Ep37: What Does It Take to Provide Excellent Chronic Pain Care? An Interdisciplinary Pain Clinic Model with Dr. Angela Mailis

(upbeat music) Hello and welcome to Paincast, Conversations on Pain and Physiotherapy. This podcast is brought to you by the Pain Science Division of the Canadian Physiotherapy Association. I'm Tiffany, the host of Paincast and an executive member of the Pain Science Division. I practice physiotherapy in Toronto. This episode is a special one. I have been mentoring physiotherapy students at the Pain Science Division Student Committee to develop episodes of a topic of their interest. These students worked very hard to deliver top quality interviews and discussions to you. I will let Ryan and Sophie take over from here. I'm Sophie, a physiotherapy student from the University of British Columbia. And I'm Ryan, a physiotherapy student from the University of Toronto. What are the systemic challenges in Ontario's healthcare system and pain management? How do we actually provide interdisciplinary as opposed to multi-disciplinary care? What does it look like to treat a patient as a person instead of a number? We had the great honor of speaking with Dr. Angela Meilas about a successful model of community-based interdisciplinary chronic pain management. Before we start, as a reminder, pain cast brings together researchers, clinicians, students, and patients to facilitate discussions, knowledge translation, and critical thinking on topics about pain and physiotherapy. The views expressed in each episode are of individual guests. Do not constitute medical advice and do not represent the views of the Pain Science Division or the Canadian Physiotherapy Association. Enjoy the episode. - Hi, Dr. Meilas. Thank you so much for joining us today to talk about chronic pain management in Canada. How are you doing today? - Very well, and a very long and busy day. And I'm all yours. - Well, thank you so much for being here and taking time to be with us. To begin, can you introduce to our listeners who you are, what you do, and what a typical week looks like for you? - My name is Dr. Meilas. A fellow of the Royal College of Physicians of Canada specializing in physical medicine. I practiced solid 43 years before most of you were ever born. And I have devoted my practice exclusively to chronic pain research and management since I got my fellowship. I became the founder of the Pain Program of the Toronto Western Hospital University Health Network, where I practiced for 33 years between 1982 to 2015. And from 2014 to now, I have a new, totally devoted to pain facility in Vaughan, Ontario. It's a tertiary care facility, but we also offer inter and multidisciplinary pain management programs. We serve the whole South and Central Ontario. And we are part of an academic network of 17 programs in the province of Ontario, acknowledged and funded by the Ministry of Health and long-term care in Ontario. Our clinic in Vaughan is the only community-based academic clinic versus 16 other programs in hospital in Ontario that is recognized and funded in certain parts by the Ministry of Health. So we over pain consultations, but also pain management. And we are a total of 26 people and staff, two physicians, five administrative staff, two IT people, and the rest are all multi-professional specialists from Cairo-practors to natural bus, psychology, psychotherapies, mindfulness, massage, and so on. - Wow, that is quite the team that you're working with then, all dedicated to chronic pain management, which is so beautiful. What specifically has made you so passionate about improving programs around chronic pain management? - I guess I breathed pain since I was back at home, I was born and educated in Athens, Greece, where I finished my medical school. And from the very early years, I was very impressed by the different reactions of my large family to pain. My mother's side of family, getting all together inisters and Christmas, they were all talking about pain and exchanging medications. While my father's side, they were all mute, never complained of pain, even if they had significant conditions. So that triggered my curiosity. And then I was observing people coming to the emergency from injuries, and I would see big men with big moustache, feinting at the side of a needle. So I was always very intrigued from even the time I was in the medical school. And of course, when I came here and I went to the specialty training, I knew probably from the second year, I wanted to go into research, and I wanted to go into pain management. That became my whole professional life. - That's very, very interesting to hear about your personal experience there, and that that is what led to where we are today. - It was definitely interesting to hear about your background, as well as how you got so interested in your pain. I know you talked a little bit about your clinic already in your introduction, but do you think you could tell us a little bit more about the clinic's mission, as well as the primary goals of your community-based interdisciplinary program? - Okay, one of the things that is very important that you understand is how this clinic came to be. Since 2009, I have served as an advisor to the Ministry of Health for different issues, starting with the opioid epidemic, where the Ministry sought my advice. And at the same time, I was the chair of a not-for-profit organization, Action Ontario. Since 2005, our mission was to educate and advocate for pain patients. We were not a support group. We were an educational and advocacy organization. And I had been very much involved with Queen Spark, organizing breakfast with the teams, educating the MPPs, the ministers of health. So I had been always involved at the same time, with the political side of things trying to create knowledge to the administrators and the policymakers that pain was a big problem in the province. So the opportunity came when they asked for my help with the opioid abuse. And then shortly after Action Ontario and myself, we're very involved to convince the government that chronic pain is a big problem in Ontario. They opened up the commission for social policy to public hearings. They became very convinced that indeed, chronic pain was a big problem in the country and in particular in Ontario, because you have to remember that health is primarily a provincial matter. The funding comes from a provisional coffers. So in 2011, I was invited with a handful of other people counted in the fingers of one hand to assist the Ontario Ministry of Health to create a white paper. A white paper is a policy paper that says, these are all the things that are wrong with pain in the province of Ontario. This is what you have to fix them. So we created that policy paper and it was on the basis of this policy paper two years later that the Ministry of Health said, "Oh, we want to change the scene of pain in Ontario "and we want to start putting funding outside the OHIP, "which is the public health system that we have." So we want to put funding extra to hospital clinics to create multi-professional groups to deal with pain. The unfortunate thing for me at that time was that I was so much inspired by the policy paper that I had decided to go out in the community after 33 years of running the pain program at the big hospital and I wanted to bring the University of Toronto in the community. So I wanted to create a pain facility that would offer all the services that the downtown hospitals would do, but also become an educational hub and do clinical research, particularly measuring outcomes. So they said, "Well, you're out of luck "because you're not anymore in the hospital, "so we're not funding community clinics." So I went and did my own way and two years later, the Ministry decided to look at my model and they felt that it was quite innovative and they