When Someone Says, "My Stomach Hurts," Stanford Listens
New GI Pain Program Pairs Experts for Coordinated, Collaborative Care
Lisa Korstad is just one of tens of millions diagnosed with a gastrointestinal disorder every year. In her case, the muscles of her stomach slowed down so much that eating anything meant hours of pain. Not just a garden variety of pain, this was a pain that doubled her over; its unpleasant sidekicks were vomiting and exhaustion. Around her abdomen it traveled, belting her body in an agonizing sensation.
"I'd never had a pain like that," she said. "It was random and completely unbearable. It happened day or night and it didn't seem to relate to anything."
Korstad became one of the first patients treated at Stanford Hospital & Clinics' new Gastrointestinal (GI) Pain Program, a recently inaugurated, multi-disciplinary treatment approach: Stanford specialists in gastrointestinal disorders figured out what was wrong, then joined pain experts from the Stanford Pain Management Center to find solutions to her condition.
It's the best of both worlds for patients, said Ravi Prasad, PhD, Director of Stanford's Comprehensive Interdisciplinary Pain Program. "Both sets of specialists, in pain management and in GI, can share and apply their intimate knowledge of their fields in a formal structure," he said. "We have a multidisciplinary conference about each patient; we all talk about the case together; we reach a consensus. It's a much richer experience and result than just reading each other's notes in the electronic medical record."
Presenting a patient with that kind of unity of thought, Prasad said, is a symbol of care that is truly compassionate. "When you don't feel empathy from your treatment team that adds to the stress you feel," he said, "and that activates your sympathetic nervous system in a way that just adds to the pain you feel."
The program's coordination of care to automatically include pain treatment is exactly in line with the conclusions of a recently released National Academies' Institute of Medicine study.
The report's findings showed that pain is a major health problem in the US, with more than 100 million Americans suffering from chronic pain. For more people to receive effective treatment for that pain, the report concluded, with more work needed to educate physicians about pain, more research to raise understanding of its mechanisms and more treatment based in multidisciplinary care plans.
Stanford's GI Pain Program responds to those challenges detailed in the report, and to others. Without care coordination between specialists, Prasad said, patients "can feel lost in the system. People were getting helped, but that lack of communication was distressing. Now, when they know that their providers are talking with each other, they're a lot more satisfied. You can feel like you're getting the runaround when you're shuttled back and forth."
Anyone who has ever received medical treatment anywhere has experienced that feeling, in one way or another. Prasad looked at the treatment system as it was and saw that patients could be better served if that system's various parts could communicate more easily and more collaboratively, by design.
He started with GI. "We would have patients come in with GI pain, and, in a lot of cases, they hadn't seen a GI physician, or had in the distant past," he said. For pain specialists to do their best work, they needed more information, Prasad said. "We needed more from GI."
The scope of GI pain is broad: GI disorders are among the most common type of complaint made to physicians. Irritable bowel syndrome has been estimated to affect 40 million Americans. The gastrointestinal (GI) system is, in fact, a finely-balanced interaction between muscle and biochemistry, with multiple parts, an average of 20 feet in length. GI specialists sometimes say the gut is a second brain. What they're talking about is the enteric nervous system that, from top to bottom, is dense with as many neurons as the spinal cord. And when something goes wrong in that system, its nerves react.
"Most GI conditions cause pain," said Linda Nguyen, MD, Korstad's GI physician. Nguyen is the director of GI Motility and Neurogastroenterology in Stanford’s Division of Gastroenterology. Some of her research focuses on GI pain. Others in her group are exploring the nature of pain from chronic pancreatitis, irritable bowel syndrome and functional dyspepsia.
Stanford's GI pain program is not limited to a specific diagnosis, Prasad said. "Part of the value in our collaboration with GI physicians is that we pain specialists get to learn more about GI disorders and new possibilities for patients for whom GI physicians have done all they can,” Prasad said, "those people who might be thinking, 'It will never get better' or 'It's all in my head.' We want to offer them a pathway to help them recapture quality of life."
Some people may feel that going to a pain specialist is like giving up, that a pain specialist will automatically prescribe narcotics," Nguyen said. "What we in GI do with the pain group is try very hard not to do narcotics, to try other things."
In fact, Prasad said, contemporary pain care, particularly that offered at the Stanford Pain Management Center, integrates various approaches: non-narcotic solutions (mind-body therapies, including cognitive behavior therapy, hypnosis and meditation) to address the psychological component of pain; physical rehabilitation, pharmacology and new procedural treatments. Those new treatments are often focused controlling activity in very specific areas of the nervous system.
Nguyen hopes that this formal collaboration will help "get across the idea to GI physicians is that pain is a complex system, and that the longer someone has pain, the harder it is to control and the more psychological impact there will be," she said. "For example, if you look at patients who come to me with chronic GI pain, half of them will also be experiencing anxiety and depression because of that pain. And we know that very common disorders like irritable bowel syndrome are made worse by that anxiety and depression."
Knowing what all the options are means Nguyen can get closer to her goal of patient care. "The most rewarding part for me," she said, "is when someone comes in like a train wreck and leaves, maybe not perfect, but at least better."
She called the Stanford GI pain program unique, and something that has enhanced her ability to make positive changes in her patients' lives. "I've worked elsewhere and taken care of the same type of patient, but with the interaction with the Pain Management Center, I don't feel as though I'm alone."
The collaborative structure will not end with GI patients, Prasad said. "We want to build more pathways between us and other fields where pain can be difficult, such as gynecology and urology. A lot of things we do in pain management are somewhat universal."
Korstad's condition has not gone away--unfortunately, treatments to cure it are few. But her pain is less. She's been treated with a series of injections that have successfully blocked activity in certain nerve roots. "They've worked amazingly for my pain," she said. "My doctors told me they were like a control-alt-delete to calm things down."
About Stanford Health Care
Stanford Health Care, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Health Care is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Health Care: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.