godfather of surgery

Chapter 1285 I'll still do this project.

Now that the diagnosis is clear, the next step is to treat the patient according to the proposed plan. However, this kind of chronic pain cannot be cured in a day or two. While treating the cause, pain relief should also be taken into account so that both the symptoms and the root cause can be treated.

In his spare time these past few days, Li Min has consulted many monographs and papers on pain, accumulating a lot of knowledge in this area.

On Friday afternoon, after a busy week of work, Yang Ping asked Song Ziming to gather the department's doctors in the conference room for a discussion-based learning session on the topic of "atypical pain".

This kind of pain is extremely common in clinical practice and often doesn't get well treated. After numerous tests, the cause remains unclear, and the treatment usually boils down to a three-pronged approach: nonsteroidal anti-inflammatory drugs, physical therapy, and rest. If it works, great; if not, there's not much else to do.

Now Yang Ping has gathered everyone together to study this type of pain. He hopes that everyone can learn some experience from Ms. Lin's case so that they won't be perfunctory or helpless when dealing with "atypical pain" in the future.

In fact, it's not just young doctors who face this situation; many expert doctors who can perform major surgeries are also helpless against this kind of pain, and some even feel disdainful of dealing with such minor issues.

"Today's learning session will not discuss specific surgical plans or cutting-edge medical technologies," Yang Ping said, getting straight to the point. "We'll just talk about a case we recently encountered, and the 'atypical pain' it involved. We encounter this kind of pain every day, but we may take it for granted or even feel helpless about it."

"Dr. Li, could you give everyone a report on the cases we've encountered in our outpatient clinic?" Yang Ping turned to Li Min.

Li Min gave a detailed report on Ms. Lin's case. After the report, Yang Ping said, "Everyone is welcome to speak and discuss freely. We don't have many rules, and you don't need to speak in order of professional title."

Song Ziming leaned back in his chair, a thoughtful expression on his face: "Ms. Lin's case is indeed classic. I've done some statistics before, and at least one-third of the patients in the orthopedic clinic complain of pain, and more than half of those are chronic pain. Like her, many patients have gone to different clinics for years, undergone numerous examinations, and still can't find a definite cause. We often get stuck after ruling out obvious anatomical problems, such as chronic injury, tumors, infections, etc., and eventually give up."

Xu Zhiliang flipped through the documents in his hand and said, “Pain is a subjective experience, while modern medical diagnosis relies heavily on objective indicators. When objective indicators are ‘clear,’ doctors are at a loss, but patients are not free from pain. At this time, both doctors and patients are prone to anxiety and mutual suspicion. Doctors may tend to attribute the cause to psychological factors, while patients feel misunderstood and even thought to be whining. Ms. Lin’s case reminds us that objective indicators are sometimes not without abnormalities, but they may be hidden in unconventional test items or manifest as extremely subtle and discrete abnormalities that are difficult for us to cover up with tests in the short term.”

"Old Xu, what's wrong with you?" Song Ziming was quite surprised that Xu Zhiliang was no longer stuttering.

Xu Zhiliang didn't react immediately: "What happened to me?"

“What I mean is, you speak now…” Song Ziming prompted him.

Xu Zhiliang then realized what was wrong: "Oh... I... what's wrong with what I said?"

It would have been better not to remind him, because reminding him only made things worse. Xu Zhiliang was speaking perfectly fine just now, but now he's stuttering again.

Xu Zhiliang's wife is quite clingy. Ever since he got married, Xu Zhiliang would tell her stories about the cases he encountered at work after getting home, and sometimes he would even stop stuttering. He was speaking quite fluently just now, but Song Ziming reminded him, and now he's stuttering again.

Seeing Xu Zhiliang's stutter, Song Ziming regretted her words; she shouldn't have said that.

Yang Ping nodded and gestured to Li Min: "Please find a few cases from the orthopedics department that you've collected in the last three months, all of which present with persistent symptoms such as 'multiple pains throughout the body,' 'migratory pains,' and 'no clear abnormalities found on examination,' and briefly describe them."

Li Min was prepared. He opened his notebook: "Female, 42 years old, teacher. Chief complaint: widespread soreness and pain in the neck, shoulders and back, accompanied by headaches for three years, which worsens after sitting at a desk. Physiotherapy and massage have only a short-term effect. Cervical spine MRI only showed mild degeneration, nerve conduction was normal, and rheumatoid immune screening was negative. She was previously diagnosed with 'cervical and shoulder myofascitis' and 'tension headache,' and was advised to 'rest more and strengthen exercise.'"