accepted to fund my program like the downtown programs in order to create multi-professional groups. So the 16 clinics in Ontario are funded 10 years, our program is funded eight years, having said that, once you have funding that allows you particularly to pay for services that have not covered by the public health care system, you start being able to provide, in my view, social medicine. Then we decided we are going to have a program that is going to be interdisciplinary and there's a big difference between multi- and interdisciplinary. Multidisciplinary, you have a number of clinicians, multi-professionals, but the links and collaboration is very loose. While an interdisciplinary team, core values are that the communication is very robust, it's a shared decision-making model and the patient is at the center. The program is patient centered. I decided that I was going to have this kind of program with very tight communication and then we created another innovative aspect that really does not exist. We felt that we should offer personalized medicine. Instead of group therapies, we offer one to one therapy. So our program consists of 60 to 90 hours of one to one treatment with the exception of mindfulness that we put in. in small groups of six because it's much more effective and cross pollinating when you have a group with mindfulness. All our other services are one to one, the interdisciplinary program, three months in duration, three times a week, times two hours with the combination of providers, apart from medical staff that oversee the treatment or we interfere with investigations, medications or coordinate the team. Each patient has access to manual and exercise therapy, which is really an active rehab, which is really the cornerstone of our approach, plus psychology, mindfulness, therapeutic massage, a natural pathic lifestyle diet and all kinds of other approaches. This is what our program is about. And to this date, we have graduated about 850 people since the inception of the program, the vast majority is women because women are the ones who go to being clinics about 70% to 75% of all our consultations are women. We have also smaller programs. Our interdisciplinary program is not advertised. Physicians can never refer a patient to us for the program because admitting a patient to the program is the absolute progative of the team that assesses the patient. Otherwise, we have limited funds. If you were to advertise such a program, every time they can hire you would come knocking at your door, expecting to get free massage, which is exactly what happens with some through word of mouth. So no consultation is done by physician only. It's primarily by a physician and a manual therapist. We happen to have five caropractors here. All of the caropractors are with me for many years that they are trained like pain fellows. They are actually much better than a pain fellow because they are quite capable on their own to do a complete diagnosis from the psychological to the physical to the medications investigations, total neuromusculoskeletal examination, come up with the appropriate investigations that need to be done or order or medications that need to be changed. I mean, they are quite capable of operating without me, but of course we work always together. But that's the level of training that my people have. So we decide if the patient meets our eligibility criteria and what is important, motivation, fire in the belly to get better, commitment, availability of time, ability to speak very good English because if they don't they cannot understand complex concepts. And so while we have regulated our distance to say that we can take patients who are within a 50 kilometer radius from our center, in reality we have patients who come to us from well, from all over from Hamilton, from Kingston, Innisfil and Barry, long distances, but they are willing to make the trip and come to us because the program is unique to patients who rent an Airbnb or move close to the area to do the program because it does not exist anywhere else. So that's more or less what our program is the big one and we have smaller, more goal oriented, multidisciplinary programs. - Well, it's actually so amazing to hear about your clinic and the novel approach that you take into approaching pain which is something that our healthcare system hasn't really done a lot of ground work in and it's also amazing. 850 graduates, the amount of impact that you've made on such a wide variety of people's lives. It's really inspiring to hear as someone who's in physiotherapy and is going to be working with patients who are also coming in for pain. You talked a little bit about having a interdisciplinary team and you're having a lot of different practitioners who work alongside of you, so like physicians, psychologists, chiropractors, mindfulness facilitators. We're having so many professionals. How do you have them all be aligned in their approach to patient care and be able to work towards a common goal for the patient? - We value more personality than we value skills. The person who comes to work with us because this is the pain and wellness family, the PWC family has to be capable to be integrated with the team to have a very pleasant and outgoing personality to be collaborator. We do not need primadonos here or people with a chip in their shoulders. No one is above each other and that the same thing goes for medical doctors and all kinds of other therapies we have here. And actually for some of my non-medical practitioners, my approach to that in the beginning was so strange that they were, are you really sure, is your medical association going to allow you to work with us? Because that kind of approach is usually very different. As the leader of the team, I also consider, and that is a common philosophy to us, that the biggest investment that we ever make is my people. So starting from this kind of premises is deviating from typical big hospitals I have been there for 33 years all third of my life is in a big hospital where people are numbers. My providers are not numbers and my patients are not numbers. They all have a special identity. They are unique people and we treat them as unique people. First of all, I'm the older person in the team, of course. Most of my team with the exceptional two or three of our psychologists are all millennia. So of course there is a gap and how do you put the millennia together who come fresh from school with all kinds of modern ideas and we are supposed to build schools? So in the beginning, we worked together with the team a year before we opened the center. So that was enough for numerous meetings to create the philosophy, to make sure we come into common lines and take extra courses so they could be prepared. The other thing of course we got with our young providers are minor therapies that they are used to treat a little fleets. They all get better so much quickly. So chronic main patients take a lot longer and their gains are not dramatic from day to day. So of course I had complaints in the very beginning, why are we going to do their slow poke? But when they realize that the little improvement for patients who have suffered for so many years is amazing for these patients and the gratitude was overflowing. The all started changing. So it was an evolution. My team was not created the way it is today, year one. We had some fight, we had some disagreements, we changed some ways through the program until we find our balance and we all sing the same song. And ultimately, this is how we make some changes even in the program, even in our eligibility criteria. We were more open before and then we realized there are groups of specific patients that are 95% likely to fail. Well, these patients, we are not taking them because the minimal amount of money, we have to be sure that we