 Lakeland Public Television presents Currents with host Ray Gildow, sponsored by Niswa Tax Service, offering tax preparation for individuals and businesses across from the City Hall in Niswa and on the web at niswatax.com. Hello everyone, welcome to Lakeland Currents where tonight we're going to be talking about something that affects you and me and all of us, pain. We've all experienced it at some stage in our life, some more extreme and some not as extreme. I've never, in the ten years that we've had our program, I've never had a doctor on who's a pain specialist and my doctor friend today is a fisherman too, so he can't be a bad guy, he's got to be a pretty good guy. Josh Horowitz is a pain specialist and anesthesiologist, anesthesiologist from the Cayuna Regional Medical Center in Crosby. Welcome to the show and welcome to Minnesota. Thank you sir. And before we get into the pain issue, which is a very large issue I understand, but tell us a little bit about your background, where you're from and what you do. Well, I've had kind of a diverse background. I grew up primarily out west in Idaho, Wyoming and the Washington State area, the Pacific Northwest. I couldn't really figure out what I wanted to do in my younger years, so I tried several other careers. I was a professional pilot for some time. Really? A commercial pilot? Commercial pilot and then I used to build houses for a living and then somehow I got a wild idea that medicine was the next step in life and so that kind of led me down a longer path and I ended up, ultimately ended up here after finishing training from the east coast and down in the south in Tennessee and so my folks live local in the area here even though I didn't grow up here. So it was important to me to be close to family and so here I am now. You have a, that's a very interesting background. I don't think I've ever run across a doctor who's been a commercial airline pilot. That's the first. It prepared you well for pain because you had passion. Well, you know, it actually was, I sort of serendipitously ended up in pain management. It sort of directed me towards the anesthesia because of the strong corollary between flying and the skill set and the enjoyment of flying which parallels very well to anesthesia and there's a lot of literature on that and there's a lot of resource management and things that comes from the airline industry and the professional flying world and the medicine now and it was a nice segue for me. I've been flying long before I ever went into medicine and so that led me to anesthesiology and then from anesthesia I became interested in pain management as a subspecialty and went down a slightly different path from some of my other colleagues that either just stayed in anesthesiology in the operating room or did another subspecialty from that. As I understand it, you're the only one in our immediate region. I know there's some in St. Cloud in the immediate area. I work for Cayuna Regional Medical Center so in the Cayuna area and the Crosby area, we're the only one and we're the only one that's really locally owned and based. There are some other practices in the area that have remote clinic sites up here but they're sort of based elsewhere down in St. Cloud and so we're really the only one that kind of keeps everything here close to home and where people don't have to have quite a drive to get to some of those services. Outside of the fact that your family lives which is very important to understand that but what else attracted you to this area? Oh, well that's easy. I'm a big outdoors guy. We talked about fishing briefly. I grew up on a ranch out west and so the outdoors have always been a big part of who I am. It was important to me to be in an area that really fit my personality and I'm not a big city guy although I've spent a good portion of my life in large cities just by design having to go through my education process but I always knew it would be a small town for me in the end. I like the personal feeling of that. I like to know everybody in town. I like waving at people when I drive by and so I had lived in the Dakotas before. I'd lived in the Midwest and it just was more fitting for me ending up in the Midwest with the values and the personal touch of people in the Midwest. I love the West Coast and it's a beautiful area and I always go back to visit and to fish and to hunt but this was very fitting for me and so when my parents ended up in this area which I think had a large degree to do with the fact that they knew I would end up out here it was just a good fit. I was just going with my instinct and everything felt right. And so far? So far. I couldn't be happier. Having been in very big cities and moved around a lot last 10 plus years with the medical training it's refreshing to be in a small town. So I love it. Welcome to the area. Oh well thank you very much. You'll have to share with me some of the fishing secrets around you. I have a relative who works in the insurance industry in the sense that he has to help identify people who are in pain and he said I'm glad to hear you're having a show coming on because he said for us it was one of the most difficult things to analyze really how seriously is the pain of this person because people have real severe pain issues and then maybe there are people who take advantage of the system sometimes in the insurance industry I'm talking about here and maybe their pain isn't as severe as they would like to have you think. That's a tough area to analyze isn't it? It's very tough and it's a subjective experience for everybody and so we have to quantify it in certain ways and put it on paper to help people understand like your friend in that industry and in the medical industry we try to put it in an expressible terminology that can be translated from person to person but what we have to remember is that pain is a very subjective experience to each person and there's multiple levels of involvement whether it's an emotional context or a memory context or a physical context there's lots of avenues that impact someone's experience of pain and so you may experience some version of pain in your life just as I may but they would be very different experiences and so that's the humanistic part of medicine that's very hard to put a test on and know what it is but that's really what we... it's a huge burden on the society in the United States. So in your practice are you the first person that