Reprinted with Permission
In the years since pain management first emerged as a discipline, practitioners have experienced dramatic changes in the field. In this article, three leading pain management physiciansAlbert Ray, MD, Daniel Bennett, MD, and John Brendel, MDdiscuss the evolution they have witnessed, the steps they have taken to address these changes, and how the BBHI 2 (Brief Battery for Health Improvement 2) test has helped them improve patient care.
Since Albert Ray, MD, started practicing in 1973, he’s seen major changes in the field of pain management. Board-certified in both pain medicine and psychiatry, Ray offers a multi-dimensional perspective.
“In the last thirty years, the science of pain medicine has grown tremendously,” says Ray. “We’ve gained a great body of knowledge and we’ve seen an enormous increase in the technology available for treatment, enabling us to treat people much more effectively and efficiently.”
“But along with this growth has come a huge increase in the cost of procedures,” Ray points out. “So, it’s become very important to distinguish which patients really will benefit from specific treatments and to be able to document this for insurance companies. In this regard, the BBHI 2 test provides a different type of scientific advance, addressing the need for an objective tool that can help provide evidence of treatment effectiveness.”
Ray administers the BBHI 2 test to every patient as a screener at intake and also uses it to track progress. “A significant feature of the BBHI 2 test is that it is normed on pain patients, making it a very accurate tool for assessing the patient’s pain experience,” he says. “Tests normed on a non-pain population don’t take into account that pain patients are prone to depression.” He also appreciates that the test is well-designed for tracking outcomes, enabling practitioners to see how current results compare to the patient’s previous BBHI 2 results.
And, Ray likes the fact that the test assesses pain in 10 specific areas of the body. “If a patient reports that his/her functioning level has gone way up but his/her pain scale still reads high, the test results can help you solve this riddle,” explains Ray. “They might help you identify, for example, that the neck pain is better, and the back pain is better, but the knee still hurts.”
While Ray practices in a multidisciplinary clinic, he notes some distinct benefits of the BBHI 2 test for sole practitioners. “For doctors who don’t have access to an interdisciplinary group of colleagues to help brainstorm the source of the patient’s problem, the BBHI 2 test provides a great tool to help quickly identify patients who need psychological intervention,” he says.
To illustrate the importance of addressing underlying psychological factors, Ray cites the case of a 39-year-old patient referred to his clinic for an interthecal pump. Having been out of work for 10 years, the patient had undergone nine surgeries on his lower back, plus epidurals, facet blocks, and implantation of a spinal cord stimulator. “More than $100,000 had been spent on care, all conducted by an excellent, dedicated physician doing everything he could to help the manyet the pain was never resolved,” he says.
At intake, Ray administered the BBHI 2 test, which revealed psychological problems. Exploring further in his interview with the patient, Ray discovered that the man had been severely abused from early childhood through adolescence. “The experience was so far in his past, he didn’t consciously think of it as having any connection to his pain.” The patient was seen by the clinic’s psychologist to treat the memory of the trauma. After three sessions, his pain was 90% improved.
“Pain isn’t a one-dimensional experience,” says Ray. “Our goal is not only to diagnose patients, but to identify obstacles that may prevent them from getting better. With the BBHI 2 test, we now have a scientific way to do that.”
Daniel Bennett, MD, an interventional spine/interventional pain physician and co-founder of the Integrative Treatment Center in Denver, says, “I’ve seen a significant evolution in pain management over the years. In the past, each practitioner operated within a specific discipline and the patient moved from one to anotherthe interventionist, the physiologist, the chiropractor, the psychiatristseeking a solution. In many cases, the patient never found resolution to the pain. Gradually, practitioners came to realize that they needed to look at the whole picture, not just one piece of it, to discern what makes a patient’s pathology unique. Now, with an integrated approach, pain practitioners are experiencing a much better rate of success.”
Bennett also points out that even after practitioners began to recognize the importance of understanding the patient’s cognitive/behavioral environment, there wasn’t an effective tool for measuring these factors for pain patients. “Pain is a very subjective experience. What we needed was a tool to compare data with the protocol, just as we do in medicine,” he says. “The BBHI 2 test has given us that tool.”
Bennett administers the BBHI 2 test to every patient as a screener at intake, and at every fifth visit thereafter. If the BBHI 2 test raises flags, the patient receives the more comprehensive BHI 2 test and then is referred for psychological therapy.
When Bennett was first introduced to the BBHI 2 instrument by test authors Mark Disorbio, EdD, and Daniel Bruns, PsyD, he was not an instant convert. “I thought the test was too short to provide any meaningful data,” says Bennett. “Even though I knew that it was based on the same validation studies as the longer BHI 2 test, I was a skeptic. But when we started using the BBHI 2 test and I saw the detail it provided, I realized what a comprehensive tool it was.”