put our seeds in fertile ground that has a good chance to succeed. So we change over the course of time. And then as I said, people who come here, stay forever. My providers are lifers because they love the environment. They love the patients. We work very tight. We have team meetings every two weeks for educational talks and also discuss all patients. But we also have other systems in place where instantaneously we can communicate. Slack, internal system. I have a patient, Dr. Males can come upstairs. We need an ultrasound. It's immediate communication at all times. That's one thing we're very tight in that. The second thing that is important, we have all come to understand who has certain skills that may be more unique. For example, if we have Coxidinia, we have a female chiropractor trained in internal rectal exam. All the Coxidinia will go there. We have a couple of others who are more trained in the concussion management protocols for that. They go there. All of them are trained in TMJ management, specific besides the GLAD program or whatever else we are doing there. So we evolved over the course of time, acquiring same philosophy and very tight links with the team. We also buy very much our providers, we have social events, we have excellent benefits. They are paid very well. So as I said, if you treat your people well, they are going to treat your patients well. So this is how we have created our facility here, which is a lot more than just a regular paying clinic. - Your team and your approach to collaboration and team building is really special to see, especially after my experience is working in a public hospital and it's definitely interesting to see a different approach to it. One thing that you said that really, really stuck out to me was that patients are not numbers and that they're all special identities and are unique people. This patient-centered care is really important and it's the approach that we all strive to have in our future practice. You think you could talk a little bit more about patient-centered care in the context of chronic pain patients and why it's so important to have this approach for chronic pain? Let me tell you one thing, which is the biggest possible block in pain management. There are two things that I have seen in my long career. First of all, non-medical services are not covered by the system. That's a huge, huge issue because probably only 30 to 40% will have extended health benefits and this may be limited. So money is a huge issue. But let's say money was falling off the sky and everybody had access to money that is still not covered. enough because the vast majority and I will be very blunt to all of you. 99% of the patients who come to our clinic after they have gone everywhere, medical and non-medical facilities had lousy therapy. What you see in the community and everywhere is assembly line, passive therapies, every step in the way. How many tenths and hundreds of patients we've seen, we see their comments because collect reviews they tell us, all of them we have published. They have all received many therapies in the community, tenths, ultrasound, laser, spinal decompression, take a seat and go for stretch exercises. Our therapies spend an hour with its patients and the majority of that is in a high-end gym downstairs so they combine manual but also exercise therapy, spinal sparing techniques, the whole thing in great detail. You don't see this kind of management out there for our chiropractor's official therapies in the community. That's sad. So even if the money was not going to be a problem, the therapy offered is a problem. On the other hand, you go into medicine and you see the majority of the so-called pain cleansing the community offer as the first form of management injections. I just wrote an article about that. Injections in the spine, joints and all of that, very useful tools but for the right patient, the right diagnosis, the right time. They are not a cookie cutter help or you go to an intervention clinic in the community and the first thing you're going to be offered is injections to everybody. So we wanted to see where does a non-intervention clinic like us come in the world of injections. 5 to 8% only of our patients will be sent to trusted by us interventional facilities for injections because this is a tool that you have to use wisely. If you have a 85-year-old with severe spinal stenosis and radical opus, injections will be one of the primary tools you're going to use to facilitate rehab or because there is nothing else available. So only 5 to 8% of our patients as compared to 95% of patients will go to injection facilities and unfortunately money is again at the root of the problem. Studies showed that in Ontario alone, interventional clinicians, the minimum billing that they had the average billing was $724,000 a year, billing or hip for injections. Some had gone over a million. As you see, both money, skills and philosophy play a very big role. This is where accountability is missing. Even when the system pays, there is no accountability. What is the outcome? So okay, you pay for that. Who gets better? We get a lot of patients from car insurance through the auto insurance thing. They have preferred therapy facilities. They all come to us failing because if you are below MIG, you miss the depression. You miss the anxiety. You miss the PTSD. If you don't know how to ask for that. So you keep forever and the pace now goes into chronicity and that it will come to us. So there are many things that are wrong with the system and having money is not enough. Remember one thing. If you hold a hammer, everything looks like a nail. If you look in the stage, who is ordering most of the X-rays will be chiropractors in orthopods. If you look, who is doing most of the injections will be the anesthesiologist and family physicians who have changed scope of practice. So this is the reality out there. So many of our young people graduate from their programs and you go with a lot of ideal. This is the type of practice you want to practice and it ain't going to happen because money is missing. The team is missing. You have limitations right and left. That's too bad because there are a lot of good young people who graduate from different programs and then their wings fall off as mine did when I was an idealistic young physician many years ago and then I learned the hard way. So that's somebody's experience who has been in the trenches for many many decades. It's amazing then that your clinic is set up the way that it is to facilitate patients being not only treated by so many different professionals but also seen as people and having professionals that are seen as people and being able to just interact just to be cared for. So I would assume that your clinic is very much in high demand. You are seeing lots of different types of patients and engaging with lots of different injuries. Are there specific injuries that you see a lot of or that you don't or is there limitations around who you're willing to accept outside of those criteria of motivated, committed, and available? First of all we see about 500 new patients a year. We take to the program 60 or 80 which is less than 20%. One major mistake in the area of chronic pain is the term chronic pain. Chronic pain due to what? The actual term of chronic pain in one aspect is pain that lasts beyond the usual time of healing beyond three months. Where do you put the pain that lasts for year after year but you have an active biomedical pathology? If I have a lousy knee with grade three, try compartmental osteoarthritis. I'm gonna be in pain day in day out and chronically until I get a total near replacement. When you see the big stats, everything that comes in populations that there is that much chronic pain in the population, but you don't know where it's coming from. A