Choosing a clinician

When you decide to seek professional help for a pain problem, finding a clinician that's right for you is no straightforward task. Many clinicians remain blissfully unaware of modern advancements in pain research, and what constitutes "optimal" care depends entirely on who you are. After all, your biology, psychology, and sociocultural context are unique to you.

We could spend countless days discussing all sorts of different treatment modalities and strategies, but there exist a few fundamental principles that every highly competent clinician should follow. No matter which sort of pain problem you have, these "ground rules" serve as a litmus test for telling the best apart from the rest.

Socioeconomic status and luck play an important role in determining the quality of care that is available to you. Despite any obstacles you may be facing, having access to accurate information and asking the right questions will get you on the path to success in the pursuit of health - whatever that looks like for you.

This article isn't perfect. It doesn't cover everything there is to talk about, nor could it ever hope to! People aren't perfect either, and as with most things in life there are exceptions to the rules. Still, it's my hope that you find these questions useful to reflect on your own situation. Take everything here with a pinch of salt, exercise critical thinking, and don't forget to approach this topic from a place of positivity and kindness!

1. Are they perpetuating or breaking the cycle of dependence?

Pain, especially when it persists, has a way of creeping into all corners of life. It eventually affects anything and everything, from your mood to your relationships and identity. What you decide to do about it has the potential to lead you to the light at the end of the tunnel, but it could just as well be keeping you stumbling around in the dark.

Persistent pain usually starts innocently enough. A new pain appears in a body part such as your back, knee, or shoulder. Your doctor prescribes a mild painkiller and tells you to put some heat on it and rest. But it doesn't get better. Before you know it, it's time again for your weekly massage, manipulation, infrared, acupuncture, or whatever other therapy you signed up for.

The pain diminishes for a short while, but it always comes back again, each time a little bit worse. You may be stressing about an upcoming appointment with a surgeon, all while your ability to do the things that bring you happiness slowly withers away over the months and years.

This is an example of the cycle of dependence. If you recognize yourself in this cycle, your number one priority should be to get out. Even if your pain has a good prognosis (i.e., prediction about how it will evolve), getting trapped in this cycle is something you want to avoid at all costs.

To break the cycle, your clinician should facilitate your autonomy and self-management. After all, you might only be in the clinic one hour per week - the real work lies in what you do during the remaining 167 hours. Your clinician should explain your condition in a way that makes sense to you, present your options going forward, and equip you with the tools and confidence you need to be more independent.

Simply put, your clinician's foremost goal should be to never see you again. Is there a financial incentive to bring you back recurrently? Is there any reason why they might not be actively encouraging your autonomy? The time it takes to gain control, confidence, and independence looks different for everyone, but it is the core of what your clinician should be helping you strive towards.

2. Do they place a strong emphasis on active therapies?

Active therapies are those where you play an active part. This includes anything from graded activity programs such as weightlifting to cognitive therapies like cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT). It should come as no surprise that passive therapies, predicated on the idea of receiving treatment as opposed to you putting treatment in action, are not something you should spend too much time on if your goal is to escape or avoid the cycle of dependence.

The relief offered by passive therapies such as massage, acupuncture, or ultrasound is short lived. They just cannot offer the stimulation needed to build physical and mental resilience, overcome fears, learn healthy coping strategies, regain control, and reduce pain sensitivity in the same way that active approaches to therapy do.

Some pains improve with the passage of time no matter what, but if you want to have the highest chance of succeeding at your health goals, you must recognize that there are no quick fixes. There is no pill, needle, scalpel, or laser beam which will "cure" you of your pain and disability. Recovering health and function requires a combination of intelligent decision making, patience, and persistence.

Passive therapies, invasive procedures, and continual medical management may form part of a holistic pain treatment strategy that's right for you, but they can never replace the vital role that active therapies fulfill. The key is to not give passive therapies more attention than they deserve. As soon as they take priority over therapies where you are an active participant, you've lost the game.

Does your clinician offer a pick-and-choose passive therapy buffet with discounts if you come back for more? Is their only activity-related recommendation some vague remark about "staying active?" Red flag. Not everyone needs intensive therapy to recover, but if you feel like you're struggling to cope with your pain, disability, and suffering, the bottom line is this:

Your clinician must help you make sense of your pain, navigate barriers to recovery such as unhelpful beliefs and expectations, and modify behaviors and activities to the extent necessary to reduce your sensitivity to pain and promote your long-term health and independence. None of this is going to happen with a passive approach. If they cannot or will not shift to an active-first mentality, it might be time to ask for a referral.