To demonstrate how the BBHI 2 test has helped him avoid diagnostic errors, Bennett relates the story of a very high-functioning patient with reflex sympathetic dystrophy of the upper extremity. Bennett considered implanting a spinal cord stimulator and explained the procedure to the patient. However, because the patient’s BBHI 2 results showed elevated anxiety, depression and somatization scores, he referred him to a consulting psychologist before proceeding further. In his sessions with the patient, the psychologist discovered that the man had an obsessive/compulsive disorder in regard to electricity and had spent four sleepless nights after hearing about the implant procedure. Because the patient was high-functioning, he had been able to effectively hide his concerns from Bennett and his team. The care team then determined that medication therapy combined with cognitive behavioral therapy would be the best course of treatment. “If we had installed the stimulator,” says Bennett, “we probably would have made him much worse.”
Bennett finds that presenting the BBHI 2 test’s normed results has made it easier to receive insurance payment authorization. He also notes that even in cases when HMOs have refused payment for the BBHI 2 instrument, the test is so modestly priced that it is still well worth using. And, he advises colleagues to consider the big picture economically. “You are going to have costs one way or another. Do you want to pay your staff for the time consumed by a problem patient for months or years, or do you want to use a low-cost, efficient test to help catch potential problems at the start?”
As medical director at the Interventional Pain Management Center in Rice Lake, Wisconsin, John Brendel, MD, has felt the crunch of increasingly demanding medical economics. “The number of patients has increased and so has the cost of run-ning the practice,” he says, “while reimbursements have steadily decreased. Every year, there’s greater pressure to do cost-effective medicine.”
The BBHI 2 test, says Brendel, has helped him meet these demands. “This test provides an easy-to-use tool to help me sort out within 10 minutes people who may need psychological treatmentbefore running expensive diagnostic tests,” he says. “It’s a very concise instrument that can be used both for screening and follow-up. In a busy practice, it’s great to have a tool that does so much in so little time.”
Working with a largely rural population, Brendel considers the BBHI 2 test especially helpful in communicating with his patients and their families. “These folks tend to have a strong bias against psychiatric treatment. If you simply advise them to see a psychiatrist, they are likely to bolt out of the office,” he says. “With the BBHI 2 test, I can show them how psychological factors are tied in with their physical pain, so that they can accept the information more easily. And, I’ve often seen family members breathe a sigh of relief in having their experience of the patientsuch as the crabbiness often exhibited by chronic pain patientsbacked up by the test results.”
The Story’s In The Detail
Brendel appreciates the detail provided by the BBHI 2 instrument. “When people don’t feel well, they tend to dwell on the negative. It’s amazing how many times a patient’s pain score may only improve by 10 or 15%, yet a review of other BBHI 2 scores may show dramatic improvement in many areas, such as anxiety level, how patients perceive their pain in relation to day-to-day functional abilities, and to what degree patients think they are going to be disabled. You don’t get this level of definition with any other test.”
Brendel finds these specifics particularly useful with workers compensation cases. He tells of a construction worker whose test results showed a pain score of 3. “With such a low pain score, you would assume the patient would be ready to go back to work.” Yet the patient’s functional complaint score was in the 98th percentile. “What I realized with the help of the BBHI 2 results was that this individual wanted to be 100% pain-free before he returned to work. It’s not easy to obtain this kind of insight through a physical examination and patient history review.”
Following patient progress with the BBHI 2 test’s computer-generated reports has made Brendel’s job easier, he says. Test results are stored automatically, and he enters codes for all procedures and for each test administration. “When I want a progress report, the computer does the work, not me,” he says. “That’s especially helpful in meeting insurance requirements. I can readily provide evidence that we’re tracking all of the indices measured by the BBHI 2 test.”
He also notes that using the test as an outcomes measure can help patients adjust their perspective. “When there are improvements, I can show them the specifics on an easy-to-read graph,” he says. “I might point out, for example, that not only is their pain score improving, but they’re less depressed, and their outlook on life is better. Giving them the details can help patients focus on their progress rather than on the problem.”
Over the last 30 years, the field of pain medicine has made remarkable gains in knowledge and technological aids, and in practitioners’ understanding of the efficacy of an integrated approach to care. At the same time, there have been significant changes in medical economics and insurance requirements. As these three physicians have experienced, having the right tools can make a real difference in practitioners’ ability to meet these challenges effectively so that they can continue to provide excellent patient care.
John K. Brendel, MD received his MD from the University of Wisconsin. Since 1993, he has served as medical director of Interventional Pain Management Clinic at Lakeview Medical Center in Rice Lake, Wisconsin. The clinic focuses on minimally invasive diagnosis and treatment of spine mediated pain in a private practice setting.
Daniel S. Bennett, MD received his MD from the University of Miami and completed post-doctoral training in anesthesiology and interventional pain medicine. In 1996, he co-founded Integrative Treatment Center, a multidisciplinary spine/pain center in Denver, Colorado. Bennett also helped established The National Pain Foundation, dedicated to the education and betterment of people who live with pain
Albert Ray, MD received his BS from Rutgers University and his MD from the New Jersey College of Medicine. He is board-certified in both pain medicine and psychiatry. In addition to operating an interdisciplinary private practice, he serves as medical director at Pain Medicine Solutions in Miami, Florida. Ray also is a clinical associate professor at the University of Miami School of Medicine.
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