This month Evelyn Corsini, of the PainEDU team, interviews Kenneth Curley, Chief Scientist, Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command & Associate Director for Science and Medicine, Center for Disaster and Humanitarian Assistance Medicine, Assistant Professor, Dept. of Military and Emergency Medicine and Dept. of Biomedical Informatics, Uniformed Services University of the Health Sciences. He recounts his remarkable story of maintaining a medical career with chronic pain.

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Questions

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Evelyn Corsini:

What is your pain history?

Kenneth C. Curley, MD: I am now 38 years old. In 1995 I was a Neurology resident in the U.S. Army when I developed a herniated thoracic disk between my shoulder blades which compressed my spinal cord. The injury was the result of a combination of an automobile accident and Army physical training.

I developed central pain syndrome and was treated with physical therapy, acupuncture, transcutaneous epidural neural stimulation (TENS), epidural and oral steroids, and oral pain medications. Because of increasing pain and neurologic problems I had surgery in May 1996 to remove the disk and replace it with bone graft and a titanium cage. Unfortunately, a fragment of the disk was left behind which migrated into my spinal cord and caused worse pain, among other problems.

In 1998 I had more surgery to remove the fragment. This was complex since I had developed so much internal scarring from the first surgery, parts of several ribs and part of a lung needed to be removed to reach my spine. The two previously fused vertebrae were removed and I had a larger fusion. They saved my spinal cord, but damaged the rib cage that supported my thoracic spine. Scarring in my chest from this second surgery retracted and my spine started to collapse. This was halted for the mean time with physical therapy and a CTLSO brace. I had residual central pain and developed intercostal neuralgias at eight rib levels due to surgical trauma, scarring and heterotopic bone formation. I continued to have neurogenic bladder and bowel as well. The physical changes of my spine from the surgeries then aggravated pre-existing cervical disc disease, which has left me with right arm and hand pain.

EC: What were your professional career goals?

KCC: My goal was always to be an Army clinician-scientist. When my injury and pain first occurred I was in the research part of my neurology residency and was able to continue with this because my work days could be tailored to my condition. But when I went back to a clinical setting I had trouble walking, which worsened as the day progressed, as well as the severe central pain, and could not continue in my training program. That is when I had my first surgery that was initially quite successful. About six months after the first surgery I developed increased pain and difficulty walking. After worsening over the next year the disc fragment was found and I had my second surgery. After a long period of rehabilitation I wanted to get back to practicing medicine, but could not because I was managing my pain with oral narcotics. Hospitals would not credential me because their insurance would not cover me. I also had an extremely hard time working the 80-plus hours a week of residency. My training directors tried to work with me but the hours and physical disabilities simply exacerbated the pain.

I was able to maintain my active medical license in one state by meeting with the "impaired physician" group of the local medical society, with the agreement that the military continued to closely manage my medical care and that I would only teach and do research.

EC: Were you able to continue to practice as a clinician with chronic pain?

KCC: Neurology became too active a medical specialty for me, so I decided to try to a radiology residency. Unfortunately, this program also was too active for me. (Non radiologists get the impression that radiologists sit a lot-that was my working hypothesis-and it was proven wrong quite effectively. Radiology is increasingly interventional in nature so one needs to have the same physical faculties as a surgeon at least during residency.) At one of the hospitals I was assigned to I was not allowed to even walk into the interventional radiology suite during procedures because of my use of narcotics. There was a great deal of resentment toward me from a small number of my fellow residents because of my altered work schedule, though I tended to overcompensate by doing additional work when I could. I stopped clinical practice in 2001 due to a combination of these physical and medicolegal issues. At that time the Army determined that I should be medically retired.

EC: How did you continue to use your professional training after your medical discharge from the Army?

KCC: Fortunately, I had continued to do research throughout my career and I was able to switch to the research and development side of things at the Telemedicine and Advanced Technology Research Center, Fort Detrick, MD where I am an IPA through the Henry M. Jackson Foundation for the Advancement of Military Medicine. I have since been appointed Chief Scientist. I also spend 20% of my work time teaching and supporting disaster and humanitarian assistance research programs at the Uniformed Services University of the Health Sciences (USUHS). I am able to telecommute unless I have meetings and my employers and colleagues have been immensely supportive of my physical requirements.

EC: What issues in treatment arose for you, as a patient who was also a physician?

KCC: I was very intimidating to some of my doctors. Because of my training and clinical background I often knew more than the doctor who was assigned to care for me. I was, perhaps, a very annoying patient, bringing in articles and research findings. The less experienced doctors were sometimes intimidated and would not let me participate in my care. I learned that the doctors who were more confident in their abilities were able to hear my point of view and be open to new ideas, so as my treatment progressed, it was mutually decided that I would only be assigned to senior doctors. The down side is that in the military healthcare system we often know one another and many of my physicians -even in the beginning-were friends. My friends are afraid of hurting me or of somehow worsening my condition with the interventional therapies we use-which is natural and which we discuss openly. Performing multi-level cryo-ablation and radiofrequency ablation with no normal ribs for landmarks is dangerous, so this is understandable.

As I noted, alot of the care I have needed has been invasive and often my colleagues did not want to treat me as they did not want to hurt me. My long-time family physician told me to ask them "is there any reason why you would decide to operate on a friend?" If they responded "because I would want to be sure that no mistakes are made", I'd say, OK, then help me.

EC: What is your pain management regime now?

KCC: Because of my messed up chest wall anatomy it has been hard to find each nerve that is generating pain signals. I have had cryoablation and now I have radio frequency ablation every 4 to 6 months as my nerves keep growing back. I do physical therapy daily and use narcotics, presently in patch form which I am finding less prone to side effects. I also use a TENS unit since we could not place a spinal cord stimulator due to all the scarring around my spinal cord. My pain has its ups and downs. By using a patch instead of oral medication I can start functioning earlier in the morning. I know I try to "over-compensate" as I feel I have to produce more than other people because of the leeway I am given. That's my problem, though, not my employer's. If they had a problem with my work schedule they would certainly say so.

EC: What do you want other health providers to learn from your experiences?

KCC: You're not allowed to be sick if you are a doctor. You don't see many handicapped doctors roaming the halls. There is also a perception by some in medicine that if your only problem is pain, then it's not a problem. Fortunately, this attitude is quickly fading with effective continuing medical education. Notably, the military has been more interested in preserving my career than anything I have experienced in civilian life. I say this because I have met a number of physicians and other healthcare providers with various disabilities and few of them had an easy time re-integrating after their injuries or illnesses.

I believe that pain patients need to be treated in the same comprehensive, multidisciplinary manner, involving the family, as is provided in palliative care programs. My medical problems have an impact on my wife and children. The most important thing is to recognize the psychosocial impact of chronic pain on the patient and their family in order to improve the quality of the patient's life, as well as that of their family.