chronic pain that is beyond the healing time of injuries. Let's say you have a small motor vacal accident, low impact, myofacial injuries, but then you continue having pain forever. Well this is not broken bones. Myofacial injuries heal within few weeks. Why is this thing continuing? That chronic pain and the reasons that it continues is because there could be anxiety, there could be depression, there could be an adjustment disorder because they lost their job and these things are not addressed. These are all factors that contribute to chronic disease. That is chronic pain that is defined in the ICD lab in a chronic primary pain or in the DSM-5 diagnostic and statistical manual mental disorders and somatic symptom disorder retombinant pain. There are different systems of classification and definitions, but if I get a patient who has failed back surgery syndrome because after surgery he got extensive scarring that encases the right S1 route and everything has failed. This is a patient that I will consider standing for spinal stimulator through my colleagues down down. So the first problem that I said exists is defining what is chronic pain. One thing that I have always thought all my young ones, my students, my residents from the University of Toronto never treat chronic pain if you don't make the diagnosis first. The first thing we are in our clinic, all of us are diagnosticians. We investigate thoroughly. We receive so many patients with diagnosis and this is BS, this is not the real diagnosis, this is a wrong diagnosis. We initiate all investigations, all blood work that needs to be done. Consultations if needed and then we decide what we're going to do with the patient. That approach from A to Z is missing even in big programs because usually they don't follow the patients. I'll give you an example. We just saw a guy who came to us from 100 kilometers. He has the diagnosis of rheumatoid arthritis for 20 years and he came to us for pain management. We look at all the files, we look at rheumatoid arthritis and he has been implacanel, methotrexate and everything. He doesn't have one eye out of the form it in his hands in his feet. He's on no rheumatoid arthritis medications and actually on examination he has peripheral neuropathy and they say oh he has peripheral neuropathy because of rheumatoid arthritis. It's extremely rare to see neuropathy in rheumatoid arthritis unless the rheumatoid arthritis is advanced. He's got nothing. As A-A, go back to the drawing board. This is what we need to investigate to come up with a diagnosis. As I'm saying, we never treat pain unless we have a clear diagnosis. The second thing that we do and we're very clear all of us, we are looking for pain generators. We are looking for biomedical pain generators either no susceptible or neuropathic or mix or we are digging deeper and we are looking at centrally mediated or nocyplastic pain which is a very big thing of ongoing chronic pain without a major pathology. This is a centrally mediated pain. Once we decide where the pain comes from then we design the appropriate treatment for a patient. Now we do offer a lot of consultations. We make all kinds of recommendations because about 30% of the people come from a long distance to us so they cannot be treated or investigated with us. But again, the interdisciplinary program is reserved only for a minority of patients, the 20% who meet our eligibility criteria. So this is how we operate. We are a tertiary care clinic that does things from A to Z. And even if we don't do interventions or surgeries, [BLANK_AUDIO] We are integrated with a downtown court with others, and we navigate the pace and being a surgical consultation, being rheumatology, being neurology, being a movement disorder, needing all of those things, we navigate the pace and through all of this integrated treatment. So we are really from A to Z. - Definitely, it sounds like patients have so many options for in clinic work, but also that you have strong referrals out to, like you said, trusted interventions as well. I'd like to touch back again, talking about you as diagnosticians, first and foremost, that's such an interesting perspective to take when taking in a new patient. And I'd really like to hear more about why you think so many patients are coming into your clinic with maybe incorrect diagnoses to begin with. - I think there are many factors I said among school. And all along I remember the many times, before Chuck GPT, before Dr. Google, many years ago, everything that I had not encountered in my books, I would say to the patient, sit quiet, and I would lay down, what, talking 40 years ago, all kinds of anatomy books and medical books. And I would spend half an hour, while the patient was still sitting, until I could put the things together and say, "No, no, no, no, this is how we have to do it." Of course now, things are a lot faster. I go to advanced GPT, already say, "In this, this is a symptom, my differential diagnosis, "this, tell me what else is in there." I can do it very quickly now. Why do they come? Because it needs that ongoing curiosity, it needs the digging, it needs the drive to look into that, and it needs the time. Family doctors are working on an untenable fee for service system that pays them only to devote 10 or 15 minutes per patient and only one program. They cannot see the whole picture, they are tied, and you cannot blame them. The system pays peanuts for them, and it's not an appropriate fee for service, it's not appropriate to pay the physicians. So of course, they're going to see one little thing here, one little thing there, not having the capacity or the time to connect things together. Impossible. The same thing goes, even in specialty clinics, and in teaching centers, you have a lot of fellows, and you see patients, but unless the supervisor is willing and capable of supervising these fellows and seeing every patient with these fellows at the end, if the fellows are left alone, they don't learn much, and everything is kind of assembly line. I couldn't tell you how many people we see with wrong diagnosis. I couldn't tell you. I think I attribute that to the fact that we like digging, we like to understand what are the pain generators and titrate the treatment towards these pain generators, being physical, psychological, mix, or whatever. As you're talking, it sounds like the issue really is not necessarily specifically with practitioners. It's with a systemic issue that's much bigger than any individual doctor in being able to provide chronic pain management care. What do you think the provincial government's role might be in helping to mitigate this? Is there anything else that they can do to support chronic pain management programs? One of the things that I learned over the years, I deal with the provincial government and funding. Since 1990, I always had funding from the provincial ministry of health for my programs, but I was always a very good fiscal management person. I felt that if you take taxpayers' money, which is what goes into programs, grants, or hip pay, you have to be accountable for that. It's a huge issue for me. Accountability is a huge issue. Well, I learned over the course of the many years that governments will give money and will have nothing on the other side of the fence as to what are the deliverables that you are expected to give. Time after time, I have seen that and I would say, okay, what is, you give this? What do you expect to receive? And how do you judge that? This is why one of my goals when I created the facility here is to collect data, have my center data driven. And if I want to say that my program has long term outcomes to return to work or school, I have to have the numbers to prove it. It's not enough at top on the shoulders. Oh, we do good job. Oh, we do have a lot of Google reviews. This is not