Having led innovative interdisciplinary clinics focused on treating pain and preserving wellness for more than 40 years, Dr. Angela Mailis believes interprofessional collaboration is the best way to deliver pain management. In this part one episode of a two-part series we chat with Dr. Mailis, a physiatrist, specialist pain physician, clinical professor, and leading authority on the diagnosis and management of chronic pain. She’s joined by Dr. Demetry Assimakopoulos, OCA’s 2022 Dr. Michael Brickman Heart and Hands Award winner, who has worked collaboratively with Dr. Mailis since 2015. Together, they share their best practice approaches to pain management. Dr. Mailis also outlines her introduction to chiropractic care, the role chiropractors play in her clinic and what she seeks in the DCs she hires.
Having led innovative interdisciplinary clinics focused on treating pain and preserving wellness for more than 40 years, Dr. Angela Mailis believes interprofessional collaboration is the best way to deliver pain management. In this part one episode of a two-part series we chat with Dr. Mailis, a physiatrist, specialist pain physician, clinical professor, and leading authority on the diagnosis and management of chronic pain. She’s joined by Dr. Demetry Assimakopoulos, OCA’s 2022 Dr. Michael Brickman Heart and Hands Award winner, who has worked collaboratively with Dr. Mailis since 2015. Together, they share their best practice approaches to pain management. Dr. Mailis also outlines her introduction to chiropractic care, the role chiropractors play in her clinic and what she seeks in the DCs she hires.
Topics Covered:
Key Links to References/Resources Discussed:
About Dr. Angela Mailis:
Dr. Mailis is a specialist in Physical Medicine and Rehabilitation, has a Master's Degree from the Institute of Medical Science, University of Toronto, has served as Senior Investigator with the Krembil Neuroscience Centre/ University Health Network up to 2015, and became a full professor at the Department of Medicine, University of Toronto in 2005. She is a member of the School of Graduate Studies at the University of Toronto and is currently an Adjunct Clinical Professor, Faculty of Medicine, University of Toronto, Division of Physical Medicine. Since she started practising in 1982, her clinical and research interests focus on the diagnosis and management of chronic pain.
Dr. Mailis founded and directed the Comprehensive Pain Program of the Toronto Western Hospital, University Health Network (1982-2015) and continues to be a full member of the Division of Physical Medicine and Consultant at the University Health Network Comprehensive Integrated Pain Program.
She is a national Evidence-Based Guideline developer, Chair of ACTION Ontario since 2005 (a not-for-profit organization for education and advocacy for patients with neuropathic pain), and a highly respected medicolegal expert in matters of chronic pain across the country.
Dr. Mailis has published more than 130 peer-reviewed scientific papers; credited with “first publications in the world” on a number of pain conditions; recognized as an international expert on specific specialty areas; has trained numerous students and international trainees; and has lectured around the world on matters of chronic pain.
She is also a Popular Science writer (has written BEYOND PAIN published in the USA and Canada) and CARP-Advocacy electronic newsletter contributor monthly (2009-2014), while her new book “Smart, Successful and Abused” will be published in September 2019 by Sutherland House. She has appeared on numerous media outlets (print, radio, TV) over the years promoting understanding and advocacy on chronic pain.
She has participated in several hospital and university committees and serves as an advisor to the Ontario Ministry of Health since 2009 as well as federal committees and health panels.
Dr. Mailis was nominated to the 75 semi-finalists “top immigrants” in Canada for 2011. She is a recipient of the Hellenic Women’s Coming of Age Celebration Award (May 2004); Division of Physiatry, University of Toronto, Achievement Award (June 2005); the 2013 Canadian Pain Society Harold Merskey Award; and the Division of Physiatry Life Award in 2014.
As of September 2014, Dr. Mailis created an interdisciplinary best-practices community pain clinic in Vaughan (Pain & Wellness Centre). The Centre was proclaimed in October 2016 by the Ontario Ministry of Health the “Demonstration Project of Ontario” as the template for further similar community-based clinics, that connect the community to the academic hospitals. The Pain and Wellness Centre not only offers chronic pain consultations but serves as an educational hub for numerous trainees, and also a research centre studying chronic pain in the community.