people come to or do you get referred from their family doctor? We do both it works both ways really I would say probably over 50% or more as referrals and that is just by nature of the health system that we have where most people are connected with a family physician or a family provider that manages their overall care and as a common example of somebody is experiencing back pain they may usually will seek help from their family provider before they're sent to a back pain specialist because common things being common a lot of those common pain syndromes can be treated conservatively and when I think it gets out of the normal scope of a family provider or an internal medicine provider anybody whether it be a chiropractor then when an extra additional skill set is required then they would come to me but we see a lot of people that just can self refer to us we do look over those to not waste their time if they would be better off seeing someone else before they see me but we do it both ways So can you take pain and put it into little boxes maybe their whole area of headaches back pains leg pains can you generalize like that before you hone in on specifics or how do you approach that? That's a great question there are categories of pain and when we break the pain process down physiologically and pathologically we know that pain is transmitted by different mechanisms and so there's pain that's caused from an injury called nociceptive pain there's pain that's caused from nerve damage or nerve dysfunction we call that neuropathic pain there's pain that comes from an emotional experience we know that very well and we've mapped that out and documented and that's sort of a, for lack of better terms a psychological component to pain and those are all interacting on the same level so not one is distinct and excludes the others there can be overlap from all of those but we do try to and the reason is it's a good question because you have to identify what you're treating and sometimes it's very difficult because there can be multiple things in the picture but if we can identify what it is and what the cause is and the mechanism and that gives us the best ability to find a treatment that will work for that person otherwise we're just kind of flying blind and we're trying whatever we may have to offer that person but it can be very difficult sometimes because it's not straightforward. In the area of research are we making progress in understanding pain? We are, there's a lot of research fortunately in this country we put a lot of effort and monetary support into studying what we do and making sure that what we're doing is beneficial to people and is not harmful and so we have the benefit sometimes it's hindsight benefit because we look back over the years and look at what we have done and ask the question what we have been doing is this beneficial sometimes we have to be humbled and we change our direction on things but in the world of pain I think large areas of research now are going into the genetics of pain looking at predispositions to certain painful syndromes and then we're getting a lot of evidence in the complementary aspects of treatments with regards to mindfulness training and with regards to the impact of treating the mind and the correlation that that has on the pain pathways which is applies to that subjective experience we all want a quick fix that's kind of the world we live in sometimes there is one sometimes it's easily identifiable often times when you approach the mind and if you think of pain as an experience if we didn't have the consciousness of knowing we were in pain, pain is an electrical signal that comes to our brain it gets processed and we experience that as pain so this huge connection between the mind and pain it can't be ignored and there's a lot of research that's going on with that I'm looking at the work that they're doing reattaching hands or they're doing things now with the brain to make artificial parts move and I'm thinking wow if we can do that why can't we figure out a way to stop that pain that's coming from your back well we to address the neurophysiologic component that we're talking about we do, we have modalities we use electricity for lack of better terms to short circuit the pathway it's called there's neuromodulation therapies where we interrupt the pain signal whether it be at the level of the spinal cord or deep brain stimulation we do it for movement disorders Parkinsonism which is really a disease of a malfunction of the circuitry in the brain and it's really all boils down to and not to discount the complexity of it but the brain is a beautiful electrical circuit and we have found ways to interrupt that circuitry and so we attach limbs, we place devices to interrupt the electrical signal and modify that signal and we're very successful with that back to your original thought the complexity of all this is what makes it difficult one isolated lesion then we have something to go after but we're proving to ourselves that the brain is adaptable, it's malleable and it is very complex and we just, we're working well we haven't figured it out yet I'm assuming you don't do surgery and that's, you're not a surgeon I'm not a neurosurgeon, no we do minor operations I mentioned the spinal, the neuromodulation and the lay term for that is spinal cord stimulation it's a minor operation where if somebody were to be found to receive benefit from a device like that it's like a pacemaker battery that gets implanted so these are day surgeries that the patient goes home but we have to be very careful about who we identify as patients for these devices and make sure that when we, that we're practicing good medicine that we go over the risks and the benefits and that we identify people in everything we do in medicine who we feel truly will benefit from this as it, as kind of the next thing to try and throw to the wind but, you know, I always try to there's this thing out there called the mom test and it wasn't it wasn't a term coined by me but I think medicine really needs to be directed in such a way that you would do something to your patient the same as you would do to your family member and not everything works, certainly not but do it in such a way that you think that there's a fairly reasonable chance that at least there's some possible benefit there and so So if you have a patient and you've reached the point where you don't really know what to do the next