good medicine to me. So if you're going as a government or any organization to give money, you have to define why do you give it? And what do you expect to receive at the end that proves that there is value to the money you gave? So that part of accountability is missing. That's one thing. The second thing is the fee for service is totally inappropriate for our medical care. This has to be totally different and has to take in account the thousand things even for our family doctors. Family doctors are seeing now a much older population with many more complex comorbidities. So they need more time. They need also more skills. And also the younger people as doctors and health providers want to have some life. Before people like us used to work 15 hours a day, seven days a week, well, no young doctors will agree to do that now. And if they do, they're burning out. And the same thing goes for nurses and everybody else. So having a decent life and quality of life, being paid appropriately for what to do and paid appropriately so you can provide the patient with what they need, armandatory elements of the system. He's not as easy as, okay, I'll give you more money and get the job done. He's so much more changed the system, changed the metal, changed the training, changed the way the doctors do different things because they could be in groups. The other thing that's so important and it is so difficult for governments to understand is that doctors are not the end all. They work much better when they have a team and they work much better when you have multi-professional teams because all the providers who come in put another piece of the puzzle and this is where medicine is so much better in a team format. Even if family practice, team work is so much better and other providers from pharmacists to nurses to manual therapists, physios, chiro, social workers, psychologists, all of this are important elements of the team. And so these are so many things I have to change. - It sounds like a lot of the issues are definitely systemic and our healthcare system appears to be very fragmented with providers all over the place, all only adding one piece of the puzzle. And having teamwork as a primary approach to collaborate for a patient seems like the right way to go with healthcare. Your clinic draws a lot from collaboration and teamwork. Do you think that the model and approach that your clinic uses is reproducible within Ontario? And if so, what role do you think that government and policymakers can help make it more reproducible? - Okay, so when my program was funded in 2016 or 17, two, three years later than all the other programs, they promised me the men ministry of health, they had visionaries and creative people at that particular government. And they said, if you manage to prove what you said that you want to offer consultations, treat patients, become an educational hub and produce research. If you manage to fulfill your goals and objectives, we are going to create other programs similar to yours on your template. Governments changed. Number one, this never materialized, there has never been any other funding to any other community paying clinic period. Number two is not as simple to collect a bunch of medical doctors, physios, gyros, social workers and say, you have a team. What binds us in our team is the philosophy that drive the way people are treated, the personalities that you put together, the common goals. So everyone in the team owns a part of that philosophy. We are not slave drivers here. We don't push people, we do not order people around, we all operate on the same philosophy. So yes, you may have money. Yes, you may have multi-professionals there, but if you don't get that philosophy that is the glue and that management and that leadership, you're going to do nothing similar to what we have. This is why many times they've told me, even if you had money, would you create more clinics? I said, I can't franchise quality, unless I have people who remember my original statement, my people as the biggest investment that this clinic can do, not just the money, the people. This is why it will be very difficult to reproduce unless you have all these elements, multi-professionals, money and philosophy. Unless you put the three things together, you cannot reproduce as easily. It definitely seems like it's really hard to not only reproduce it, but you do definitely need to help from the government and policymakers, which they ultimately did not uphold their end of their promise. Since chronic pain is such a large issue with so many patients and access to programs like yours isn't very easily available, what advice would you give someone who is managing chronic pain and wants to seek appropriate care, but might not be able to access care such as program like yours? There are alternatives. First of all, start from the premise, not not all chronic pain, here's to be treated the same thing. You remember I told you in the beginning that as we evolve, we realize the certain groups of people are extremely difficult to treat. You have to rationalize your care because you have little money from the government, so you're going to put it where it has a much higher chance of the patients that can be found. Because we want to prepare our patients for success, not for failure. That's one thing. The other thing that is very important, then you have other parameters. The patient is coming from a very big distance. The patient has a language problem. The patient has a vastly different culture to which we have to be very sensitive as a multicultural society because they're not going to be treated the same way. For example, certain groups would say, "Oh, I can't go to Wauqua Fitness." No, I can't go to public. No, I don't want the mail or I don't want to get my clothes off and be treated. So these are all the things that you have to take in account. Did you sink radically and find out what are you capable of doing in the system? And of course, the other thing that is difficult, because there are so many variations in idiosyncrasies, our system is not well equipped to deal with everything appropriately and at the same equal level. That's life. There's not money that goes through the window. They are not professionals who speak 20 languages. So there are inherent difficulties in the system. So given the difficulties, how do you try to do something? One of the best things that the Ontario Chronic Pain Network has done, which is the network of the 17th Ministry-funded programs. You remember I told you, 16 hospitals, basic clinics, and one of ours? The Ontario Chronic Pain Network has been amazing because they have created a system that you should all know, www.poweroverpain.com. This is a free portal accessible to everyone in Ontario. You get into the portal here, all kinds of webinars, all kinds of self-management skills, everything from self-management for pain, for stress, for sleep, for diet, and things like that. So this is a free portal. So the worst of the worst of the case, if this patient has access to understand, speak English and has access to a computer, that is what you can give. Now, if the patient lives in a very big distance, does speak English, has no one to get him to anywhere's transportation, you become more and more limited to assist. So remember the power over pain that can be given to everybody as a free portal. The other thing I advise everybody, I'm talking about different health providers, who really has an interest in pain. And they want to do the best they can, get educated, attend courses. My advice is one sentence, never practice alone in chronic pain, which means find out other similarly minded medical, non-medical people that can create a network that you can rely, if you have a difficult pace on if you need advice, get this kind of network for support. Chronic