About Dr. Demetry Assimakopoulos ('Dr. Demetry'):
Dr. Demetry received his specialized honours undergraduate degree from York University in 2008. He concurrently earned a specialty in Fitness Assessment and Exercise Counseling, and the title of Certified Exercise Physiologist (CEP) through the Canadian Society for Exercise Physiology (CSEP).
Dr. Demetry graduated from the Canadian Memorial Chiropractic College (CMCC) in 2012 and immediately began practising in midtown Toronto. In 2014, Dr. Demetry became the Clinical Coordinator for the University Health Network (UHN) Comprehensive Integrated Pain Program at The Toronto Rehabilitation Institute. In the hospital setting, Demetry works with a team of physicians, nurses, occupational therapists, and physiotherapists to adequately diagnose and manage chronic pain.
He earned his diplomate in chronic pain management through the Canadian Academy of Pain Management in 2015. He has since been hosted by several provincial associations across Canada to lecture to health care providers on the conservative and interdisciplinary management of chronic pain. He was happy to finally join the fabulous team at the Pain and Wellness Centre in November 2017.
Dr. Demetry was voted to receive the members' choice 2022 Dr. Michael Brickman Heart and Hands Award from the Ontario Chiropractic Association for embodying a generous and giving spirit (the heart) with remarkable passion and dedication to chiropractic care (the hands).
Episode 14 - Managing Pain with Interdisciplinary Care: Part 1
Introduction:
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Welcome to ON Spinal Chat, where we explore what O-C-A is doing or supporting to help enhance your patient care, grow your practice or advance the chiropractic profession.
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Dr. Angela Mailis believes interprofessional collaboration is the best way to deliver pain management. Having led innovative interdisciplinary clinics focused on treating pain and preserving wellness for more than 40 years, she speaks from experience.
I'm Leslie, and in this part one episode of a two-part series, I'm chatting with Dr. Mailis, physiatrist, pain physician, clinical professor and leading authority on the diagnosis and management of chronic pain. After founding and directing the Comprehensive Pain Program at the University Health Network, or U-H-N for thirty-three years, she established the Interdisciplinary Pain & Wellness Centre in Vaughan in 2014.
Two years later, the Ontario Ministry of Health proclaimed the centre a template for similar community-based clinics that connect the community to academic hospitals. Learn her team’s communications, support the patient’s journey, and how cross-pollination plays a key role in fostering mutual respect. In this episode, she's joined by Dr. Demetry Assimakopoulos, O-C-A 2022 Dr. Michael Brickman Heart and Hands Award winner.
As the first chiropractor U-H-N hired, Dr. Demetry has worked collaboratively with Dr. Mailis since 2015. Listen for insights on their best practice approaches to pain management. Dr. Mailis also outlines her introduction to chiropractic care, the role chiropractors play in her clinic, and what she seeks in the D-Cs she hires.
Main interview
Leslie:
Thank you, Dr. Mailis, for taking the time to meet with me today. What is unique about your Pain & Wellness Centre in Vaughan compared to other interdisciplinary clinics?
Dr. Angela Mailis:
Our unique interdisciplinary pain management program is one of a kind in the province. We have a lot of services all under one roof. The centre is medically directed, which means I am here 100% of my time, which is kind of unique because in most facilities the head doctor is on and off.
Let me explain a few things. Multi-professional is a place where there are different professions. Now, how they are relating between themselves can separate them in solo practitioners, multidisciplinary teams, or interdisciplinary teams. The difference between a multidisciplinary team is that you could have several professionals. I see the patient. Then I send him next door to the chiropractor, and the chiropractor sends them next door to the naturopathic physician.
That is multidisciplinary. Several professionals see the patient, but there's not very much communication, no integration. An interdisciplinary team, and there's plenty of research about interdisciplinary teams, is very much different because it's not just the health professionals that comprise the team, but the way they communicate, the way they set common goals for the patient. The way they execute these common goals and these types of interdisciplinary teams have been found to be really superior when it comes to chronic pain management, and so that’s what we have here. That means we communicate all the time and all the providers are in the same journey for the patient, and that is a huge difference.