"Male, 50 years old, programmer. Chief complaint: soreness and pain in both wrists, elbows, and knees, accompanied by morning stiffness in the fingers (less than 15 minutes) for one year. Rheumatoid factor and anti-CCP antibody were negative, erythrocyte sedimentation rate and CRP were normal, and joint ultrasound did not reveal definite synovitis. 'Undifferentiated arthritis' or 'early osteoarthritis' was considered, but the degree of pain was inconsistent with the slight degeneration on imaging."

"Female, 28 years old, dancer. Chief complaint: deep bone pain in multiple areas of the ankle, calf, and hip, which is more pronounced after training and partially relieved by rest. Bone scan showed mild increase in metabolism in the stress area, and MRI showed sporadic bone marrow edema, but no stress fractures. Overuse syndrome was considered, but the improvement was limited after adjusting the training volume, and the patient felt a decline in physical fitness."

"Male, 35 years old, sales manager. Chief complaint: migratory stabbing or burning pain in the chest, ribs and back for eight months, sometimes related to breathing and turning. Heart, lung and stomach diseases were suspected, but relevant examinations were normal. The pain clinic considered 'intercostal neuralgia' or 'somatic symptom disorder', but drug treatment was ineffective."

With each case mentioned, the brows of the orthopedic doctors present furrowed more deeply. These situations are all too common, so common that they are encountered almost daily in the orthopedic clinic.

“These patients share similarities with Ms. Lin: the pain is real and significantly impacts their lives; routine examinations are insufficient to diagnose a textbook disease; and the explanations and advice they receive are often vague and ineffective,” Yang Ping said slowly. “We often categorize them using descriptive diagnoses such as sub-health, chronic fatigue syndrome, fibromyalgia, and myofascitis. But these labels are more like collections of symptoms than diagnoses of causes. They may comfort some patients, but they offer limited help in finding interventionable causes and achieving precision treatment.”

Xu Zhiliang moved his lips as if he wanted to speak, but hesitated, afraid of stuttering, so he simply remained silent. Song Ziming leaned forward: "The problem lies in orthopedics, and even the entire medical system. In training and practice, we are better at handling specific problems—for example, a fracture, so we reduce and fix it; an infection, so we treat it… For this kind of diffuse, systemic pain with vague indicators, our toolbox seems a bit limited. We instinctively apply what we know best: orthopedic surgeons look at structure, rheumatologists look at immunity, and pain specialists look at nerve conduction and central sensitization. But what if the cause is elsewhere? For example, in Ms. Lin's case, the cause lies in toxin metabolism and microscopic bone metabolism."

"So, Professor Yang, I believe the key to solving these kinds of problems lies first and foremost in a shift in mindset?" Song Ziming added.

“Yes,” Yang Ping affirmed. “We need to shift from a mindset that excludes specific diseases to a mindset that constructs a holistic pathophysiological model of the patient. This model may need to span multiple systems: the musculoskeletal system, the nervous system, the endocrine system, the metabolic system, the immune system, and even psychosocial factors. These are not isolated, but rather a network that interacts with each other and jointly leads to the experience of pain. This is not just a change in mindset, but requires extremely strong basic medical knowledge and the ability to connect basic and clinical aspects.”

He paused, then continued, drawing a mind map on the whiteboard as he spoke: "Taking Ms. Lin as an example, our thought process is as follows: pain is localized in the bone (deep, migratory) → injury, inflammation, tumor, and structural abnormalities are ruled out → extremely discrete changes in bone signal are found in the examination → what would cause local bone fragility? → bone quality (mineralization, transformation, matrix) issues are considered → what affects bone quality and metabolism? → minerals, endocrine, and toxins are investigated → suspicious exposure sources are found from the patient's life history → targeted testing verifies the hypothesis. This is a path of reverse deduction, continuous deepening, and integration of diverse information."

"In the reasoning process, questioning is very important. Often, questioning can find the starting point, and then you can follow the clues to find the cause."

Xia Shu listened for a long time, seemingly lost in thought: "This requires doctors to not only have profound specialized knowledge, but also a broad foundation in related disciplines, as well as a strong curiosity and detective-like patience. Under the high-intensity work in outpatient clinics, this is very difficult to achieve."

“It is indeed difficult, but not impossible to begin,” Yang Ping said. “We can start with some basic principles and clues to establish a preliminary screening and thinking framework for dealing with ‘atypical pain’.”

