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Foreword
“The brain is the organ responsible for all pain”: John Loeser packed enough dynamite in fewer than ten words to blow up centuries of erroneous thinking about pain. His statement, implausible to patients and controversial inside medicine, carries the authority of a neurosurgeon who understands that the brain not only interprets electrochemical signals from the peripheral nervous system but also interprets social signals proceeding from outside the body. The brain thus serves as a matrix where the interior biology of nerves and neurotransmitters meets the exterior environment of history and culture—all played out in human consciousness. Consciousness, as a product or an emergent property of the brain, is where our memories, fears, desires, habits, dreams, and irruptions of concealed mental life all prove relevant to the human experience of pain. Anesthesiologists and neurosurgeons, among the earliest modern pain specialists, temporarily turn off pain by interrupting nerve transmission or by turning off consciousness. What happens, however, when the pain refuses to disappear? Chronic or intractable pain is the dilemma that prompts John Loeser’s revolutionary statement that the brain is the organ responsible for (as he puts it boldly) “all pain.”
John Loeser’s statement appears in the September 1991 issue of Theoretical Medicine. Specialists in the 1980s had begun to explore biopsychosocial models for pain, John Loeser chief among them, but his statement constitutes (as I read it) a bombshell shift in emphasis. The indispensable, underlying role of the brain implies that pain—despite its neural substrates—can assume the contingent shapes of an individual consciousness, as personal as a fngerprint. It can absorb any permutation of variable infuences from a particular era, a distinctive set of pain beliefs, changing sociocultural contexts, and even gender. Chronic pain especially, even if it coincides with visible lesions or invisible tissue damage, requires a multidisciplinary approach that extends beyond the traditional repertoire of drugs and neural blockades.
The statement that the brain is the organ responsible for all pain did not rock the feld of pain medicine like the Melzack/Wall gate control theory. It was uniquely John Loeser’s conclusion—the culmination of years of clinical observations and
research—that remains in my view a concept deeply relevant to all felds concerned with human pain.
John Loeser, as a major fgure in the invention of the multidisciplinary pain center, calmly presided over the conficts that accompanied the growth of pain medicine as a science-based clinical discipline. I witnessed arguments at pain conferences in the early 1990s so acrimonious that the disagreements I was familiar with, in the far more genteel humanities, looked like tea-party talk. Through it all, John Loeser proved a sane and cohesive presence, keeping the dialogue open and moving the discipline of pain medicine forward. He did all this largely through a personal power so remarkable, as Jane Ballantyne shows, that it cries out for a biography.
Jane Ballantyne’s fne biography constitutes almost a sideways or stealth history of the modern pain movement. She worked with John Loeser for many years, and her detailed landscape of people, anecdotes, episodes, and ideas creates a rich context for understanding a multitalented man who is equally at home in his command of the operating room and in carving wooden masks based on northwestern indigenous traditions. A respectful, bantering way with children, for example, goes beyond his professional role as a pediatric neurosurgeon to touch on the importance of family ties—like his devotion to the family of his predecessor John Bonica. What John Loeser accomplished in pain medicine is inseparable from qualities that, however elusive and incomplete any description, add up to a remarkable and distinctive personal style.
Style is a useful term in thinking about John Loeser because it sidesteps the ideas of personality and character rooted in the nineteenth century, when character suggests a fxed moral center, and personality suggests an innate disposition, like cheerfulness. Style derives from the ancient Roman instrument used for writing (Latin stilus), and it proves similarly useful in communication. Style, to modern thinking, is not separate from content or substance: style is substance. John’s intellectual grasp, his friendships, his willingness to fght for his beliefs, his love of argument, and his tireless zest for travel in promoting new associations for the study of pain all help constitute the personal style that makes him the substantial fgure and the right person to assist and to champion the timely growth of new multidisciplinary centers. It is a personal style that communicates a way of being in the world that other people almost instantly respect.
I had a privileged position to observe the respect that seems to spring, almost unbidden, from John Loeser’s distinctive personal and professional style. The Rockefeller Center at Bellagio offers its facilities for weeklong international conferences on social issues, and the conference for which I was a co-chair brought together specialists to discuss relations among pain, suffering, and narrative. Narrative was not then and is not now a standard topic in pain medicine. As the three co-chairs, which included pain specialist Daniel Carr, divided up the organizational duties, John’s initial contribution was to invite prospective speakers. The conference and the book that resulted owe their success directly to John. Amazingly, everyone we invited to be a speaker accepted. No one, I learned, turns down an invitation from John Loeser.