Leslie:
So what helps make communications between yourself and other members of your team so effective?
Dr. Mailis:
We work on a template, and even when we get new medical trainees, we expect them to follow the same template. It’s not a template that I impose. It’s a template that we agree on as members of the team. We know what the chiropractor is going to do. How the history is going to be taken. How the physical exam is going to be conducted. What is the process for the different investigations that we do? How do we discuss together what the pain generators are and what are the next steps? You know, we have to connect all of those elements to create your opinion. You are on the same road. Sometimes we have to debate, but this is how we learn. And then you've got to have very strong communication, you know, where you're going.
Leslie:
Okay. Tell me a little bit about your work culture.
Dr. Mailis:
We have a lot of published research that confirms the value and efficiency of our work culture, very specific culture and philosophy in the centre results in staff retention, because losing staff is almost unheard of for the last eight years that we function in our centre. We believe our people are the biggest investment we have.
Healthy and happy health professionals are able to treat our patients better. Continuous health education is not only a must, but is an ongoing process. So that's one thing. The second is a culture of listening to all of our health professionals. So it’s a ship. And if the ship has only a captain and doesn't have sailors and engineers, it goes nowhere. Our people share our philosophy.
They bring forward their ideas. Big changes are always communicated and approved by the whole team. In other words, we create a collaborative environment. We pay very well, have very good health benefits, and we also support our staff with social encounters. We care about their families. So ultimately, we have ended up with a family of health professionals who respect each other, talk to each other all the time, and make decisions together.
Leslie:
So tell me when a patient comes into the centre with a neuromusculoskeletal (n-M-S-K) issue or condition, how do you approach that and what happens next?
Dr. Mailis:
We have two streams of patients who come to us. The first stream is through medical consultation because we are a tertiary care clinic and family physicians and specialists will refer patients to us with all kinds of pain problems.
Now, all patients are seen on consultation by a combination of a medical doctor and a chiropractor. We always see patients together, so it's kind of teamwork, a dual approach to medical consultation. At that first consultation, the history and the physical examination helps us to detect what we call pain generators. The philosophy is that we do not treat pain unless we understand what is generating the pain.
In other words, is it some kind of physical pathology in the bones or muscles or joints like nociceptive, musculoskeletal pain? Is it something because of damage to the nervous system, central or peripheral, which is neuropathic pain? Is it a combination of both, or is it a third kind of pain that is called nociplastic due to changes in the central nervous system, an increased sensitivity to perceiving pain even when there is no damage in the peripheral tissues?
So determining the pain generators is fundamental in us deciding what we need to do to treat the patient. Many times we order investigations, we order medical trials of medications or sometimes we send the patient for special injections or we will do investigations from M-R-I to C-A-T scans to orthophysiological studies. Once we decide what are the pain generators or the combination of them, then we can decide on a plan of action for treatment, and a select group of these patients, one different program, one medical consultation would be submitted to the full-blown interdisciplinary pain management program we have, which combines all health professionals together with specific goals. The interdisciplinary pain management program is offered only to about one in five or one in six in-patients that we see on formal consultation, because we set the eligibility criteria. The interdisciplinary pain management program is where the whole team comes into force.
Not only the medical doctor is the lead, but the chiropractor is the lead – the core person for active rehabilitation. And then we have a psychotherapist, mindfulness, body-mind code, therapeutic massage and naturopathic physician. So this is where the whole team comes to work together in a long program. We have this particular program, which lasts three and a half months, and the team meets very often to discuss common goals or concerns they might have, or the progress of the patient.
Patient selection of specific patients in the medical consultation would lead them to specific treatment programs where you call the team and then it would be the big program, a comprehensive interdisciplinary program, or a more limited program of lesser duration for specific goals that involves two or three different professionals as well. So that's a second part.
Not all patients who appear on medical consultation will be treated here. Some come from far away and they want one single consultation and an opinion. We have patients who visit us from Kingston, London, Ontario, Ottawa, Thunder Bay – everywhere. They come for the special diagnostic skills we have. And then there is another group that has very serious biomedical problems.
