Report from the AAPM Conference

Author: Siegfried Othmer

The American Academy of Pain Management is an organization oriented toward integrated pain management, and welcomes health professionals of any stripe. To further insure that hierarchical status is not promoted, the name tag does not give a hint of pedigree. The ISNR did the same, with both standing in contrast to the AAPB, where labels could be attached to labels down the lapel, to make sure the world knew who the truly important people were.

There were lots of talks on migraine, so it is still very much an issue in pain management. One talk in particular was memorable. It was by an Alaskan who interspersed his talk with a slide of his ultralight sitting on the snow. This could hardly be a conventional talk. He insists on the patient making all the necessary lifestyle adjustments (such as improving sleep hygiene) before any medical intervention is even considered. He announces perfectly seriously that “I make the patient do everything before I do anything.” He makes people maintain a headache diary, one that makes them track known triggers and other lifestyle factors, as well as recording any aspects of prodromes. This helps to identify and confirm the connection with specific triggers, and thus increases commitment to the program. He also asks them to start taking certain supplements, such as Vitamin B-2, magnesium, and CoQ-10 and he closely monitors their progress. These measures alone are sufficient in his experience to bring about a reduction of between 50 and 90% in migraine incidence over a period of weeks to months.

Further, he strongly limits the use of rescue medications to no more than two incidents per week. That is to minimize the problem of medication itself becoming part of the problem. On hearing all of this it became clear to me how well a neurofeedback strategy fits with this approach. The patients come to an MD expecting immediate help, and when they don’t get it, they may well end up somewhere else. The strategy recommended here may only work in Alaska, where this fellow may be the only doc within easy reach. The biggest problem this MD faces is the usual one of compliance. Stop smoking? Stop drinking coffee? In Alaska? You must be kidding. The high success rate achieved here may therefore reflect the cohort for which compliance was not problematic. He does not count the ones who abandoned the program in mid-stream. So neurofeedback could be inserted here just to help with compliance. It also allows the patient to see that the MD is in fact “doing something.”

What I got out of this talk was the clear benefit of a headache diary to gain commitment to a self-regulation strategy. And it would help the early success of our work if we could get people to be more mindful of the usual triggers.

Our own talks were at the end of the conference. We heard that the conference organizers wanted these talks to anchor the final day of the conference, when people have a tendency to leave early. But people have to know that the subject is of interest to them first… Sue had a huge crowd last year when her talk was scheduled at the best possible time, 11 AM on Saturday. But if the intent was to hold the audience, it did not work. We had only a small audience on this occasion. We had, however, been in the exhibit are the whole time, so we had many individual conversations. There had just been a talk by Gabriel Sella on EMG feedback for Myofascial Pain Syndrome, a natural lead-in to our talk on neurofeedback. Sue also talked about MPS, and Sella was in the audience. However, we did not have a chance later to get his reaction either to our presentation or to Dick Gevirtz’s claim that Heart Rate Variability training also yields good results for MPS.

The audience was surprisingly sober and humorless throughout the conference. Several speakers took a stab at humor, and things always fell flat. We had heard discussions of the old chestnut “It’s all in your head, my dear” several times during the conference, so at the end, I said that with our neurofeedback work we had given new meaning to the phrase “It’s all in your head….” I struck out too. Maybe that’s a joke that only an MD can use.

The emotional highlight of the conference was a talk by Rosemary Gibson on “The Human Face of Medical Errors.” She has just published a book on the topic with the apt title of “Wall of Silence.” She contrasts the realities of how medical errors are treated with other situations. For example, records are even kept at the national level of animals that die while being transported in airplanes. Surely that is something that happens rarely. By contrast, fatal medical errors are a problem that would be the equivalent of a 747 crashing every day---some 100,000 fatalities per year. One medical school teaches that among other skills the MD must learn to bury his mistakes. This attitude is not new. “In In dozens of accounts of errors in the ancient Greek texts, none advocates or illustrates telling the patient or a relative about the error.”

