Evolution of the DOC Framework

DOC beginning

The DOC (Direct your Own Care) program evolved after I discovered that, through a systematic approach that addressed all aspects of a chronic mental or physical problem, I could almost always help patients become more functional.

What surprised me most was that not only would they improve, but many also experienced almost complete recovery. Patients who had been disabled for quite some time saw a remarkable reduction in their pain, stopped taking narcotics, and returned to a nearly normal lifestyle. Often, this new lifestyle was more active and fulfilling than anything they’d known before. This level of recovery far exceeded both my patients’ and my own expectations.

 

Changing my practice

I moved to Sun Valley, ID, in 1999, during the worst phase of my own 15-year battle with chronic pain. My practice shifted from being a complex spine surgeon at a major medical center to becoming a primary care physician handling all aspects of a patient’s spine issues. There weren’t many resources available, so I coordinated most of the care.

I was experiencing multiple physical and mental symptoms, including migraine headaches, crippling anxiety, intrusive thoughts, major depression, tendinitis, insomnia, thoracic and lower back pain, tinnitus, burning in my feet, and over a dozen of the other known 33 physical symptoms of a stressed nervous system.

I had always been diligent in doing everything I could to help patients avoid surgery, but I did not understand chronic pain. I applied a surgeon’s mindset to non-operative care. No matter what aspect of the problem arose, my goal was to solve it—quickly. Over time, a predictable pattern and structure emerged. My practice shifted from being a complex spine surgeon at a major medical center to acting as a primary care physician, managing all aspects of a patient’s spine issues. With limited resources, I coordinated most of the care myself. After personally trying this approach, I also began to heal. When I left Sun Valley to return to Seattle in 2003, I had largely broken free from the grip of chronic pain.

The DOC project

 Here is the core of the DOC project:

• Sleep
• Effectively processing stress
• Physical conditioning
• Medication management
• Life outlook
• Education about the nature of chronic pain and the principles behind the solutions
• Family dynamics

 

• Addressing sleep was the first step that clearly made a significant difference was a Back then, only a small percentage of physicians dealt with sleep issues. I took an aggressive approach and would start with simple “sleep hygiene” issues. But if a patient wasn’t getting enough sleep within a couple of weeks, I would try different combinations of sleep medications. Most people responded within six to eight weeks. A significant percentage of patients experienced a dramatic improvement in their pain. It wasn’t until years later that I read a major paper showing that lack of sleep could induce chronic pain.¹

• Dealing with stress was the next concept that emerged, which I discovered through expressive writing. Since I did not have access to a pain psychologist, I recommended that patients read David Burn’s book, Feeling Good. Many refused to read it, or they would read it but not engage in the writing exercises that he strongly recommended. The book presents a program of self-directed cognitive behavioral therapy. His research showed that 85% of people would respond with an improvement in mood. I liked using the book because patients could immediately engage with it, whereas it usually took weeks or months to see a pain psychologist. Then I noticed that only those who did the recommended writing responded.

• The physical conditioning component of the DOC process was not new to me, and I had the privilege of working with excellent physical therapists right next to my office. I was introduced to a high standard of evaluation and care. We were also near an athletic club, and incorporating resistance training into the program quickly became a routine. Weight training builds strength, which reduces stress on the body. It also triggers the release of hormones that boost your sense of well-being. Additionally, it appears to have a neurological element in that you are proactive, taking control instead of being at the mercy of your pain.

• Medications are a crucial part of healing, although most people eventually stop taking them as their sleep and pain improve. My approach was the opposite of typical practice. I believed that people needed some relief from symptoms to participate effectively in the rest of the DOC process. I would keep patients on their initial medication doses, including narcotics. All medication discussions were conducted face-to-face. The aim was to reduce medication gradually, but the patient always had the final say on how fast this would happen. What I didn’t realize at the time was that anxiety is often equivalent to pain, and fighting over medications can be counterproductive. When the patient was in control, they had a sense of control—an antidote to anxiety—and I rarely encountered issues with patients stopping their medications. In fact, as pain decreased, side effects increased, and patients were eager to stop taking them. I also understood that no one truly wants to be dependent on meds. The only requirement was that they had to stay actively engaged in the other aspects of the DOC process, although I didn’t have a name for it back then.

• Life outlook turns out to be perhaps the most important aspect of healing, even though it started by chance. I had been working hard with a middle-aged woman to help her manage her pain and return to work. It was somewhat challenging, but she gradually overcame her chronic pain. When it was time for her to go back, she told me she never actually intended to return to work. I became upset and realized I had never set clear goals with her. I started asking every patient specifically why they were seeing me and what they wanted to achieve. What became clear is that goal setting is a key part of stimulating neuroplasticity. Your brain develops where you focus your attention. It’s similar to learning a new language—you have to decide what you want your life to look like, what you want in it, and then pursue it. Otherwise, you remain focused on the problem, not the solution. An important related aspect is forgiveness—you can’t move forward until you learn to let go.

 

• Eductation and understanding the nature of a problem is crucial before solving it. This is especially true for chronic pain because it is very complicated and each person is different. The usual way to handle chronic pain is to manage it, not fix it. Simple treatments are often used just for symptoms and do not target the root cause of a fired-up nervous system and constant high stress chemicals. My book, Back in Control: A Surgeon’s Roadmap Out of Chronic Pain, arose from my need to explain the problem to my patients. Its main purpose is to give a context of care, and it’s helpful to understand why and how different treatments work – or don’t.

• The final aspect of family dynamics that emerged during my years of practice in Seattle involved understanding how family interactions influence chronic pain. We recognized that chronic pain exerts a severe toll on families. It became evident that a patient might participate in many parts of the DOC process, but family dynamics could undermine all efforts. Conversely, by addressing how families interact around pain, patients often found significant healing. We started establishing household rules related to pain. The main rule was that the patient could never discuss their pain with anyone, especially family members. The corollary was to avoid complaining, giving unsolicited advice, or criticizing. Essentially, just be kind.

The DOC process offers a framework for you to organize your thoughts about your pain, identify your specific issues, and follow your own path. I have seen hundreds of patients break free from the deep abyss of pain. There is no clear beginning or end, as you will learn tools that help you handle daily stresses. As your anxiety decreases, pain lessens, and creativity and joy come back. Helping people move out of pain has become the most rewarding and enjoyable part of my career.

One story

A few years ago, I started working with a woman in her 30s who had been experiencing severe anxiety since she was ten and had developed widespread pain throughout her body. She kept pushing forward despite everything. She was a talented musician but had to put her music on hold because of her pain. Her life gradually became smaller as she tried different treatments that didn’t work.

She started working with me on the DOC process, beginning with expressive writing and exploring pain. Sleep was a major issue and took months to control. However, a few weeks after she started writing, she noticed improvements in her anxiety. She also had access to a somatic therapist who helped her relax. Over six months, her anxiety decreased significantly, her pain disappeared, she stopped all medications, and she re-engaged with her music career. She can’t put into words how happy she is to be free from chronic pain and anxiety and to be thriving.

References

1. Agmon, M and G Armon. “Increased insomnia symptoms predict the onset of back pain among employed adults.” PLoS ONE (2014); 9(8): e103591. doi: 10.1371/journal.pone.0103591.