Michigan Today - January 2008

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Carmen Green: Easing the pain

by Lynne Raughley


January 15, 2008

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Carmen Green

Carmen R. Green, M.D., Associate Professor of Anesthesiology and Director of Pain Medicine Research at the U-M Health System. Photo: Martin Vloet, U-M Photo Services

Once, while giving a talk to a group of elders, Carmen R. Green, M.D.—Associate Professor of Anesthesiology and Director of Pain Medicine Research at the University of Michigan Health System—asked how many in the group experienced regular or chronic pain. All but two raised their hands; and upon further questioning, one of the two admitted, "Oh, I just pray on it." Green's eyes widen a little as she tells this story. A pain specialist, she regularly treats patients living with chronic pain at the university's Back and Pain Center, but she worries just as much about those who aren't receiving appropriate treatment.

In fact, plenty of people do more than pray when they're hurting—among patients seeking medical treatment, pain is the most common complaint—but, according to Green, primary care physicians have not really been taught how to diagnose and treat pain. In time, Green anticipates that pain management as a specialty will attract more physicians; but she also hopes that patient pain, like diabetes—which twenty years ago was largely treated by specialists—will be treated by primary care physicians, with only the complicated or intractable cases being referred out.

"I think about pain as a human rights issue, and I consider the under treatment of pain a medical error," Green says. Therefore, "How do we get people the care that they need?" It's an important question, both for individuals and for society at large—the number one reason people go on disability is pain. Pain costs the nation more than cancer and diabetes combined, and as the population ages, the problem is likely to grow. Green's goal as a physician is to enable people with chronic pain to lead a fully functioning life.

In her clinical role at the Back and Pain Center, Green works toward this goal one patient at a time. As a researcher, she widens the field of inquiry, in particular by studying disparities in treatment. "Race, gender, and ethnicity play a big role in how people get treated for pain," she says. Studies by Green and others have shown that women with metastatic disease receive less treatment for pain than men in a similar condition. Another study demonstrated that people living in minority neighborhoods—regardless of income levels—are much less likely to be able to obtain prescribed opioid medications from their local pharmacies. Yet another found that minority patients admitted to emergency rooms were less likely to receive narcotic pain killers than whites were.

These differences matter to everyone, Green points out. "Just because there are disparities doesn't mean that white men always get great care. They don't. But if we improve the care for vulnerable populations, then we can improve pain care for all."

Big factors in the diagnosis and treatment of pain are education and communication. Green uses the metaphor of the game "telephone." What did the patient say (or not say), what did the patient mean to say, and how did the doctor interpret what the patient said? Once, a patient who had participated in a study of pain management for end-stage disease sent Green a note saying, "I never thought my pain could be related to my cancer. Do you think I should talk to my doctor?"

Patients and doctors both need to be better informed about treatment options—"There's more to pain management than just the oral pain medicines," Green says. "We have a whole toolbox worth of things." Among these tools are physical therapy, psychotherapy, surgical procedures, steroid injections, and nerve blocks.

Recently Green stepped into an even wider field of inquiry. Caring for patients had always informed her clinical research; now her research guided her during a sabbatical year as a Robert Wood Johnson Health Policy Fellow—considered the premier health policy program in the country for over 30 years. These competitive fellowships, offered jointly by the Institute of Medicine and the Robert Wood Johnson Foundation, provide exceptional mid-career health professionals the opportunity to participate in health policy processes at the federal level. As a fellow, Green got to help create and influence national health care policy.

Green spent several months doing an intensive orientation where she met the people who shape health policy in the United States—at the Centers for Disease Control, at think tanks like the Urban Institute and the Heritage Foundation, in the state houses of Massachusetts and Oregon, and in the West Wing with the Bush Administration to name a few. She then spent the remainder of the year in Washington, D.C., working on Capitol Hill as a  health policy analyst.

While there, she was engaged in the behind-the-scenes work that goes into crafting policy, and helped people on both sides of the aisle understand what she knew as a pain expert. Both houses of Congress had changed control and the presidential campaigns were beginning to get underway, and Green wasn't immune to the excitement, but she was there to help make policy, not presidents, and although she interacted with many of the candidates, the real thrill for her was working toward improving people's lives and understanding the policy process.

Green says that the fellowship was a year of being uncomfortable. "You know how to take care of patients, though there are always challenges. But [working on policy] was learning a new language, a new way of thinking." And just when she'd start getting comfortable, she would be asked to do something new: write a speech, set up a hearing, or assist in drafting legislation. "It was like doing a medical residency again."

Difficult as the work could be, Green embraced it, saying, "If you always work in your comfort zone, then you have blinders on." She says that the stories of her patients prepared her. "When I went to Congress, my goal was to be a public servant," she says. She brought with her to Washington the voices of her patients—their stories about pain, about access to care (or lack thereof), about insurance nightmares—because very few of them would ever have the opportunity to speak directly to members of Congress, or White House staffers, or the people running federal agencies such as the CDC or the NIH.

After her return, Green was asked to serve on the Institute of Medicine's Board on Health Care Services—an advisory body that focuses on health care organization, quality, costs, and accessibility of care—which will enable her to stay engaged in health policy and public service. Pain is her field, but she says, "I plan to be a life long learner.  I want to think broader, and drill deeper. I look forward to continuing to go beyond my comfort level, now that I'm back."

And she knows that one person can make a difference—one person providing care, one person telling a story that changes how others think about something, one person willing to work hard and risk discomfort to ease the pain of others.

 

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Lynne Raughley

"Faculty at Work" writer Lynne Raughley lives in Ann Arbor Michigan with her husband and their three-year-old son.