We see about a quarter of our population are over 65. So the over 65 very often will have multiple musculoskeletal and neurological problems, from strokes to peripheral neuropathies, diabetic neuropathies, osteoarthritis, hip, knees...Many of these people will go for injections or will go for hip or knee replacements or surgeries because of the conditions that they have. There will be a third group of patients that need simple therapy, one single stream of therapy, either here or in another institution.
So they don't need all the forces of the team. There is a fourth group that they have exhausted all means, and the only thing we can suggest for them is just some self-management through webinars. If you have somebody who is in chronic pain for 45 years and they have not gotten off the bed, we cannot treat them. Let’s be realistic: we are not God’s replacement on this earth. We can't treat everybody. So a select group of patients that we feel have the motivation and the capacity to improve and we have the capacity to treat them and they can devote the time and be consistent in their attendance, they are the ones who get the flagship, the big comprehensive pain management program for three and a half months. And then another group will be treated with a smaller program with two or three health professionals of limited duration, again with a chiropractor being the centre of that team because their problem is usually musculoskeletal and can be treated with active rehab.
And then we have ancillary services like massage or naturopathic medicine, besides the medical service that can help these patients. The objectives are more limited, but the problem also is more limited and easier treated. So we have a smaller program for that.
Leslie:
Okay, Thank you. I'm going to go now to Dr. Assimakopoulos, or Dr. Demetry, as your patients call you. So, Dr. Demetry working within the Pain & Wellness Centre or other clinics, how would you summarize your approach to pain management?
Dr. Demetry Assimakopoulos:
The first thing that I want to do is listen to the patient and let them tell me their story. And that is absolutely vital because if you take a cross-section of a lot of patients who suffered from persistent pain, many of them will report that whenever they see a health care provider, they're not afforded the opportunity to speak their whole story.
So I really want to give them the ability to tell me that in their own words, reasonably uninterrupted. I'll focus them sometimes. So that way we develop a really good therapeutic alliance, and that creates the root of the relationship that I have with patients. The next thing I want to do is make sure that no really scary or sinister pathologies are present that haven't been detected in prior encounters with health care providers.
And then I just try to rule those things out. So something that would warrant an emergency referral or advanced imaging or a referral to another professional. And then I dive into psychosocial history simply because it is important to understand the person not only biologically, but also the cognitions, the thoughts, the behaviours, the psychological status, and their entire psychoemotional upbringing.
Because those things can create vulnerability in the creation of a persistent pain experience. But also not only does it increase their vulnerability, but it actually changes the way that person experiences pain. Then I'll do a thorough musculoskeletal exam and I do a neurological examination on every one of my patients because if anything has been missed, it's been some kind of disorder of the nervous system.
And I approach this almost like a detective because if I’m the second, third, fourth, eighth person on the docket, then I want to make sure that nothing has been missed. And then finally, I approach my diagnosis from three standpoints. One is what is the underlying phenotype that this person's pain is coming from? So is it more of what we call a nociceptive pain where pain is coming from non-neural tissues? Is it coming from a condition of the nervous system?
So, neural tissue. Or is it a pain disorder that is perhaps contributing from those two mechanistic descriptors? But the actual processing of all of these signals coming into the nervous system to the brain, the cortical/subcortical structures, the brainstem, etc., the processing of all those things has become maladaptive, which is the driving factor of that person's pain experience.
And then finally, what I really want to determine is, is the phenotype - not necessarily having to do with the pain mechanistic descriptor - but is this person's dominant determinant of health a psychoemotional one, whereby this person would require a referral to a qualified mental health professional in order to co-treat because beyond a certain intensity if there are psychoemotional issues or challenges that this person is having, it really creates a ceiling for how much improvement that this person can have.
I'll go ahead and I'll communicate those things to the patient. And one thing I really want to do is give the patients power over their symptoms. That means, one, having a good therapeutic alliance, a trusting relationship, using things like shared decision making. I'm a big proponent of teaching patients how to modify symptoms, making patients feel safe so when they do engage in things like therapeutic exercise, they feel that it's safe and that they can do so.
