A personal experience learning from two pain pioneers, J.J. Bonica and W. Fordyce: Lessons surviving four decades of pain practice

2.1 My first mentor John Bonica

At three AM one night in April 1973, the telephone rang. “Hi, Steve. This is John Bonica. We need you in the pain clinic. How soon can you start?” Not “Was I interested?”, “Can you come?”, no discussion about salary, just an order from “the chief” as was typical of Bonica. And of course, I went and then began my real training as a pain physician being the teacher for the residents in anesthesia.

A bit about Bonica. He was the driving force behind the present exploding interest in pain research and pain practice. I had a lot of contact with Bonica, as a mentor and teacher and later with him as my patient and felt that I knew him well. The timing of the phone call for the job was typical. It was not that he did not consider the time difference from Seattle to Montreal (3 h) but it was the last of the things on his list to do at midnight in Seattle, up in his office/library under the roof of the gracious house on the shore of Lake Washington. He worked there till midnight, seven days a week his whole life when he was not travelling. And that was the one of the things that I learned from Bonica – hard work. I could never work as hard as he did and he was not shy about reminding us all that we needed to be more work oriented just as he was.

Hard work had been his life and the pattern he set began when he was writing the landmark text published in 1953, “The Management of Pain” while involved as the chief of a busy private practice in anesthesia that also had a teaching program for future anesthetists (Bonica, 1953). The drive to create a comprehensive text, not just a book describing blocks, was a mark of Bonica’s work ethic and also his need to know more and have attention to detail.

2.2 My second mentor William E. Fordyce

But Bonica had a blind spot when it came to pain. He endorsed the biopsychosocial model of Engel (1977), but it came later in his career. He knew that psychiatric disease was often an accompaniment of chronic pain and had a psychiatrist on his team from the beginning. But the psychological aspects were not easy for him to understand and especially not for his own pains. My education from this viewpoint came not from Bonica or his influence but from a psychologist named Bill Fordyce. Bill was trained as a behaviorist and did his doctoral thesis on behavioral processes. He worked in the Department of Rehabilitation Medicine at the University of Washington and in the 60’s, began operant behavioral management of chronic pain based on a positive experience with a single patient that had defied the best that the rehabilitation physicians could do. From a pilot program, Bill developed a continuing eight-week program for two hospitalized patients in that department and was a contributor to the Friday conferences when I began as coordinator of them during my pain rotations. The program was very successful and widely acknowledged as a pioneering work in pain management, especially after Bill’s textbook “Behavioral Methods in Chronic Pain and Illness” was published in 1976 (Fordyce, 1976). I was impressed by Bill’s common sense approach to pain patients and his discussions of the operant factors working at sustaining pain behavior in patients where the medical evidence for disease or illness was very slight. The real apprenticeship with Bill began when there was a major change in the pain centre.

2.3 And what did I really learn from John Bonica other than that I could never work as hard as he did?

• I learned that you need to take time and listen to pain patients.

• You need to do a very careful examination, not only in the areas where the pain is described but also as part of a more comprehensive general examination.

• You need to have as much information from past evaluations as possible, especially testing.

• You need to look at the röntgens yourself and get help from a radiologist if you are not comfortable with this.

• You need to discuss with the patients all the findings, often helped by the röntgens, scans, etc. and a skeleton. Discussion about what is not present as well as what is present is important.

• You need help from as many appropriate consultants as necessary for the difficult problems.

• Nerve blocks must be done with great care and planning if they are to help with either diagnosis or treatment. A placebo block is necessary as well in diagnosis.

• Nerve blocks (and now infusions) alone cannot diagnose or treat the majority of chronic pain.

• You must read constantly, not only about pain but also to refresh old knowledge on basic science and medical illness/disease since this is being added to at a fast pace.

2.4 And what did I learn from Bill Fordyce?

The best way to put this in short form is to quote many of his aphorisms.

• “If you have something better to do, you do not hurt”. Those with empty lives suffer more and are more likely to take their suffering to a doctor where it is explained as pain. Fill up your life with work, family, recreational activities and the pain is in the background.

• “Hurt does not equal harm”. Chronic pain is a signal that the nervous system is not working well, not that there is something wrong with your body.

• “Pain is transdermal, it depends on events inside and outside the body”. We focus on the medical problems but people do not live in a vacuum. Their social milieu can have a profound affect on their pain behavior and suffering.

• “If you want to make a silk purse out of a sow’s ear, you need to start with a silk sow”. This comes from the English saying, “You can’t make a silk purse out of a sow’s ear”. i.e. things can be so bad that it is impossible to improve them. This is true for some pain problems and you need to limit your resources to those with the best chance of improving. It is OK to say that you do not understand the problem and/or you cannot help.

• “Use it or lose it”. This is not psychological but physiological. If you stop using your body, it shuts down and many chronic pain problems persist because of deconditioning. Training helps!

• “No pain, no gain”. This is not Bill’s quote but he used it. You cannot come back to a higher activity level with training without expecting some aches and pains. They may also be where your chronic pain is but that should not interfere. Remember “Hurt does not equal harm”.

• “Information is to behavior change as spaghetti is to bricks”. All the talk therapy you do with patients may not help. They will say that they do things differently, more exercise, less medication taking, less lying down during the day but if you do not watch them exercise, monitor medicine, monitor daily activities, they often just continue as before treatment and tell the nice doctor/psychologist that he/she is helping.

• “Allchronic pain has a behavioral component”. The medical model cannot explain all pain behavior that we see. Pain behavior is saying that you have pain, taking medications, not working, going to the doctor, etc. The psychosocial model is the most important explanation for those disabled because of pain.

2.5 And there was one important principle that I learned from both John Bonica and Bill Fordyce

“treat the patient, not the diagnosis”

Every patient is different and they come to tertiary pain clinics because rote treatment of a diagnosis (which might be wrong) has not helped. Physicians are so afraid of missing a medical diagnosis that they often force the patients’ signs and symptoms into a convenient diagnosis, often a favorite diagnosis that makes treatment easy.

“If you have a hammer in your hand, everything looks like a nail”

Both Bonica and Fordyce were open to ideas from all sides and wanted help for those difficult patients that the medical system had failed. They both wanted to know the patient better before deciding on a diagnosis and wanted the treatment specifically for that patient. Sometime we had no diagnosis but did have a treatment.

But Bill did work with (or in?) the biopsychosocial model. There was a team evaluation so that important medical issues could be ruled out by a physician before patients came to treatment. There was also a physician with the treatment team and the physician and the psychologist shared equal responsibility for the patients under treatment. The physician’s role was mainly to legitimize the pain as “real” and to evaluate new aches and pains or increases in the old pain under the treatment program.

4.1 On the positive side

The new popular phrase in western medical circles is “personalized health care”. It arose from genomics and means that we must recognize that one size does not fit all because of genetic differences. The meaning has expanded somewhat and now many use it to describe a variety of treatments that are grouped for the individual patients. Too often this means only combining two or more medications.

Another popular phrase is “multimodal treatment” which evolved from Bonica’s idea of multidisciplinary evaluation and treatment but is used in a broader sense to mean the combination of psychological therapies with medical therapies, often for diagnoses thought to be purely biomedical, e.g. arthritis.

4.2 On the negative side

Any ideas that are a few years old are considered passé. We must have something new, we must have something modern. Newer ideas, newer medications, newer behavioral therapies are accepted rapidly and assume importance far greater than they deserve because we do not analyze them carefully and do not look at them in light of past experience and past knowledge in the pain field.

Santyana’s curse is alive and well in pain medicine. Beware because it can have an effect on all of us to the detriment of our patients.