He continued writing and talking:
First, we need to re-examine and refine medical and life histories.

"We can't stop at 'where it hurts and how it hurts.' We need to ask about the details: the exact nature of the pain, its rhythm, activity, posture, stress, diet, and its relationship with a woman's menstrual cycle. We need to delve deeper into her occupation, hobbies, eating habits, living environment, pets, travel history, medication history, including health products and traditional Chinese medicine, and unusual points in her family history. That's how we uncovered the clue about Ms. Lin's painting pigments."

Second, conduct targeted and unconventional physical examinations.

"In addition to examining the painful areas, a comprehensive physical examination is necessary to look for clues in subtle, non-painful areas: skin, nails, mucous membranes, lymph nodes, thyroid gland, etc. At the painful areas, try different techniques, such as the stress palpation used on Ms. Lin, or a range of motion test in a specific direction, which may elicit a more typical response."

Third, we should view and interpret the inspection results rationally and in depth.

"The normal range does not equate to an individual's optimal condition. Borderline abnormalities, such as blood magnesium at the lower limit of normal or vitamin D deficiency, may have pathological significance in specific individuals. Discrete imaging findings, such as micro-bone marrow edema or localized cortical irregularities, even if the report states 'considered degeneration or artifacts,' require careful consideration in conjunction with clinical findings. When routine examinations are inconclusive, one should be bold enough to request more specialized and cutting-edge tests based on clinical suspicion, such as specific metabolomics, trace element analysis, functional medicine testing, or even gene sequencing."

Fourth, establish a regular mechanism for multidisciplinary collaboration or possess knowledge that integrates multiple disciplines.

"Orthopedics alone cannot solve all pain. We need to establish more convenient and in-depth communication channels with rheumatology, pain management, neurology, endocrinology, clinical nutrition, occupational disease, and even psychiatry. It's not just about simple consultations and referrals, but about early joint assessments for complex cases. If doctors have such comprehensive knowledge, they can complete the joint assessment in their own minds."

Dr. Li Guodong also figured something out: "From a scientific research perspective, this patient group is also a treasure trove. Beneath their pain may lie subtypes of diseases that are not yet fully understood, or new pathological mechanisms. If we can systematically collect clinical data and biological samples from these patients with 'pain of unknown cause' and conduct multi-omics analysis, we may be able to discover new biomarkers or even define new disease entities. This is more valuable for exploration than simply tracking typical cases of known diseases."

Another PhD student smiled wryly: "The idea is good, but the reality is that outpatient clinics are overcrowded, and each patient has limited time. Conducting such in-depth consultations and reflections takes time, and for outpatient doctors today, time is precisely the scarcest resource. Moreover, not every case of 'atypical pain' can find a clear chemical exposure factor like Ms. Lin's. Many cases are indeed complex states with multiple intertwined factors, including central sensitization and psychosocial factors playing a significant role."

Yang Ping agrees: "You're right, resource limitations and the complexity of causes are objective realities. We can't possibly conduct a thorough investigation of every pain patient. But that doesn't mean we should give up our efforts to explore in depth; we should establish a comprehensive diagnostic model for pain in our minds."

"I think this 'unexplained pain' can be studied as a new research topic," Yang Ping summarized. "Our research does not pursue a short-term number of cases, but focuses on the depth and quality of diagnosis and treatment, as well as the exploration of mechanisms. Even if we can only thoroughly resolve three to five such difficult pain cases a month, it will be a tremendous change for these patients. At the same time, this process will be an excellent training ground for the clinical thinking of all the doctors involved."

Upon hearing "researching atypical pain," Zhang Lin immediately said, "It sounds very meaningful and challenging. Everyone is very busy, but Xiao Wu and I are willing to research this topic."

Zhang Lin knew that Song Ziming and Xu Zhiliang, these big shots, disdained to research this kind of topic. If he didn't take the initiative, the topic would definitely be snatched away by other doctors. This was a rare opportunity, and it was the best time for him and Xiao Wu to make their transition.

Xiao Wu was thrilled: "Yes, we are willing to study this topic, even if it takes five or ten years."

“Let me do it. Let us graduate students do these basic research projects. You have many big projects to do and time is tight.” Li Guodong was not about to let this opportunity pass.

“I think Li Min and I are best suited to work on this project together.” Li Guodong asked Li Min to be his comrade-in-arms.

Li Min was also very interested and immediately agreed.