pain is a business and a very difficult to practice it alone. I would say to everybody being a physio, being a chiro that you operate in a small clinic, try to find out other minded people, try to create a network where you can rely on, or you can send a message, say, can we discuss that pace? That is a much better support than having none. So these are some of the basic pieces of advice that I will give to young people who want out and practice in smaller cities, smaller towns and so on. Have you found that your practitioners and health care providers that work within the center, do they have different experiences working there and being able to have this conversation versus working as individuals? They do, but the one thing that we do also, all my provider have people and networks that they trust. So what do we see somebody who comes to us from Oakville? And we know what is going on and they cannot come to us. We say, these are the providers that we trust, our members trust. So all these are vetted providers across the central Ontario. If we know, other resources we use, and I don't know if this is accessible to the public, but we use very much the Canadian Memorial Chiropractic College in terms of clinics. All of these young chiropractors practice other senior clinicians that they have several clinics, and they charge very, very low rates. And they do a very good job because they are young ones and they want to work hard. So there are several clinics. It is the same thing that patients could go to the dental school. If you are training as a dentist, you need patients. So the fees are much lower in the young dentist's graduate. They practice under senior clinicians. The same thing comes with the natural pubic college, the massage college. I don't know what happens with physiotherapy. Do you have any clinics where we treat the public or do you always practice within hospitals? How does it work? Yeah, we have both where you can work in public practice in hospital or in private practice as well in a clinic. No, but we are talking clinics where young physiotherapists practice and you can offer very low fees to the public. All of these other clinics that I mentioned are very low fees to the public. And it's a huge resource for those patients who can't afford us or can't afford other clinics for unimodality therapy. So do you have anything like that? Not in every university. I know at the University of Alberta they have student physiotherapy clinics, which I did my last placement and I really, really enjoyed it. We offer low fees. We are supervised by a faculty member. But not your universities have that. Physiotherapy is one of the professions that is really remarkably absent in this aspect where we consent our patients. The young ones who are graduating, they are going to give our patients. We have excellent reviews from our patients that cannot afford the regular facility. That's even single therapy because they need just manual and exercise therapy when they go to the students clinics. And they have excellent therapy. I mean, we receive all kinds of thank you for our pensioners and things like that. That's something that is obviously very much missing. At least I don't see that in the University of Toronto. And I don't know about other universities in Ontario that train physiotherapists in Ontario. I don't think so. If it's alright, I'd like to shift our conversation just ever so slightly. We've talked a lot about the way the program runs. Obviously this funding accessibility, which I think is such a highlight of the program. So you've lots of different patients that are coming to see you. What is happening with those patients? Can you illustrate for us and for our audience what it would look like for a patient to come to your clinic in a chronic pain state and what it looks like for them to graduate from the program? First of all, there are different paths. All patients who come to us are coming as a medical consultation. But you have to remember, our model of care is hybrid because only half of our operations have funded from the Ministry of Health. The other half, all the providers who are here have their private patients. If a patient was to send his brother to see my ex therapist, they don't have to come to me. They go directly and they pay like they do in all other facilities for a specific kind of product. Not robathic or other whatever services are there. So that's the private part of our operations. But when it comes to a tertiary care clinic as a facility, then they are all having to be referred. There are no self-referred patients and medical specialists. So you can't really knock at the door. We don't have walk-ins. The physicians have to send a specific referral or some problems start from that time because 40% of all our referrals will reject them because they don't contain appropriate information. You can't get a single handwritten note and not even be able to read it. That says, "Oh, three back surgeries or high levels of opioids, please assess." No X-rays, no past use. Of course, this is going to be rejected. And half of this, we send, of course, specific forms and say, "This is what we need." And half of this will come back. The other half will never come back because they never do the job. It's a huge issue for us. In appropriate referrals or referrals with minimal information, for a tertiary care clinic and a major issue, we just published a paper that shows how much time we waste for inappropriate or misleading referrals. Imagine that they could refer to our pain-cling. Somebody who has ADD or somebody who beats his parents. We receive referrals just like that. So forget the referral. The referral has to be appropriate. The patient, we have a waitlist and we're between two to four weeks. The patient will be paired with a chiropractor and a medical specialist to see the patient. So the patient spends here two hours. They feel specific forms, body diagrams, the pH-Q9, the gut-7, the BPI. Then the minor therapies will see the patient, do the physical, and then we see the patient together. We sit down, I may repeat parts of the examination that we discuss diagnosis and management. We order tests, whatever is needed. This is the original point. And after that, patients go to different directions. Those for the interdisciplinary program will be guided to an intake and then they will be for the big program. Those who have a very specific goal, let's say somebody who has a mechanical problem and maybe some dietary problems or need a pain education will be paired with only to providers for a short, goal-oriented, multidisciplinary program of limited duration. Other patients will go into certain investigations and be channeled to other specialists. If I do the work and say, "Oh, no, no, no, this guy is not just a plain mechanical backman." His rheumatoid arthritis will be referred to a rheumatology. Those, as I said, five to eight percent of our patients may need interventions. We see complex regimen pain syndrome. We see fail-back surgery syndrome. Once treatments have been finished from the medical point of view, they may be going down for spinal stimulators to the university health network. work. There are other patients that we return back to the family doctor with recommendations. You only need to do this, this, this, or do these tests, bring the patient back, we'll follow up. So there is medical management, there is unimodality management, there are interventions, there are spinal stimulators, there are just simple medical manipulations for the treatment, and then there are the big programs and smaller multidisciplinary programs. So there are several directions that these patients can take. Absolutely, and you mentioned earlier a little bit about how long chronic pain takes to treat. That it is a very extensive process to help someone improve in