And it's really just about following that patient over time and ensuring that that person achieves a goal. And that's kind of step three where I determine, well, what does this person want to be able to do? And then chasing that becomes the underlying treatment and goal post.
Leslie:
Okay. So how do you think your experience differs from other chiropractors who work in interprofessional or interdisciplinary clinics?
Dr. Demetry:
So the difference that you might see in me working with a patient for that first initial assessment. One is the duration. So I usually take a little bit more time with my patients. Two, I look at it from the perspective of a detective. I really want to identify what all the variables are and I want to make sure that all the bases have been covered because in my world a lot gets missed and that allows me to make more informed decisions.
The other thing is that while I do use manual therapy, I don't use it very often in this clinical population because I find that many times if someone has seen a chiropractor or a physiotherapist in the past, that manual therapy has been tried and it either provides a pain-relieving effect, but it's transient or it's not that effective.
And I want to look for other means to allow the person themselves to modify symptoms and control them because once a patient develops the ability to control symptoms and understand its behaviour that sets the foundation for recovery, I'll give one example now of a patient I'm seeing currently. So this person has a chronic and persistent S-1 radiculopathy.
The pain doesn't pass the knee, but based on all the clinical factors, we were able to clinically identify it. And then Doctor Mailis and I confirm the diagnosis with E-M-G nerve conduction studies or neurophysiological testing. So there was objective evidence of that. And this person was doing regular manual therapy and it might provide them up to three days of partial relief and the patient was given a couple of stretches to do, but they really weren't compliant with doing them.
So when I saw them, my approach to the assessment was, what can I do to take your pain away? And that was actually a lot of fun because getting that person prone, and then getting them to extend through the lumbar spine to the end range repeatedly actually took away their symptoms. So that would be your textbook McKenzie Technique. And then the person also had some nerve root tension signs both in the sitting and supine positions.
They still had some buttock pain after doing those prone extension exercises. So after that, we did a seated sciatic nerve neuro-dynamic slider, and that took all of their pain away. And then I said, you see, we understand what the pathology is, we have an understanding of the diagnosis, we know the mechanistic descriptor. but the most important message here is that you can control your symptoms and you can control them at any time.
So if you employ these techniques, then by the next time you see me, you're going to be a lot better. And there was a lot of resistance there because the patient was very stressed. They just couldn't plan out their day to do the exercises. Finally, we just had a heart-to-heart and we came to an understanding that this patient is really motivated. They just had a lot of difficulty figuring out how to plant these seeds into their day. Once we figured that out, within two weeks into our program, this person has little to no pain. So now I can take my doctor hat off and put my trainer hat on and really start building confidence with things like lifting, squatting, lunging, day to day things that this person might be intimidated by and doing.
The other thing that I do very commonly is I really like to teach patients just how resilient their bodies are. So for a patient with chronic back pain who has a fear of lifting, I'll bring them into our gym and I'll line up a bunch of kettlebells but I won't tell the patient what their weights are. And I'll give them some tips on how to lift confidently and how to just be fearless in terms of their lifting technique.
And then I'll get them to lift these three or four or six different weights and they'll guess how heavy the weights are, and then we'll go through them again. And I’ll say, well, what did you say this one was? And they'll say, you know what that felt like 25 pounds. Well, actually, no, that's 45 pounds. The next one was 50, and this person would have lifted all the way up to 100 pounds, not knowing how heavy this thing was.
And then I get to reveal to them in this kind of grand gesture that they're way stronger and way more resilient than they think they are. So being in the gym isn't necessarily about building strength per se. It's about building confidence in their ability to move, and that just opens the floodgates for them. So the full-fledged program is a collection of 60 to 80 hours over the course of 3 to 4 months. And that doesn't only include chiropractic, it includes all the other disciplines. So in total, I'll get 24 visits with a patient, which is around the time where we have to do a reassessment per our college rules anyway. In some cases, I'll do two, three, four visits with the patient and they're completely out of pain or they're significantly improved. And then we can just spend time messing around in the gym and helping them reach the physical goals. Other times we nurse them a little while longer and the person might be kind of progressively improving as the time goes on. So it's really dependent, but the patient that I spoke about with the chronic L-5 radiculopathy, I think we're two weeks in.