There is something down-to-earth and accessible in John Loeser’s style that lends an almost tangible weight to his evident intellectual power. A belief that the brain is the organ responsible for all pain does not begin as an abstract or a theoretical idea. It originates in the clinic, and it has to prove its worth in the clinic. Its clinical origin, in fact, depends on John’s close working relationship with psychologist Wilbert Fordyce. Jane Ballantyne gets John to describe a eureka moment when he frst grasps the implications of Fordyce’s psychological approach. It is Loeser and Fordyce together who create the new multidisciplinary hallmark of the University of Washington Pain Center, as visitors arrive to transfer the model across the globe. John, as its long-time Director, is thus at the center of an expansive new international growth of pain medicine, for which he also provides (in his extended presidencies of key organizations) a crucial stabilizing force.
His openness may be among the most important qualities that both invite respect and help constitute his distinctive style. As an undergraduate at Harvard, his openness fnds expression in a particular interest in other people, other views, and other ways of life. After quickly nailing down premed courses, as Jane Ballantyne describes, he chooses an interdisciplinary major that combines courses in cultural anthropology, sociology, social psychology, and psychology. I can add one supporting detail: as a resident, he takes an evening course at the UW on Pharaonic Egypt. His intellectual openness and broad interests mean that any argument—whether you are a fellow student, a professor, or later a colleague—is similarly open to question. In a Festschrift published in honor of his good friend and distinguished colleague Ronald Melzack, John criticizes the pro-opioid view that Melzack had proposed, infuentially, 10 years earlier in Scientifc American. John Loeser’s high standards mean that you would better bring your intellectual A-game and be ready for a counter-argument. Anything less just will not cut it.
John Loeser continues (even retired in his 80s) to challenge colleagues with arguments that threaten to upend settled views—as in “A new way of thinking about pains” (2022). He also co-teaches a seminar on pain for UW undergraduates, both engaging a new generation of thinkers and feeding his own need to keep on learning. The pilgrims that Chaucer describes with a few deft strokes in the Prologue to the Canterbury Tales include a clerk (riding a lean horse) who prefers reading Aristotle to pursuing worldly reputation or gain. “And gladly wolde he lerne,” Chaucer sums up, “and gladly teche.” The description reminds me that John’s intellectual openness includes an attractive sense of gladness. On the other hand, as someone who enjoys the social pleasures of good food and fne wine, John (I suspect) would also be glad to fnd a better ride.
Groundbreaking concepts sometimes come in pairs, as with Wallace and Darwin. John Loeser reimagines pain and its treatment in concert with Bill Fordyce, but he also possesses the singular style and widespread respect needed to help put this bold new approach on the global map. Readers of Jane Ballantyne’s invaluable book now get to see him in action, including a dangerous moment in a war he opposed when— on a makeshift operating table cordoned off with sandbags—John surgically removes a live grenade embedded in the skull of an elderly Vietnamese man. Who, as the saying goes, does that? Meaning, nobody in his or her right mind. Who—to
ramp up the apparent craziness—would volunteer to do that? (John did.) His calm and skilled dedication to the neurosurgeon’s delicate work—as well as a desire to relieve pain, a devotion to a knowing about other lives, and a resolute rejection of self-display—offers only a start to thinking about the remarkable life of the truly amazing John Loeser.
Emeritus of Literature University of Virginia Virginia, USA
David Brown Morris
Preface
John Loeser will be remembered for his founding and sustained leadership in the feld of pain medicine. Yet, before the feld of pain medicine even existed, he was a highly respected neurosurgeon, co-author of the defnitive text on neuroembryology, a decorated Vietnam veteran, husband, and a father of three. When he became swept up into the pain world, the idea that pain management should be a medical discipline was new. The founders of the discipline believed that medicine could do a much better job of reducing people’s physical pain (pain felt in the body) using better diagnostics, newer technologies, better knowledge of pain mechanisms and processes, focused pain interventions, and newly developed drugs. There was much excitement in the air because the participants strongly believed that they were on the road to signifcantly reducing human suffering. But as with many grand initiatives, mistakes were made, some of which caused iatrogenic harm. John Loeser’s great strength was that, despite sharing all initial enthusiasms, he always recognized when assumptions had been wrong and spoke out early and clearly. Today, four decades after the heady days of the founding of pain medicine, one can ponder what those four decades have achieved. In fact, despite setbacks, what has been achieved is much more than that was even hoped for: science has provided important insight into the mysteries of pain. This insight is already helping those who suffer from pain through improved channeling of resources, avoidance of iatrogenic harm, and realistic expectations. As the story of John Loeser unfolds in this book, so does the story of pain medicine. That link exists because John’s involvement in pain medicine has spanned its history, and so has become his primary identity.
