Several years before Bonnie’s dramatic illness, in the early 1980s, I injured my back, rupturing two discs, while playing squash. A chronic condition began that haunts me to the present. The discs were treated first with two levels of chymopapain, an agent long since discredited as an approach to disc rupture. In the end, I required complex and repeated back surgery, largely because of the use of this unfortunate agent.
Following the surgery, I had many months of severe back pain, eventually diagnosed as originating in destabilized facet joints. In desperation, I travelled to Cincinnati, where a special clinic provided what was then new, radiofrequency coagulation of the nerve endings of the facet joints from high in the lumbar region down to the sacrum, a procedure unavailable in Canada at the time. As in Bonnie’s case, the cost was completely covered by Canadian Medicare.
The facet pain disappeared. But a new grinding pain was uncovered. Eventually, MRI studies showed that the end plates of the fifth lumbar and sacral vertebrae had eroded. It looked like the area had been eaten away, resembling Swiss cheese. The reason for this is unknown, but it was hypothesized that after the chymopapain got through “eating” away the offending discs, it continued on to eat the vertebral bodies. To escape from this pain, I was placed in a removable body cast from the thorax to low on my hips. In that state, for six months, I continued to practise and, within limits, even attend births.
In the end, finding a way to get out of the body cast was a major issue, finally aided by acupuncture delivered by our friend Bernard. Once I had escaped the cast, by word of mouth I collected a number of chronic back pain patients in my practice.
One memorable referral came via Bonnie, for an editor at the NFB. I made a house call to her Montreal East End apartment. Always looking for teaching opportunities, I brought along a young medical student, Vincent Lacroix, who was one of my advisees. The scene was stunning. The patient was on the first floor, where she had been for almost a year. Her husband and child lived on the floor above, the two floors connected by a spiral staircase. The patient had been suffering from severe back pain ever since the birth of her child, now a little more than a year old.
Mothering the child was impossible. The patient had a level of stiffness that was unique in its severity. She was in constant pain, immobile, depressed, suicidal and certain that she would never recover. The medical student became fully engaged with the family. In fact, he became a kind of godfather to the child.
We employed home physical therapy, massage, acupuncture and psychotherapy. As well, I used antidepressants and pain-relieving drugs. Who cares which treatment worked best? It was an emergency that required pulling out all the stops. Within a few weeks, there was major improvement, and within six months, the patient was mothering her child and back at work. The medical student went on to become a family practice resident and ultimately head of sports medicine at McGill.
Without telling me what she was going to do, the patient wound up on a popular CBC Radio talk show, where she told her story in four-part harmony, naming me and the medical student as her “saviours.” The floodgates opened at the Herzl Family Practice Centre. A huge number of patients were calling, asking for appointments with me. Of course, all had severe back pain that interfered with their lives and employment. I could not handle the volume and had to develop a strategy. I instructed my secretary to say that my practice was full, but if the patients were willing to be seen by a first-year family practice resident (emphasize first-year), I would work with the resident in the provision of care. This screening manoeuvre reduced the number of patients to about twenty, all extremely pain-ridden and desperate.
I met with the residents and reassured them that each would receive only one such patient. I instructed them to begin each encounter with the following:
After this opening, almost all the patients cried. At last, someone was listening. By this time, much of the pain was at least partially in their heads, in the sense that chronic pain always has a major psychological component. Nevertheless, the patients did not want to hear about their psychological state. Most patients come to a family doctor because they have conceptualized their pain as somatic, or physical, rather than psychological. It’s the nature of our role.
After starting with those two opening statements, the residents could hardly believe their success with the patients. For all, we used multiple modalities, all at the same time. To everyone’s surprise, almost all twenty patients improved in a major way, sixteen of the twenty returned to work and all but one made major improvements in their quality of life. Two patients were very special cases, which I took on myself.
Mr. D. was a merchant seaman who was crushed against the side of the lifeboat and the hull of the ship in a Halifax lifeboat drill. He had been attempting for years to receive compensation from the company. He had been labelled a malingerer and even spent some time at the Allan Memorial psychiatric hospital in Montreal. I focused only on his somatic complaints. Central to my treatments were injections of the painful areas in his lower back.
At first, I used local anaesthetic agents with good success. Later, I used saline solutions, and then distilled water. Whatever I did worked, such that his visits were reduced to every three months. Usually, he would arrive bent over in apparent severe pain. He would leave upright and smiling. It was clear that there was a major psychological component to his pain.
One day, I received a phone call from his lawyer, who told me that I would soon receive a subpoena to appear in court. Why? Because the lawyer would use me to show that it was not in the patient’s head after all. It was in his back, illustrated by my success in using physical not psychological modalities.
I explained that I would not be a good witness for his case, as to a large extent it was indeed in his head, but as the patient conceptualized his pain as physical, I treated the physical. The lawyer did not further engage me.
A few weeks before Bonnie and I were to leave Montreal for a new life in Vancouver, I was shopping in a nearby supermarket, where I clearly recognized my merchant seaman patient. He was smiling and chatting with people. His gait was fluid. He was upright and apparently healthy and pain free. I followed him surreptitiously as he did his shopping. No question, it was my patient. Should I confront him now or on his next visit? Do nothing? A week or so later, my patient appeared in the office in his usual pained and bent-over state. I decided that I had to say something.
“I can’t help noting that I saw you in a supermarket and I was struck by how normal you looked. How is it that you looked so good then and you look so bad now?”
Smiling, he said, “Dr. Klein, I don’t come to see you when I am feeling well.”
Ms. M. was a patient who presented with an unusual bent-over and twisted posture.
I asked, “Tell me, why are you walking like that?” to which she responded, “Like what?”
This is what Freud called La belle indifférence. It was classic for a conversion reaction, patients who convert their psychological symptoms into physical, often very bizarre, symptoms. A family practitioner can go their entire practice life and never see a conversion reaction; it is even very rare in psychiatric practice.
The patient was the sister of two of my patients and the daughter of an elderly man also in the practice. As this was such a complex psychiatric problem, I consulted Dr. Laurence Kirmayer, a friend and psychiatrist who was also an anthropologist and expert in transcultural psychiatry. We developed a program to delve deeply into the issues in the patient’s life. We learned that she had suffered abuse at the hands of her father, my own patient!
Family practice could not be more complicated. Whole-family care can at times be both a blessing and a curse. Two of the three daughters had suffered the abuse, and the third was also my patient.
As we listened to her story, the abnormal posture seemed to unwind, and within several weeks she was standing erect, stating that a great weight had been lifted from her shoulders. Maintenance visits consolidated the gains, and she went back to work.
But what to do about the father? It turned out he had a serious cancer. Nevertheless, the daughters decided to confront their father and their mother, who they felt had failed to protect them from their abusing father. In a dramatic family conference, the daughters told their father what he had done to them and the profound effect his behaviour had on their lives. They were also able to express their confusion as to why their mother had not protected them. As their father slowly declined, he was able to acknowledge what he had done, and he deeply apologized for their pain and life disruption, leading to further improvement in the daughters’ health. Just prior to his death, the daughters forgave him.