of the perverse insurance system we live under. A quagmire and a failure-I feel a part but also feel helpless as an individual in a complex system. I fear that until we address the totality of these types of issues, our health care system will continue to groan and fail for many similar individuals.

Sad, So Sad

She was 78 with bones to thin I could see through them on xray

And a spine so crooked, she could challenge a pretzel

She had seen three world class surgeons who had said "No"

But here she was,hope in her eyes, asking for my help

She was 78 and in pain and her predicament so sad

Her problem was nature and the bad hand it had dealt

And no medicine nor surgery could outwit Mother Nature

So no one wanted to help, it just wasn't their job

She was 78 and her husband even older

No one wanted them to suffer but there was no easy answer

And together they refused to accept and so on they wandered

Wasting resources and time and getting less help than they should

She was 78 and in pain and the system conspired

So that she kept up her futility, remained in great pain

And once again, I shook my head and knew in my heart

She had failed the system and the system failed her.

George Harrison So Sad

Is this right?

Had a patient today who I have been working up for back and neck pain.  She has been on high doses of narcotics for many years (something called Opana-always a red flag to a neurosurgeon).  This woman is rail thin, has no neurological deficits and essentially normal MRI scans.  Her heavy doses have been routinely prescribed by her PMD while she has never done a day of PT or real pain management-she also has not worked in more than 4 years...am I missing something here?
Another patient same day-obese, injured lifting at work, maintained with just narcotics and "rest" for 15 months-exam normal, MRIs normal-only seeing a chiropractor who she swears does wonders...but not miracle enough to return to gainful employment and stop drawing workman's compensation.

Sojourner Truth suffered from serious back pain

The estimated annual cost of workplace low back injury in the US is between $50-100 BILLION!!! These account for 1/4 of all claims.  Studies show if out of work just 6 months, there is a 50% chance of return to full time work.  After 1 years that number drops to 25% and after 2 years nearly 0%. (Bureau of Labor Statistics)
I don't mean to pick on these two women, rather to use them to illustrate how our system is broken-

• Too many physicians find it easier to just give narcotics than deal with the challenge of a more comprehensive approach
• With increasing time constraints, it is simpler to complete paperwork (even if annoying) than to confront the patient
• Maintaining the status quo is less trouble than challenging the patient to lose weight, start exercising, and retrain.

I would never want to penalize an employee truly injured at 

work but within the realm of low back injury, the "state of the state" needs significant improvement.

How far have our treatments come?