Reprinted with Permission
Nationally-recognized anesthesiologists Bhupinder S. Saini, MD, and Nileshkumar Patel, MD, welcome a wide range of pain patients to their clinic, Advanced Pain Management, in Milwaukee, Wisconsin. Dr. Saini established his practice ten years ago and was joined by Dr. Patel at the clinic in 1998. Prior to joining Advanced Pain Management, Dr. Patel was a Clinical Professor of Anesthesiology with a pain management fellowship at the Cleveland Clinic Foundation.
According to the clinic’s Executive Director, Vishal Lal, MBA, CPA, the doctors and their staff see approximately 25-30 patients each day at hospitals throughout Milwaukee. The majority of patients suffer from low back pain and headaches, receive treatment over a period of 2-3 months and have been referred by a physician.
In addition to their state-of-the-art procedures, Drs. Saini and Patel share a multidisciplinary approach to patient care. They work closely with patients and consult with other specialists to determine the underlying cause of the problem and the most complete course of care. Their approach may involve one or more options ranging from medication and surgery to physical and occupational therapy, psychotherapy and exercise.
A key component of their multidisciplinary approach is the P-3 (Pain Patient Profile) test by C. David Tollison, PhD, and Jerry C. Langley, DC. Published by Pearson Assessments, the P-3 test helps screen for the presence of depression, anxiety and somatizationthe factors most frequently associated with chronic pain.
Dr. Patel first became aware of the P-3 test four or five years ago while practicing at the Cleveland Clinic. He and his colleagues looked at nearly 70 instruments that assessed concurrent psychopathology in pain clinic patients who were not improving.
“We really liked the MMPI-2 test, the Pain Inventory, the P-3 test and the BHI (Battery for Health Improvement) test,” he explains. “Many of the others, however, didn’t have a reference pain population. Instead, they compared everything to inpatient or outpatient psychiatric patients. That wasn’t what I wanted. I wanted to know if my patients were more depressed, more anxious and had more somatization than the average pain patient.”
Currently the P-3 test is the only test Dr. Patel uses unless other factors indicate that the MMPI-2 test, the Pain Inventory or the BHI test may be appropriate.
“I don’t give the test to patients with obvious disk herniations, acute pain after an injury or cancer pain,” he explained. “And I also don’t routinely use it with elderly patients. But for pretty much any chronic pain patient, using the P-3 test is justified.”
Over the course of his use of the P-3 test, Dr. Patel has found several key features that help differentiate the test from others. These include:
• Ease of use.
“The patient completes the questions as part of a normal history. It’s so simple--I can feed the completed questionnaire into the computer immediately and by the time I see the patient, I have a good idea of his or her psychological make-up.”
• Understandable results.
“P-3 data is presented in a clear, tabulated form in a black-and-white chart that is easy for me and for the patient to digest.”
• Clear recommendations.
“The frequent recommendations are very easy to read and give to the patient and referring physician. Most of the patients are very grateful to know that there are other factors that can be addressed that may help them.”
According to Dr. Patel, the surgeons from whom he receives referrals value the information that the P-3 test can provide prior to surgery.
Citing a recent study,* Dr. Patel notes that patients with somatization are more likely to have false positive discography. If discogram results are misinterpreted, the surgical outcomes with fusion will also be poor. In populations with concurrent psychosocial barriers, he continues, the surgical outcomes from back surgeries are poor.
“Thus it is important to identify and address these issues prior to laminectomy, discectomy and fusion. Our referring surgeons are appreciative of the additional information since psychological issues do affect the results of diagnostic injections and outcomes from surgical treatments.”
Dr. Patel cites several benefits to his practice as a result of using the P-3 test.
“First, it enables me to identify psychosocial factors that I would otherwise have missed, especially depression and anxiety.
“The results also enable me to take better care of my patients. For example, with a workers compensation patient who has been mislabeled as malingering, P-3 results allow me to say in a reliable and objective way that the patient is being honest.
“The P-3 also enables me to make more efficient use of concurrent specialties. This helps to reinforce the fact that we are not just looking at the physical aspects and that we are concerned about the whole patientmind, body and spirit.
“In that respect, the P-3 test helps payers, patients and the referring physicians to have additional confidence in us.
Overall, Dr. Patel agrees that the biggest obstacle to accepting the P-3 test is that many physicians “feel that they can predict concurrent psychopathology simply by talking to the patient. The reality is most of us don’t have the time to go into the psychological issues and we’re poor predictors because we’re not trained for it.”
“Yet the patient must be seen as a whole,” he concludes, “and until you address the psychological issues, it is unlikely you will have any long-term improvement in your patients. “
*O’Neill, Conor, Derby, Rick and Kenderes, Laura. (1999). Precision Injection Techniques for Diagnosis and Treatment of Lumbar Disc Disease. Seminars in Spine Surgery, 11, #2, 104-118
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