In Reply: - We appreciate the opportunity to respond to Drs. Khan and Erjavec. Their comments show several of the issues and concerns we discussed in our article.

It is difficult to understand the rationale of Dr. Khan's position with regard to the usefulness of psychologic treatments for pain. His confusing references to the empirical basis for psychologic treatments and his global dismissal of such interventions as "neither successful nor economic and, therefore unprudent [sic]" reveals a fundamental misunderstanding of the contemporary pain literature that defies further comment. His perspective should not be dismissed lightly as the ill-informed opinion of one isolated practitioner. Unfortunately, it represents an attitude that pervades the world of biomedicine.

Dr. Khan's concluding remarks eloquently portray the biomedical myth that lies at the root of the problem of intractable chronic pain. His prediction that, "at the end of the day, we will be convinced that pain is a simple sensory messenger from the damaged tissue crying out loud 'Please fix me'" is quaint, but very disturbing. Although, unlike Dr. Khan, numerous practitioners do not grossly oversimplify this complex clinical problem, many well-meaning physicians practice as if this is the case. Contemporary medical education emphasizes nociception while ignoring the psychologic and social aspects of chronic pain. One of the major points of our article is that as long as the practitioner remains limited to a biomedical model those patients who are the most overwhelmed by pain will remain enigmatic. [1]It is our belief that to help those patients who show "minimal pathology with maximum dysfunction" [2]the anesthesiologist needs to learn a whole new set of conceptual and clinical skills.

In his letter, Dr. Erjavec shows an awareness of the importance of psychologic and social factors of chronic pain. He acknowledges that the proceduralist must "first and foremost be a communicator and a behavioralist and well-rehearsed in the biopsychosocial skills of pain medicine before being given the privilege of performing procedures." It appears that, as we suggest in our article, he restricts nerve blocks to those patients who have high levels of psychosocial functioning and clear organic etiologies indisputably amenable to nerve block therapy. [1]Therefore, according to Dr. Erjavec's stated position, we disagree mainly about practical matters rather than about conceptual issues. We applaud his efforts to screen patients for psychosocial problems that mitigate the decision to perform a procedure. We suspect, however, that most anesthesiologists lack the skills to perform such evaluations. Our article outlines the changes in training we believe are necessary. [1] 

Unfortunately, in the real world, many "needle-jockeys" function more as technicians than as physicians. The incentives and pressures of modern medicine leave little time to practice the "art" of medicine. The major purpose of our article was to describe new opportunities for anesthesiologists to learn old medical skills that are devalued by biomedicine. It is important to understand that overwhelming chronic pain is not a biologic event, but rather an all-consuming personal experience. [3]We advocate a biopsychosocial approach that is tolerant of incomplete medical knowledge and that accommodates medicine's limitations. When complete understanding is abandoned as a goal, the traditional tasks of the physician-listening, witnessing, and relieving suffering-are not relegated to a small corner of medicine, the so-called art of medicine, but are returned to the core of medical practice and medical education. [4] 

Louis Jacobson, M.D.

Charles Chabal, M.D.

Department of Anesthesiology

Anthony J. Mariano, Ph.D.

Edmund F. Chaney, Ph.D.

Department of Psychiatry and Behavioral Sciences Anesthesiology and Mental Health Services; VAPSHCS; Seattle Division; The University of Washington; Seattle, Washington

(Accepted for publication March 25, 1998).

Jacobson L, Mariano AJ, Chabal C, Chaney EF: Beyond the needle: Expanding the role of anesthesiologists in the management of chronic non-malignant pain. Anesthesiology 1997; 87:1210-8
Carron H: The changing role of the anesthesiologist in pain management. Reg Anesth 1989; 14:4-9
Kleinman A, Brodwin PE, Good BJ, Good MJD: Pain as a human experience: An introduction, Pain as Human Experience. An anthropological perspective. Edited by Good MJD, Brodwin PE, Good BJ, Kleinman A. Berkeley, University of California Press, 1992, pp 1-28
Goodwin JS: Chaos and the limits of biomedicine. JAMA 1997; 278:1399-40