I think we did session number five on Wednesday, and she said she was about 80 to 90% improved. So not only do I do the manual therapy with this patient, but I just spend a lot of time building that confidence for them, and that's worth its weight in gold.
Leslie:
So let's go back to Dr. Mailis. When did you start working with chiropractors and what surprised you the most?
Dr. Mailis:
I practised medicine for 41 years. I spent 30 years at the Toronto Western Hospital where we had different therapists, occupational therapists and physiotherapists. I went through my whole life with physiotherapy in the hospital. I never knew anything about chiropractors, and I had never worked with chiropractors until probably 2013 or 2012. And then the last two years that I was still there in the hospital I came across the Canadian Memorial Chiropractic College through a strange situation. My younger son decided he was going to be a chiropractor and I had no idea what a chiropractor was. He was admitted to the college. And then I got a call from a very respected colleague of mine, Dr. Eldon Tunks, who founded the first Interdisciplinary Pain Management Program in 1979 in Hamilton. And he said, my daughter just graduated from the Canadian Memorial Chiropractic College. You better go and teach there as I do. And then I got involved with the college, and I was very surprised, actually, because I started to discover the amount of education they had. I realized the depth of the training. And my invitations were coming from the more senior chiropractic students in their last year. They were organizing all these kinds of talks.
And I was very impressed by their zeal to learn and the topics they wanted to learn. That is where my surprise is. But then it was clear to me that that was my path to go. And so when, in 2014, spring, my clinic coordinator at the Toronto Western Hospital retired, I decided that I was going to look for a manual therapist because I wanted to make sure that the clinic coordinator - because I always work in a team - had the capacity to do a good physical examination. And this is how I met Demetry and I was impressed by his skills, and I ended up bringing him on as the clinic coordinator for the Comprehensive Pain Program. He was the first chiropractor that came to the University Health Network and we worked extremely well and this is where I became more and more integrated with the chiropractic school.
Leslie:
So, Dr. Demetry, tell us about your experience joining the University Health Network.
Dr. Demetry:
I would do the histories and physical examination so that way it would free up time for Dr. Mailis, and then she would come in after the fact and make sure everything was the way it should be. And then we'd come up with a plan of management. But because there was no chiropractic job title I was hired on as what was called a practice leader. That particular title would have fit in with the funding that she had on a yearly basis. So I went on for a few years from 2014 to 2019 as a practice leader, and at that time there was an organizational U-H-N wide change where they wanted to restructure allied health care. So the title of practice leader was being abolished and people were being reallocated to different positions or even let go.
I was very lucky because my job was funded by government funding. So whether I was a practice leader or not, they wanted to keep me, but they needed a different title. At the end of 2014, Dr. Mailis gave up her position at the U-H-N and still has an appointment with the University of Toronto, but stopped being director there and opened her doors at the Pain and Wellness Centre.
So the program was transplanted to another U-H-N site, Toronto Rehab, and Dr. John Flannery, who's another physiatrist, became the director of the program. So when all this restructuring occurred, H-R, a number of our clinic managers and Dr. Flannery all came together and just said, well, why don't we just let this guy practise based on his title? Why don't we just call him a chiropractor?
And then they investigated and said, oh, my gosh, this title doesn't even exist. So they created it for me and it's something I'll always be eternally thankful for because they put that faith in me. That laid the groundwork for me to start treating at the hospital because before that I couldn't treat because I didn't have an official scope of practice per the hospital's infrastructure.
And then the other thing that we wanted to do was approach C-M-C-C to have their post-licensure senior residents do rotations with us. That way, it created a collaboration between C-M-C-C and our program. That really has borne a lot of fruit. Not only is it my favourite job working with the residents, but they learn a ton of things that they otherwise wouldn't have learned.
They work with the physicians directly, just like I do. They do observations on our inpatient neuro floor. They see E-M-G nerve conduction studies. They see fluoroscopic and ultrasound-guided interventional treatments. So because now there was a chiropractic title, well, these people are chiropractic residents. There's a whole infrastructure for it.
Leslie:
What a transformation. So over to you, Dr. Mailis. What role do chiropractors play in your clinic?