3. Do they inspire trust, confidence, and safety?

Pain is a protective response designed to keep your body safe from danger. Perceived threats in the environment can profoundly affect your pain experience and pain-related behaviors. It doesn't matter if the threat is actually dangerous or not - as far as your pain system is concerned, the danger is real.

Health-related decisions are some of the most important and personally relevant decisions you will ever make. Add to this the fact that your clinician is intimately involved in helping you when you're at your most vulnerable, and it's easy to see why the last thing you'd ever want is for your clinician to be perceived as a threat by your pain system. Your clinician needs to be a source of safety.

To ensure a sense of safety, it is essential to form a relationship with your clinician based on mutual trust. Trust can take time to develop, but don't disregard first impressions. Pay close attention to the feeling you walk away with after an initial consultation with a new clinician. Do they leave you feeling empowered and cared for? Or depressed and anxious?

It is well known that self-efficacy (i.e., self-belief) is one of the most important determinants of long-term health outcomes. Your clinician should be someone who inspires boundless confidence. Finding confidence in your own body when it feels like it's failing you is hard. But while you might not always believe in your ability to climb that mountain, your clinician sure as hell should.

Does your clinician pile on top of your worries? Does it feel like they aren't really listening to you? It goes without saying that a clinical environment characterized by disinterest, fearmongering, and pessimism poses a significant hurdle to you evolving in a positive direction.

4. Do they set goals and monitor progression?

The unfortunate reality is that many clinicians do not practice intelligent goal setting. Goals give direction to pain management and rehabilitation. You and your clinician should collaborate to set realistic goals, taking into account your preferences, values, and other constraints.

Once you have worked together to identify overarching goals, you must break them into smaller chunks. Staged goals are achievable in shorter timeframes and form the basis for planned progression, a crucial aspect of best-practice therapy often forgotten outside of professional sports contexts.

Gradually improving stress tolerance (both mental and physical) is one of the key ways the pain system desensitizes, but meaningful progress will only be made if the stress you are exposed to is sufficient. When you consistently apply the right kind of stress, you adapt to it and your resilience improves. A greater stimulus is then needed to keep progressing.

Planned progression means that when you reach a predetermined goal, you will progress in some way to build toward a new, previously unreachable goal. The idea is to always be providing an ideal dose of stress (neither too little nor too much) that keeps pace with your steadily increasing capacity.

Pain management without goal setting and progression is like throwing darts in a dark room and hoping to hit a bullseye. Setting realistic goals and monitoring progress is like turning on the lights. It's much easier to hit the mark when you know where to aim and how close you got on your last attempt!

The future is unpredictable, especially when it comes to something as complex as pain. Be it stalled progress or a stressful setback, plans will inevitably need to change. Your clinician should know how to react to whatever comes up during the process and help you work through or around it.

Instead of stressing about achieving a specific goal at a specific time (the result, something inherently out of your control), try to focus on what you can do to move in a positive direction (the process). What do you presently have control over that will increase your chances of future success? You and your clinician should work on fostering a process-oriented mindset.

5. Are they afraid of saying "I don't know?"

Humility is a virtue - and nowhere more so than in medicine, where we've been getting things awfully wrong since the beginning of time. Humanity today collectively understands quite a lot about pain and painful conditions thanks to the hard work of countless scientists and philosophers, but there are still many unknowns and "truths" which could turn out to be wrong.

Some clinicians give false impressions of their knowledge and abilities. One archetype to watch out for is the "certificate collector." You know, the person who has a dozen diplomas hanging on their wall from all the weekend courses they've attended. This says more about their desire to be perceived as wise than their actual knowledge.

The best clinicians set their ego aside and put YOU at the center of care. They should not be trying to show off how great they are. One of the best ways to assess this is by asking questions about your condition. If you keep asking relevant questions, eventually you should get the response, "I don't know."

If your clinician never admits fault, it might be that their pride and arrogance prevents them from conceding that they do not, in fact, know everything there is to know about your condition. Your clinician should never dismiss your questions, either. If there is something they don't know to which there's an answer, they should offer to research the topic for you or direct you to a trustworthy source.

As a rule of thumb, the more cautious your clinician is about giving absolute answers to even the simplest of questions, the better. The correct answer almost always starts with, "it depends on..." Circling back to the very beginning, pain (and health) is an infinitely nuanced field where the answers to most questions depend entirely on your personal context.