chronic pain. If you a family member who is in chronic pain or you're supporting someone who has chronic pain, what do you think is important to know, trying to support someone who's going through intensive chronic pain treatment such as your program? First of all, very many times we find out that when our patients come here, unless you miss a limb or somebody has taken your ear, your nose, chronic pain doesn't show up. So many many times they have problems, and when we say chronic pain, I want to make sure that you understand what I mean, chronic pain, chronic pain beyond the normal time of healing, where many central embedded factors and emotional factors contribute to the perception of pain. That is the most difficult part. If I get chronic pain because somebody has end-stage osteoarthritis, my next step of the investigation is to ship him down to one of my surgeons, and they get the total knee replacement. The door closes there because they're coming back and saying thank you dog, I'm so much better now. We are talking this other chronic pain with all the predicaments of centrally mediated and the rest of the stuff. So patients very often will say nobody understands us. It's very important that sometimes our therapist psychologists are having family counseling to make sure that they educate the immediate environment of the patient as the what chronic pain is. One of the things that I wanted to do for a long time, I always wanted to create a pain and wellness health channel in YouTube that is going to have regular episodes, short video clips that train the lay public, but also many, many of our students and other health professionals in all kinds of concepts like the ones I'm discussing. What is pain, what is chronic pain, what are the different forms, what do we have to do, what is nocyplastic pain, what is neuropathic pain, the whole thing. So we have been filming a lot of these episodes and we are going to go up in the air on pain and wellness YouTube channel within the month. If your organization is interested, we'll give you all the links so you can follow because it's everything, pain in men, pain in women, pain in children, pain in culture, pain in psychology, all of those things and then specific on topics. All of those things because it's going to be an indefinite source of knowledge and of course, because we're not only interested in pain, we're interested in wellness, wellness is a totally different concept because we have type two medicine. We try to treat conditions that are already developed. Type three medicine is preventing these conditions from occurring. So that is where a part of wellness, if you want to have your grandchildren 30 years from now, what do you think you should be able to do to reach that level? So we're interested in other concept of ours is not life span, it's health span. So I have many of our providers who are very much into the longevity things and we plan to bring this over the course of time in episode. So that channel will be a big source of information for so many of the patients and our young trainees and other professionals, so I let you know about that. That's one thing. And the second thing that I'm interested in, we are going to launch it soon at another vision of mine, a mature women's health program, 50% of the earth's population will go through menopause and nobody talks about that. It's only over the last two, three years that there has been a menopause gold rush and everybody talks about that and strangely, because I'm a researcher, we start repaying more attention and we started giving specific scales just to realize that more than half of the women who seek care are also in Florida, many menopausal symptoms. Nobody has connected the possibility that many of these women go to pain clinics because of all the other hormonal changes. So we are introducing new programs to address also the hormone thing in women. So I'll let you know all of those things as we go through the passage of time. So when you have somebody with chronic pain and you want to help their relatives or the caregivers understand that, there will be tools, power over pain is one thing that you can give to all your clients and then of course, there are other training programs that exist for lay people. When our channel goes up, I will let you know and they can look into that. And there are all kinds of support organizations and there is also pain Ontario and other pain organizations in different provinces that have all kinds of materials. So if you know that this exists there, you can draw a number of resources to give to your patients. No, thank you so much for letting us know about YouTube channel and also the potential recorded educational videos. I can imagine that would be a gold mine of information and resources for not only the patients, but also professionals who are working with patients who are going through pain and chronic pain. Speaking of educational and pain education, I know that it is a very crucial part of pain rehab. Currently, with your interprofessional team, who on the team is more involved with pain education or is it everybody has their own part in it? And what means of education have you found to be most effective with patients? We have signed an agreement with the Canadian Memorial Karol Practice College to train their residents. When young caropractors graduate, a small percentage of those going to what would be similar to a master's degrees, sports medicine and things like that. So all of these young caropractors in the residency programs rotate through our center. And they are exposed to medical consultations, the interdisciplinary team. They are exposed into treatment into their rooms with their patients. So the majority of our caropractors have taken this kind of trainees from the caropractic college. And then we have pain medicine residents that have an obligatory rotation with us for about a month. One of the most important thing, not only the consultations that they see, but for the first time they get into the provider's room, they're taking down to the gym. They see a hands-on approach and that's amazing for most doctors who have no idea. Why caropractors and not physiotherapists? Because when I was setting up the team, it was all kind of fortuitous. First of all, for years, I had no freaking idea what a caropractor was. I always knew physiotherapists because this is how it grew up in the hospital. And then, strangely, my younger son decided to announce to me that he was going to go after Kinesiology. He's an athlete, a bodybuilder. He decided he was going to go on the caropractic college and said, "What's that?" So anyway, I became more integrated and then I was asked to teach. And I had other clinicians who went to this and I was kind of amazed by the depth of the education they have, amazed. And of course, one thing that I found is how much humbled I was by the amount of knowledge other colleagues had that I didn't have. And so this is where I learned to appreciate how each member of the professional team can bring skills that I don't have. And this is where the collaboration strengthens each professional. We all get stronger from learning for each other. This is what I call cospolination. So when we are setting up the program, it was much easier for me to be integrated and I picked up almost everyone who had been the president of their class. And I was the one who brought the first ever caropractor to the university health network as my clinic coordinator two years before I left the hospital. And then they got a clinic there and all of that. So we ended up going with the caropractor college because they were very interested in coming to us. They were very interested. They appreciated what we do. And they were very interested to have links with us. And this is how it came. Now we are out searching as we are