Dr. Mailis:
They are diagnosticians. My chiropractors are extremely well-trained. They are capable of taking a full history to perform a full neuromusculoskeletal, detailed examination. And when they come to present the patient to me, I will challenge them. I say, okay, what do you think the pain generators are? What investigations do we need?
They are quite capable in discussing the type of investigations and imaging electrophysiological studies that we need to do or whether we need to send the patient elsewhere for a spinal stimulator or injections, or we need to treat them here. And then we see the patient together again. They are quite capable of taking patients from A to Z and express opinion as to the diagnosis and what recommendations they make far above and beyond what they have been taught in school.
They know their medicine very, very well. And then they are leads when we treat patients in terms of active rehabilitation. Out of our interdisciplinary program, the chiropractor will see the patient twice as much as any one of the other professionals, because their core issue is active rehabilitation and return of functionality for these patients from the physical point of view. Notwithstanding, but all my chiropractors are being trained currently in other therapies like pain reprocessing therapy, which is totally unique, which connects the brain with the interpretation of pain and changes somehow the brain wiring through labeling the pain in a more benign fashion.
These are therapies that are not just musculoskeletal. These are therapies that tap deeply into brain wiring, into behaviour in the way the brain feels, the pain as a threat and how you relabel the pain, So it's not as much threatening to the person as it normally is in chronic pain situations. So this is very important to me because I foster all extra education that will allow my health professionals to acquire extra skills and the same training has been offered to my massage therapist, psychologist….
So when there is a training intervention, it applies to many of my professionals. So we all have the same language that we understand and speak. So when I opened up this facility, needless to say, I turned to chiropractic and I ended up having four chiropractors in my setting and they are by now better than any pain fellow that I have trained for medicine over the course of years.
Actually, our centre serves as an educational setting for the University of Toronto Pain Medicine and all pain medicine residents. The pain medicine residents are certified by the Royal College in a specialty of anesthesiology, neurology or physical medicine. And they do two more years of pain medicine. So they are called residents in pain medicine. And when they finish, they obtain another certification qualification from the Royal College as pain medicine specialists. It’s these residents who already have a Royal College specialty who come and rotate through our centre.
And guess what? I get all my chiropractors to teach them neuromusculoskeletal skills and this is why my program is well known in the University of Toronto and became a compulsory rotation because this is where pain medicine residents get skills that they have a hard time acquiring anywhere else because they don't devote that much as my people do to train the residents. So there's a big difference.
Leslie:
So what would you say to other physicians about collaborating with chiropractors?
Dr. Mailis:
I think the collaborative model is the best possible model. Just because we are physicians, it doesn't mean that we have to have a chip on our shoulders. I never did. I respected all colleagues for the knowledge that they could provide me and vice versa.
To this date, years after we have the centre, I enjoy being with my chiropractors because I know I'm going to learn something new. So that ability to be open for cross-pollination is a very important thing. That is what I would say to other physicians.
Leslie:
What three competencies do you value most in the chiropractors you've worked with in your clinic?
Dr. Mailis:
Their skillset in neuropathic conditions - that's one thing. They have knowledge bases because we are looking at people who not only know the physical components but understand the science behind that, and their willingness to acquire new knowledge. So that’s number two. And number three, their personality. We are a family. It's a team here. Positive energy is transmitted to our patients. Positive energy is helping the team to be kinder when we hire new people, we just don't look at the skills and how much knowledge or diplomas they have, certifications...
But do they gel with us? Do they gel with our patients on personality and social skills? I would say emotional quotient is very important to us. So these are the three things: skills, knowledge, and willingness to acquire new knowledge and personality.
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Outro:
Thank you, Dr. Mailis and Dr. Demetry for sharing your interdisciplinary approach for diagnosing and treating chronic pain. Thanks, Dr. Mailis, also for walking us through your program with tips for aligning collaborative communication with patient care and staying ahead of the curve.
We'll be back in June with part two of this series. In it, Dr. Demetry will share must-read articles on managing chronic pain, a patient case study, and how you can hone your chronic pain management skills. I hope you'll join us.
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