One nurse, upon realizing she had made a mistake, was told to write a report on the matter and mail it to herself. One mother, reporting on the aftermath of the death of her son due to medical error, said:
“My husband and a nurse supervisor clear his belongings out of the hospital room with his body lying on the bed. My husband and daughter drive back to the motel. I am not ready to leave my child and try to stay and sit in the hall, still clutching the clean pillow I had been planning to put on his bed that morning. The ward resumes its normal activity and I realize it is futile to stay. I am driven back to the motel in a police car by two security guards talking about paint.”
“I will never forget the way we were simply turned out into the street. The only call we ever got from the hospital was asking us if we would donate our son’s eyes.”

Upon completion of her talk, several MDs got up to tell of their own brushes with medical error. Some 35% of docs have personal experience with this either with regard to themselves or a family member. So it is not a question of “us versus them.” One doc spoke of his sister being among the five people who received an organ donation from a person who had been diagnosed with rabies. All five died.

It should be said that the problem is beginning to be addressed. In this venture, legal redress is both a hindrance and an incentive. On the one hand, in the aftermath of medical error, “lawyers are the only ones who listen.” On the other hand, fear of litigation prevents things from being treated with the candor required. We have here a problem similar to that faced by the Catholic Church. How does one shift from a closed to an open system without bankrupting the institution in the transition?

The exhibit area had a different look this year. Low-level laser photic stimulators were well represented. These have applications to wound healing and to chronic pain. Len Ochs uses photic stimulators regularly in his work. It is another complementary technology that is accessible to the non-medical practitioner. There were a number of vendors for medical office software that included some areas of interest to us, such as symptom tracking. The specific offerings would not be suitable to our network, but they did stimulate some ideas. Thought Tech had a booth. We understand that the latest version of the Infiniti software has just been released.

I had a visit from a psychiatrist from Louisiana at the booth, and she immediately suggested that we be about the business of doing double-blind studies on autism so that she could in good conscience use neurofeedback with her growing caseload of autistic children. I took the position that there was no scientific issue that remained to be addressed with such a study. Moreover I thought the whole enterprise unethical---wiring up autistic kids for forty sessions of sham training, etc. Not in our office. We are getting bolder in our assertions, and it felt good. In fact, however, our visiting psychiatrist remained firm in her position…. We will simply advance the agenda with those who are not so doctrinaire.

The booth next to ours was sponsored by NAET, which refers to Nambudripad's Allergy Elimination Techniques (NAET). The originator of the technique was there, so we had a lot of opportunity to compare notes. As it happens, they have Ayers’ instrument, but aren’t using it a lot. We have heard good things about NAET from our clients over the years. The results presented by this group at their talk were quite impressive for fibromyalgia and other chronic pain conditions. They spoke of getting excellent results with the autism spectrum as well. The technique involves manipulations based on acupuncture meridians. Allergic susceptibilities are identified using muscle testing, and then desensitization is done using the acupressure-based manipulation techniques.

Dr. Devi Nambudripad came to this technique through a long-term personal history with chronic pain, one which was remediated after a food sensitivity was identified. She was initially quite skeptical of this diagnosis because she had been a life-long vegetarian. Her personal success led her to investigate the technique further. If what she says is correct, then allergies could be a much larger issue than we have realized.

Rheumatologist Thomas Romano talked about ESTABLISHING AN INSURANCE
FREE PRACTICE

Some gems from his talk:

FACTS ABOUT THIRD PARTY PAYORS:
· They take no responsibility for the medical care they influence (i.e. attempt to ration).
· They are delusional. They actually represent themselves as advocates for their insureds! ("Good hands," "Good neighbor" -- GOOD GRIEF!!!)

SOME REASONS WHY YOU MIGHT WANT TO FREE YOURSELF FROM THIRD PARTIES:
· You can streamline your office. No need for staff to do third-party billing, pre-authorization work, etc.
· You can significantly decrease your overhead
· You can bill and get paid for what you do -- no more "downcoding," insulting accusations, irrational polices, etc.
· You avoid Medicare audits/false claims act indictments.
· You avoid HIPPA insanity.
· You avoid the situation you may be in now -- all the disadvantages of being an employer and all the disadvantages of being an employee -- with scant advantages of either.
· You take control of your practice and chart your own course!

Nuggets from the conference:

“One person with a belief is a social power equal to 99 who only have interests.” John Stuart Mill

“Weak stimuli excite physiological activity, moderately strong ones favor it, strong ones retard it, and very strong ones arrest it.” Arndt-Schultz Law

“If at first the idea isn’t absurd then there is no hope for it!” Albert Einstein