level would be then a neurosurgeon, is that where you would usually direct them? That really depends so it's important to identify when you just don't know something or when you think you need help and sometimes that's very early on and that's frustrating for me and it's frustrating for patients when you come to a specialist and the specialist says, I just don't know you know there's no merit to I think wasting anybody's time or trying to fool them into something that may not be of benefit but it depends on the person that person may need a neurosurgical or an orthopedic spine evaluation from a surgeon as an example if they have some pathology in their back or in a nerve that I can't remedy myself they may need help from a mindfulness standpoint, they may need to learn relaxation techniques they may need to learn to separate the emotional component from something that they're dealing with every day they may need physical therapy and to restructure the body and the musculoskeletal system we're a structural being and we're built like the frame of a car but we're not built to last forever so we break down and we wear out and parts have to be replaced and it takes a discussion an analysis of what's going on to see where do we go next not everybody needs surgery not everybody will benefit from surgery and it takes the right person to evaluate them you talk about mindfulness, are you a person that uses yoga or acupuncture or those kinds of things? I don't have any training in that myself would you refer patients to that? back to the question you had there's a lot of evidence and research there's a lot of research right now that's going into complementary therapies and acupuncture is a great one because we have a lot of data on acupuncture and the benefit from acupuncture for certain things is as good or better than what we do with modern medicine and so the struggle is sometimes is paying for some of these complementary therapies that they're not often reimbursed in our society yet and so yoga has wonderful data to support the effect of impact on chronic back pain for example and acupuncture has very very good data and so it's sometimes hard though in our society to open our mind to those types of things those are not usually they have and they're not quick fixes and we're much more in tune to the drive up window and we want something that we can get and walk away with that day and we're all victim to that too we're rushed in society these days right, yeah it's really interesting but do you think I know this isn't necessarily your field but are we making progress on Parkinson's at all that's a great question that I would say my experience of that is referenced from being an anesthesiologist and training in a large center where we did a lot of Parkinson related treatments my angle of viewing this is from the movement disorder side of implantable therapies and we've come a long ways we do deep brain stimulation as an example for these movement disorders Parkinson being one of them and so I would say over the period of time that we've treated this disease we've come a long ways but I think that's still a disease that requires a lot of funding and a lot of investigation and I'm not a Parkinson expert by any means but it's a very challenging disease to treat and it's rapidly growing I mean with men not that women can't get it but it's just a frightening trend and it always makes suspect the question of you know is the incidence of the disease increasing or are we just being better attuned to detecting it and we're becoming more diligent I know I've had patients recently who I've sent just because I've had a small concern because I know in catching a lot of these diseases early is very important and so our thresholds for evaluation for these things and our knowledge of how to detect them is becoming we're becoming more sensitive to it so that could be why it's becoming more prevalent in our society so in your new practice and I'm not a how long have you been here oh boy not quite we're just getting up on three months now from the time we actually opened the doors this maybe isn't a good question do you typically a person in your position would you see more people because of the age of them or because they've been in accidents or is it just a wide mixture of everything it can be either one I would say because of our location and where we are and our lack of access to certain other specialists such as spine surgeons I tend to see a lot of back pain which is good I think because of all the painful syndromes back pain tends to be when we're talking about what is straightforward what is not nothing in the body is ever really straightforward but when it comes to back pain we tend to fall under the spectrum of more treatable things that we have a lot of evidence for and a lot of tools in our tool bag so I see a lot of back pain I see a lot of the back pain maybe related to motor vehicle accidents people have injuries you know they're out working whether they get injured on the job or they get injured during recreation or they just happen to move wrong we just tend as we age to not be as flexible and malleable as we were when we were younger I see a lot of kind of I call it birthday related changes of the spine where just the more birthdays we have we kind of wear down and we have arthritic pain and the good news about that is that falls into that nociceptive pain pattern that's kind of a arthritis related specific mechanism of pain and that tends to be respond very well to therapy so we have great results from that I'll give you a counter example where people get pinched nerves we herniate a disc or we pinch a nerve and those sometimes will respond to conservative therapies certain injections and if not then those are the people that sometimes have to be evaluated by my colleagues the spine surgeons but it's amazing to see the different types of pain states some of the most common diseases in the United States diabetes diabetic peripheral neuropathy is a huge burden just by means of us having such a high degree of diabetes in this United States so I see a lot of that some we can help more predictably others we kind of have to chip away at it and we rely on the medical therapies which nobody likes taking medicines but unfortunately sometimes we don't have a lot of other things I don't like taking medicines and I don't like my family members to take medicines but sometimes we don't have much else to