But despite it being central to his later life and career, pain medicine is not all there is to John Loeser. His friends describe him as a Renaissance man, which he is. It is hard to imagine how he fts all his passions and interests into one life, but then superhuman levels of activity go hand in hand with exceptionalism. He has always read widely, with keen interest. He started his reading habit in childhood, since there were shelves full of books in his childhood home (and no television). There is not much he has read that gets forgotten, and he still reads prodigiously. His life has been full of travel and cultural exploration. He has made friends all over the world. He is a lover of art and creates beautiful replicas of native Northwest carvings. He
fell in love with the Northwest when he frst moved to Seattle to be a neurosurgery resident in 1962, and the lure of the Northwest never let either him or his children go. He lives on Mercer Island, a short trip over a long bridge from the city of Seattle. Three of his four children and his seven grandchildren also live on the Island. The fourth lives in the eastern part of Washington state. They are all very close—children, grandchildren, and grandparents—in no small part because of John’s strong sense of family. They all work hard, mess about in boats when they can, and get together often. How many of us are so lucky?
John Loeser is a warm and passionate man. His story is largely a happy one. Dedication to family life is central to his life. That is not easy for a busy neurosurgeon, but after a heartrending divorce from his frst wife, he was especially careful to remain a central fgure in his children’s lives. He could not have done it without the support, companionship, and love of his second wife Karen, with whom he shares his fourth child David, and to whom he has been married for over 40 years. Two years ago, John became paraplegic after surgery to relieve pain in his back of sudden onset due to a bacterial discitis. The associated septicemia was a near-death experience. But remarkably, he has rallied. He will tell you that he had not planned on ending his life as a paraplegic. He worked to rehabilitate and can now walk short distances unaided and longer distances with a walker. He threw away his wheelchair. He is driving, travelling, eating out, meeting friends and family, and still reading prodigiously, doing wood carvings, writing papers, and teaching at the University. A remarkable man, with a remarkable path through life.
Seattle, WA, USA
Jane C. Ballantyne
People
Asgaard, George N 1914–1997 Dean of UW Medical School
Bailey, Percival 1892–1975 Professor of neurology and neurological surgery at the University of Illinois, Chicago. Close colleague of Harvey Cushing
Bales, Robert Freed. 1916–2004 Social psychologist, small group interpersonal interaction
Basbaum, Allan. Professor and Chair, UCSF Department of Anatomy
Beck, Aaron 1921–2021 psychiatrist, regarded as father of cognitive therapy and CBT
Beecher, Henry K. 1904–1976 1941 frst endowed chair in anesthesiology in US. 1955 The Powerful Placebo.
Benedetti, Constantino (Nino) Anesthesiologist and leader in palliative and hospice care
Bond, Michael Physician researcher, England
Bonica, John J 1917–1994 Anesthesiologist and founding father of pain medicine. Brennan, Frank Palliative care specialist and lawyer
Brown, Roger 1925–1997 Social psychology, children’s language development
Bruner, Jerome S 1915–2016. Cognitive psychologist, learning theory, educational psychology
Burchiel, Kim Chairman Emeritus Department of Neurological Surgery at Oregon Health Sciences University (OHSU)
Butler, Steven Anesthesiologist. Professor and pain specialist Utrecht, SwedenWard, Arthur 1916–1997. 1st chief of neurosurgery at UW. Interests stereotactic surgery and epilepsy.
Carr, Daniel B Anesthesiologist and endocrinologist
Cohen, Bernard 1914–2003 Professor of the history of science and author
Cushing, Harvey (1869–1939) Harvard and Yale. Pioneer in brain surgery.
Delateur, Barbara Psychiatrist, trained UW, later chief of the Johns Hopkins Rehab Med
Devor, Marshall, Professor of Pain Research Hebrew University of Jerusalem.
Ellenbogen, Richard G. Professor and Theodore S. Roberts Endowed Chair of the Department of Neurological Surgery, UW
Engel, George L 1913–1999 Internist and psychiatrist, formulation of biopsychosocial model
Fey, Steven UW psychologist
Fields, Howard, Professor of Neurology and Physiology emeritus UCSF
Fitzgerald, Maria Professor of Neuroscience, UCL
Foley, Kathleen Neurologist and cancer pain specialist
Foltz, Eldon L 1919–2013 neurosurgeon, developed frontal cingulumotomy for pain treatment
Fordyce, Wilbur “Bill” E 1923–2009 Rehab psychologist, pioneering work on chronic pain
Fowler, Roy S Jr. Rehab psychologist
Granum, Douglas Tacoma artist who has worked in multiple mediums
Halpern, Lawrence M. 1931–2009. Professor of Pharmacology, University of Washington
Jensen, Troels Neurologist researcher, Denmark
Killam, Eva K 1920–2006. Research pharmacologist.
Killam, Keith F 1927–1998. Pharmacologist.
