By the time patients show up at Dr. Charles Buzzanell’s practice, many of them have little hope they will be free of their chronic pain. “They may have been given the message that therapies have worked for other patients, implying that they are a failure at treatment,” says Buzzanell.
Part of his prescription is a dose of realistic optimism.
Buzzanell can’t pack hope into a pill, but winning the trust of disillusioned patients goes a long way to treating their pain. Optimism is more than magical thinking that an illness or medical condition will simply go away. A healthy dose of hope, conveyed by the doctor, can help start the healing process.
A 2010 survey that took in 83 different scientific studies measuring optimism on physical health found a common thread. The studies ranged from longevity, disease survival, cancer outcomes, pregnancy outcomes to pain tolerance. In each survey, those patients who had more optimistic outlooks fared better than the pessimists.
Dr. Buzz, as he’s affectionately known to his patients, heads the Blue Ridge Pain Management Clinic in Asheville. Patients get referred to him after other specialists have often tried to treat their health issues but failed to get a fix on their pain. “When they come in, they feel often discredited and demoralized. We see a lot of patients who’ve had repeated surgeries for the spine, and they’ll say, ‘Well, it didn’t work,'” he says.
These patients “have been forsaken. Their lives are unmanageable. They’re at odds with their employer and may be facing disability,” Buzzanel says.
They aren’t hopeful, but listening and validating their pain is a first step.
Dr. Buzz makes sure to test each patient’s psychological and emotional baseline. He’s as likely to prescribe anti-depressants as an opiate for physical pain. “We can do specific procedures, to calm things down. That reduces the need for oral medication, particularly narcotics,” he says. “We’re turning down the rheostat, or pain volume.”
But Buzzanell has to temper expectations with a realistic optimism.
“We have to do a reality check. [Patients] do have to deal with a sense of loss, that things are not going to be the same as before. If someone says, ‘I want you to relieve all my pain,’ that’s probably not realistic. If someone says, ‘If you can reduce my pain enough so I can do this activity,’ then I can say it will take some time, but we will get there.”
One of the toughest things for chronic pain patients is to realize that the pain is going to be part of the fabric of the rest of their lives, says Buzzanel. But pain doesn’t preclude a good life.
He recalls one patient, a young woman in her early 30s, who had fractured her spine and undergone extensive surgery. “She avoided paralysis, but she was having this horrible hip pain. At first the surgeons thought it was a reaction to the hardware implanted in her back,” Buzzanell recalls.
Careful examination traced the pain problem to some soft tissue that could be treated with injections, says Buzzanel. The woman told him that she had experienced “five years in a funk” because of the persistent pain. Now, he reports, she feels joy in raising her child and has injections every three months to keep the pain at bay.
Buzzanell still tries to offer that kind of realistic optimism when the diagnosis is dire.
“Even with terminal cancer pain, we can provide effective means of pain control with relief of anxiety and depression symptoms,” he says. “The majority of patients facing terminal illness are willing to pace through the illness course if they can be reassured of relief of pain, anxiety and depression.”
Mortality itself may be affected by mental attitude.
A 2006 study looked at nearly 7,000 students who had taken a psychological test when they enrolled at the University of North Carolina in the 1960s. Among the most pessimistic third of the subjects, the death rate over the next 40 years was 42 percent higher than the most optimistic third.
Likewise, in a study of 1,000 men and women aged 65 to 85, after nearly 10 years of follow-up, those who described themselves as “highly optimistic” had a 55 percent lower risk of death from all causes when compared to those who were termed “very pessimistic.
Treating the whole person
A positive mental attitude is just standard operating procedure at the Minnie Jones Health Clinic of the Western North Carolina Community Health Services.
“Hope is intrinsic to our medical care,” says Nivedita Roy, director of behavioral health at WNCCHS. “It goes hand in hand in medical. We find that when we incorporate optimism that patients are more inclined to follow recommendations.”
A majority of WNCCHS’s 15,000 patients are on Medicaid or often unable to afford insurance even under the Affordable Care Act. The Minnie Jones clinic is the safety net for many people living in poverty, or single mothers struggling to stay afloat financially, the homeless, the disabled, the elderly, transgender people or those suffering with HIV, a still stigmatized disease.
Hope may be a reach for these patients until they can feel at home with their medical team, treating not just their symptoms, but talking about other transportation or child care issues causing stress in their lives, Roy says. “We don’t treat the well and wealthy. Patients who come in usually have multiple chronic complaints, and they are lacking in hope and optimism.”
Depression is a common condition that has to be treated along with chronic disease. Roy points to studies that show depression is the third-leading cause for patients coming to a primary care provider.
Treating patients’ mental attitudes makes as much difference as well as boosting blood counts or leveling sugar. “Western medical culture is so fixated with disease and dysfunction. Something is wrong, something is broken,” Roy says. That professional approach can often make patients feel like they have no power over their own health.