offer so when a person comes into your office what's the first thing you do then do you spend some time getting analytical data just anecdotally to see what what's happening yeah we it's important to just hear somebody's story you have to you have to talk to people and a lot of times you'll pick up small things that may not have seen relevant before but it's important to me to there has to be a personalized component of medicine still you know we're busy in the world of medicine we try to see get as many people in the door as we can so they have access to us and that is a double-edged sword because the busier you get potential for the less access you have for people but so we work in teams and what I mean by that is we have nurse practitioners and PAs and kind of advanced practice providers and wonderful nurses that all help us build a system where they have access to the physicians but the physicians have help and support and so it's my philosophy that I try my best to see every new patient that comes in as long as I'm in town but that's my personal philosophy because if somebody comes to see me I feel like they should have a conversation with me and then we come up with a plan I always use the analogy it's kind of in a way you're selling something you're offering your plan and your services to somebody by no way are they committed to your ideas every physician just like different mechanics they may have different ideas on how to fix the same problem and so you should have the ability to say yes or no and so they come in we sit down we talk you learn about the person because some people just by the way of their experiences in life they may the disease may suggest a therapy like an injection but the person may not be amenable to that may want to do that so people are people and you got to get to know you have to get to know each individual person what do you find the most frustrating thing about your specialty oh boy you know that's a great question there's a lot of frustrations you know we work real hard in medicine today to be good team players with the insurance systems and things and we we have a lot of great benefits in this country with regards to our medical care sometimes when things just aren't working you know and you have to be honest with people and say that sometimes we try things and they just don't work and that's frustrating for me and it's frustrating for the patients because sometimes you have to reach that point where you say I don't really know what else to do or I don't have anything else to offer we we need to go somewhere else and we need to find something else with all the national debate about prescription drugs yes are you seeing a change in the medical community about you know I'm sure there's a lot of times where that they've used all their options and there aren't other options you know I mean there are I've know people have been in severe accidents and you can do all the therapy you want to isn't going to help them but do you see that because of the political pressure in the news media do you see a change or there's a big change there's a big change and you know I think there's two different perspectives on this I come into it from the new and recent perspective so I think I have an advantage because I don't have a history of being at a different place in time where we didn't have the government influence pushing us one direction right now and it goes back to the evidence of things in the research what we've learned over the last 20 30 years is some of the things we've been doing may not have been as helpful to people as we thought they would be and when we say helpful what we look at is over time we say does it change the person for the better does it improve their quality of life and then we always have to ask the question is it doing any harm for them and with some of the things we do with regard specifically to opioids in some instances over the long term we've found that unfortunately we've probably been hurting a lot of people unintentionally with good intentions originally but we now have the evidence which we didn't have we have hindsight we didn't have hindsight 20 years ago we found a good product with regards to the opioids that worked well but we didn't know what the effect they would have in 20 years so I say I have a different perspective because I come out now in a world where we have the support of the government and the national institutions to limit the prescribing of some of these medicines to people if they're not appropriate and there's a lot of pressure from these regulatory agencies to monitor people and to keep doses lower than perhaps we had in the past and so if somebody in my opinion if they have are improving in their quality of life their function is maintaining we have to look at that in context to the person and ask are we really doing you a disservice in the long run and that's a hard question to answer sometimes I can imagine especially in your field where you're dealing with so much abstract information and to give credit probably the ones that bear the brunt force of it are you know everybody has access primarily to a primary care physician or a family doctor or provider and they deal with that probably more than I do just by way of access in this country and so they come to me perhaps for help and a consultation on opioid management or whether this person is appropriate or not and I don't think they get the credit of the challenge that they're seeing and because they're dealing with I deal specifically with pain they're dealing with pain and diabetes and heart disease and blood pressure so I try to support them but my main goal really is and a lot of people don't like this but my main goal is to not hurt somebody I don't want to make them better off than they were when they come in pain is frightening for people changing things is frightening and so we have that's the emotional context we have to reassure them that it will be okay and that we're going to take them in a good direction but it may be difficult we're out of time we have a topic and you can be reached through the Cayuna Regional Medical Center we have a wonderful website you can call a hospital and really you can arrange a referral through your family provider you can just come see us give us a phone call but we welcome everybody you've been watching Lakeland Currents what we're talking about what you're talking about I'm Ray Gildow so long until next time