My Early Evolution of the DOCC Project

In 1999 I moved to Sun Valley, Idaho to be close to my son who was seriously competing as a mogul skier. I went from a large group and a huge hospital in Seattle to a small practice and a community hospital.

I was a tertiary referral surgeon who ended up seeing primary low back pain. I had a lot of experience with the physiatrists in supervising non-operative care. I had access to excellent physical therapists. I also had access to physicians who could perform excellent cervical and lumbar blocks when needed. I had already been working on helping patients sleep. I also knew which patients were under a lot I of stress and at high risk for becoming disabled. I had had a lot of personal success with using the “Feeling Good” book and started to have my patients use it to deal with the stress of chronic pain.

As a surgeon, we become used to triaging our patients. We are trained to look for problems that we can solve surgically. If surgery is not indicated we will do the best we can do provide some non-operative treatments. As it is not our primary training and interest, we generally don’t tackle it that aggressively. In Sun Valley my situation was much different than in downtown Seattle. Over 90% of my practice was non-surgical. However, I was the main resource, I just put my head down and went to work without expectations. I did have a strong non-operative background but what was different in this situation was that I applied my surgical mind set to non-operative care. I was also had some training as an internist and understand that the mind-set often has to be managing rather than curing. I just did not know any better.

Not sleeping is not an option. Regardless of everything that I have pointed out in this book, no real progress can be made if you are not getting seven to eight hours of sleep at night. Not only are your coping skills compromised, the brain’s perception of pain is altered. My strategy was to start an aggressive sleeping pill and see the patient back in five to seven days. If it wasn’t effective, I would increase the dosage or add on an additional medication. Usually within two to four weeks, I was able to get my patients to sleep. It was not uncommon for that to be the definitive treatment.

I would start the stress management along with the implementation of sleep meds. By two to four weeks, I would expect my patients to be participating in a daily writing program. I would utilize “Feeling Good” as the basis for the writing. As the stress management strategies would kick in, sleep would often improve. I would not start physical therapy for six to eight weeks after these other strategies were partially working. With uncontrolled stress and lack of sleep, the nervous system is on fire. Doing aggressive soft tissue work with a sensitized nervous system causes an abnormally high number of pain fibers to fire with stimulation.

Pain medications were used on a short-term basis to allow therapy to be done. I went through a phase where I would put patients on long-term narcotics to keep them functional. They eventually are counter-productive.

Goal setting was critical. I found it imperative that within one to two weeks that the patient and I were on the same page. Without a goal, anxiety levels remain high, which contributes to a sensitized nervous system. Once a definitive plan was in place, frustration levels of both the patient and myself would diminish. That also had a calming effect on the nervous system.

I would work extremely hard all parties to avoid loss of a job. Once you have lost your job, the whole game completely changes. You are now at the mercy of the worker’s compensation system. Although they are well meaning, it is a huge system and just not that responsive to your personal needs.

Education also decreases anxiety and frustration. I utilized an excellent book, “The Pain Cure”, by Dharma Khalsa, M.D. He is a pain specialist who wrote a wonderful explanation of chronic pain. He also discusses almost every option available to help manage the pain. I would tell my patients I wanted them to become extremely smart in regards to chronic pain.

The bottom line is that I would see my patients every week until all aspects of care were implemented and having a beneficial effect. I would then decrease the visits to every two to three weeks.

The vast majority of the time I was able to keep workers on the job and prevent them from becoming disabled.

What shocked me was that many patients who I had thought were permanently disabled would “come back to life” over twelve to eighteen months. I had already “labeled” them as “terminal pain patients.” I did recognize my own labeling and treated them like everyone else. Over time the labels would drop off. What was interesting was the patients who did well would just walk in one day and take charge of their care. They did become very knowledgeable about all the variables involved in chronic pain and disability. They would essentially fire me.

When all this began I had no concept of the role of anxiety and frustration in the evolution of chronic pain. I now realize that much of the DOCC program revolves around regaining control, which decreases frustration and thereby helps alleviate anxiety. I was just trying to help my patients cope with the pain as I could not see a structural problem that I could solve with surgery. I never thought that the pain would decrease. As it is well-documented that if a person is off work greater than two years the chance of ever returning to work approaches zero. It was again surprising to see many patients not only return to work but thrive in other aspects of their lives. As the DOCC project has evolved the results have been more consistent.

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