developing our programs for a physiotherapist that we want to make sure she has both orthopedic skills but also pelvic floor therapy because that's the other thing we are putting in there. So we are in the search for that. So this is how it transpired that we have caropractors but we want to unhums our stuff with physiotherapist but we also need specific skills. So we take observers from physical medicine residents to family practice electives to pain medicine residents who are already certified, born certified or FRCP on these ideologies of PMNR and neurologist. And then of course we take as I said caropractic students and if people want to observe we had a number of requests from young medical students and we decided we are not going to take them because many of the young ones the last moment cancel when we have set up a whole program for them. That happened to us today. So it seems that we put so much effort ourselves, so much time to organize programs and they are very young ones. They drop us just like that and I said I'm not interested. So if anyone wants to be a observer we are going to vet them very well and see if it is worth our time because so far some of our time has been spent unwisely and usually one observers come, they watch everything, they get a tour of the facility, they speak the psychology is in the end. They sit in concepts, they get into the room with the providers and this is how they try to get some idea of how we operate. A two of our Cairo practice are also members and are formal teaching in the CMCC. Maybe that has answered your question and of course I'm still a formal member of the University of Network. I teach undergraduates when I have the opportunity is just that my day has only 24 hours and I need 48. I totally understand that feeling. We all wish that we had more time to do the things that we want to do and it seems like there's always responsibilities that just keep popping up. So I wanted to ask you looking ahead into the future. Are there any new advancements or developments in pain management or in the field of pain medicine that you would like to see in the coming years? Yeah very much so I would like to see the system in our province, revived, paying more attention to that, produce big changes and also include accountability. I don't want to see changes without accountability tag to it. So there are many many things that can change but you have to remember where the smallest wheel in the whole vehicle, policymakers, administrators, conditions, international conditions are all shaping our environment. So other than that there are several new techniques for pain management including pain reprocessing therapy that attempts to rewire the brain central sensitization. We have 10 practitioners that have been all trained in pain reprocessing therapy in our centers. So we try to really get into the future where interested in digital technology or interest in the NEI, what interest to introduce all kinds of approaches that could make us more efficient and may help the patients as well. That's definitely changed that we would all like to see, especially to help all the patients that need chronic pain care. Is there a message that you would like to send to policymakers, how care providers or just the general public about the importance of interdisciplinary pain management? I don't know how much louder I can be than what I have been all my life. All my life as you want to think that I say I'm a huge proponent or multi-professional teams, a huge proponent of the need for cross-pollination. This is more of the thirst of learning and one person cannot know it all. And the other thing that's very important to me is the respect for the different providers that has to be an even plain field. It can't be on the top of the pyramid and everybody else is at the bottom. So there's a whole lot of changes that I would like to see but I don't know if it will happen in my lifetime. I know that you've been a really, really strong proponent and you've been a very loud voice in our pain community and you've also been a very strong advocate for interdisciplinary pain management. But what about people like us or just listeners or patients? How can they support the cause of expanding pain management and move towards a more holistic and interdisciplinary pain approach as someone who's not involved with politics or had connection to policymakers? For the patients, the one suggestion that I make to everyone, you must be an advocate for yourself. I'm a very big proponent of self-advocacy and also when I see patients here come with their caregivers, we deliver our notes to the caregivers or the patients because our notes are their weapon. And so I'm a very big proponent or educating patient of sharing knowledge with the patient, of sharing knowledge with college, creating networks, as I said, and even the small cities can create networks, never practice pain alone, never be a loner in this area. So I don't know how much more I can say self-advocacy and these networks are the only thing that I can advocate and tell the patients and also to provide them with resources which exist if you go to the OCPN Power over pain and all other kinds of areas. Amazing. Dr. Males, do you have any concluding thoughts for us before we end our interview here? I will only leave you with what has been really my guiding force over the 43 years of being in the area of Croni Paine where when I started it was no month's land, no woman's land and everything I remember was a fight to get the things going. When I left the hospital to create my clinic, they said the diva of pain is crazy. This was the rumor. Look what she did. She left all her hospital to go there. Nobody says that. Now, and I remember what Stephen Jobs, the founder of Apple said, those crazy people who think they can change the world, they are the ones who go and do it. And one final thing, you can have a vision. A vision is different than a dream in my books. Dream is winning 649. A vision is a goal and an objective. A vision needs thinking, planning, scenario A, scenario B, scenario C, all of this risk mitigation until you reach your vision. So I said to my staff, don't you dare come here and tell me you have a big idea without telling me who, what, when and how. Work on the idea, present me with a plan and then we can go but don't bring me a fluff. So anything you can do, this guy may not be the limit, but be planned, creative, but also regimented, disciplined, and know where you want to go. Set some realistic goals, but know they will go the extra mile. So vision and creativity are not a totally different thing from obtaining something that other things is impossible. As long as you plan and you do not deviate from the goal. So that's the only thing I can say. Wow. I mean, sitting here, I feel inspired just to figure out my plan. Thank you so much. Your words throughout this entire interview have been inspiring through and through and educational. I know we appreciate it greatly and I'm sure our listeners appreciate it as well. So thank you so much for your time. Thank you very much. And I'm going to let you know when our channel goes up in the air so you can disseminate in your groups. Thank you for listening to this episode on interdisciplinary chronic pain care. If you want to read more on this topic, we've included some articles and links in the show notes. Paincast is a freely available resource for you to advance your knowledge about pain and physiotherapy. We will continue to provide you with top notch evidence-based, practically oriented content. To help more people know about this amazing resource, follow us, rate us, and share our content with your network. Follow us on Instagram at paincast.psd where you'll find bite-sized knowledge in one to two minutes. 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