“We teach a core concept here – skills before pills,” explains Dr. Todd Wallenius, the medical director at WNCCHS. In addition to writing necessary prescriptions, they encourage patients to make use of skills such as exercise, mindfulness techniques, practicing of gratitude and self-care.
Taking a team approach to those patients, WNCCHS staffers aim to treat the whole person. Teams include doctors, nurse practitioners, behavioral therapists and caseworkers, says Wallenius.
It takes training on the part of the staff to get patients to trust them and put them into a more optimistic frame of mind about their particular ailments. “A lot of people come in with the frame of mind, ‘I just want to pop a pill than have to participate in doing the small things that can improve my health,’” Roy says.
Even a dire diagnosis can be delivered realistically but with hope. “A 22-year-old kid comes in and gets an HIV diagnosis. He’s devastated. He wants to check out. He thinks he’s going to die. There’s so much shame and stigma,” Wallenius says.
Gaining that patient’s trust and confidence takes time.
“ I often will ask, ‘How long do you want to live?’ And usually, they want to live to a ripe old age,” says Walllenius. “And I say, ‘That’s achievable. We as a team are going to help you achieve that. But you’re going to have to do your part.’”
It takes a team to recover
At CarePartners, teamwork between therapists and patients is crucial. Physical therapist Kristin Garner makes realistic optimism part of the rehabilitation therapy.
Her patients, who have suffered traumatic injuries from motor accidents, strokes or other conditions, are generally not going to get better unless they put the effort into their own recovery, she says.
In Garner’s 21 years of experience, the patients with more optimism are more likely to recover more quickly than those who are downbeat or discouraged. “It’s really evident with super-geriatric, the 90-year-olds. Many of them come in with amazing attitudes. There was one fellow who came in after he broke his hip doing aerobics. He was 94 and he rocked it.”
Garner finds that mental attitude is the deciding factor in how quickly recovery occurs.
“There’s the person who says, ‘I’m going to get home, I’m going to do this.’ That person does so much better than the one who says, ‘I’m in such pain. Please don’t touch me. I can’t get out of bed. I can’t move.’”
But optimism has to be realistic, Garner says, especially with patients with spinal cord injuries. Many of them may have expectations at odds with medical reality. “Their goal is to walk, and for some people that’s not really realistic and for others, it’s a possibility,” says Garner. “You hope for the best, and maybe the science will discover a way for you to walk.”
She adds, “You don’t want to take away their hope. Their idea of success may have to change. Not that I’m going to get up and walk, but I’m going to be independent in my chair, and I’m going to live on my own again.”
And Garner has to work against over-confidence. “None of us want to be reliant on someone else. But you have to call for help. We don’t want our patients to fall and break a hip.”
It takes a community of therapists and other patients in a setting like CarePartners to heal broken bodies and get people back to their lives, she says. Garner still gets Christmas cards from former patients.
Hope breeds hope among the patients, who may be in the rehab hospital between a week to a month. “This is a place where you see all these people working hard, you see other people struggling. it’s kind of hard not to try. They see others with worse injuries and say, ‘I can’t really complain,’” Garner says.
Even the crabby patients or the pessimists can change their minds and get with the program, she says. They may be slower, adjusting their attitude. “The majority are optimistic; overall, people are optimistic. They want to get better.”
Hope for the healers
Instilling optimism in patients also helps the medical personnel in an often grueling pace.
At the Minnie Jones Clinic, staffers make it a point to validate their patients, thanking them for coming in.
“When I go to my doctor, I say, ‘Thank you.’ And he says, ‘You’re welcome,’” said Scott Parker, the clinic’s communications director. “Here you hear the medical providers thanking the patients. There’s a total reversal.”
Optimism makes it easier on medical providers over the grueling course of their careers. “We live in a time of provider burnout. You have to engage half your time filing records on a computer instead of with a person face-to-face. We need a team to take care of chronically ill people,” Wallenius says.
Healing the body includes mind and spirit or the whole person, providers insist. Patients who find a community or a team of providers often fare the best.
“Hope is not pie in the sky. We try to translate that into reality for our patients,” says Roy at the Minnie Jones Clinic. “We say this is what we’re seeing for you. And this is the way you can help work through this problem with us. There has to be an emphasis on respect and human dignity.”
In the end, healing is more of a human art than just a science of technology.
“Included in our Hippocratic Oath is the vow to relieve pain and suffering and above all do no harm,” says Buzzanel. “That implies not harming them by robbing them of relative hope.” He also says, “Realistic message framing that acknowledges their human condition, while explaining what can be done to work toward reducing pain and suffering, fosters hope and optimism.”
Buzzanell, who has been in Asheville since 2004 and has spent his career treating chronic pain, considers his specialty a calling within the medical profession. “A pain specialist is a weird combination of medicine, life coaching, psychology, a little bit of surgery with secular ministry,” he says. “Hope is part of the art of medicine.”