Kluckhohn, Clyde 1905–1960 Arthropologist and social theorist
Koella, Werner P 1917–2008. Neurophysiologist
Krusen, Frank H 1898–1973 Physiatrist, “founder” of feld of PM&R
Lehmann, Justus 1921–2006 Physiatrist, founding chief of the UW Rehab Medicine Dept
Liebeskind, John 1935–1997. Neuroscientist and pioneer in studying pain’s effects
Livingston, William K 1892-1966 Neurologist
Melzack, Ronald 1929–2019 Canadian psychologist, gate control theory of pain
Michael, Jack 1926–2020 Psychologist, pioneer in applied behavior analysis
Murphy, Terrence M 1937–1996 UW anesthesiologist, pain specialist
Noordenbos, William 1910–1990. Neurosurgeon. Netherlands.
Penfeld, Wilder 1891–1976 Pioneer in epilepsy surgery and neural stimulation. Founded the Neurological Institute and Hospital at McGill University
Ripley, Herbert S 1907–1968 Psychiatrist, Chief of UW Psychiatry
Saunders, Cicely 1918–2005 Physician and founder of the modern hospice
Silbergeld, Daniel L. Arthur A. Ward Professor of neurological surgery UW Sweet, William H. 1910–2001 Chief of the Neurosurgical Service 1961-1977
Torgerson, Warren S. 1925–1999. Psychologist latterly Johns Hopkins, Baltimore
Turk, Dennis C. John and Emma Bonica Endowed Chair in Anesthesiology and Pain Research
Turner, Judith A Psychologist, IASP past President
Van Orman Quine, Willard 1908–2000 Philosopher and logician in the analytic tradition
Ventafridda, Vittorio 1925–2008 Anesthesiologist and leader in palliative care
Wall, Patrick D 1925–2001 British pain neuroscientist, gate control theory of pain
White, James C. 1896–1981. Professor, Harvard, Massachusetts General Hospital, specialized in surgical control of pain
White, Lowell “Bud” D. 1928–2018 Neurosurgeon, educator, published poet, author
Winn, H. Richard Chairman of Neurological Surgery UW 1983-2002 Currently Professor of Neurosurgery and Neuroscience at Mount Sinai School of Medicine
Woolf, Clifford Woolf Neurobiologist, Boston Children’s Hospital
Acknowledgements
My thanks must go frst to John Loeser himself, whose unstinting support of this project made my job easy. Apart from the hours we spent together, either going through photographs or just chatting, he must have spent hours himself looking through his whole life’s inventory. He dug out personal notes, letters, papers he had written, mementos, and anything he thought might be useful to me. The strength of his friendships became clear through his introduction to me of the many people who have been important in his life, with all of whom he maintains contact, starting with relatives and friends who shared his childhood and college years through friends he made in pursuit of medical excellence. He encouraged his family to be completely open with me, which they were. He was also willing to tell me his own story, warts, and all.
Next, I must thank Francis (Frank) Keefe, who told me early on that he was interested in the project and asked me to send him chapters as I wrote them. Frank’s encouragement and critique were invaluable to me, especially since nobody other than John himself was reading along. David B. Morris, author of the prize-winning book “The Culture of Pain,” spent several hours with me at the beginning of the project teaching me some of the pearls of biography writing. I would have written the book very differently had I not been the benefciary of his wise words. Louisa Jones, who was the executive director of the International Association for the Study of Pain (IASP) from its inception until her retirement in 2006, diligently recorded IASP’s activities, a record I have relied upon. She was also kind enough to spend time with me bombarding her with questions, remaining available to me whenever I had further questions. Louisa’s sense of fun shines through in the stories she tells, including in her much-treasured record of the early years of IASP, “First Steps: The Early Years of IASP 1973–1984.” Louisa’s geniality colored the pioneering days of IASP and made them much more than just hard work. Rosemary Kimmel was John’s administrative assistant from 2003 until her retirement in 2019. She kept John’s working life in order throughout the many years of her employment and is still the keeper of his records and his resume. She supplied me with a treasure trove of papers and photographs and spent time talking to me about her Loeser years.
xv
I will simply list here other people since their roles are detailed throughout my text. Thanks to living in the age of Zoom meetings, I was able to have fruitful remote interviews with some of those I could not meet in person, including John’s sister Jane Ransom, his niece Debbie Tauber, and his cousins Jim Newman and Katherine Levy Hall. I was also able to remotely interview John’s very good childhood friend and later Harvard classmate Tony Levy, his Harvard roommate Bernie Gross, and his medical school classmate Simon Stertzer. Kim Burchiel, who trained in neurosurgery under John, and Tom Cikatz, surgical technician who spent years working with him, both gave me valuable remote interviews, as did Ernie Volinn, fellow thinker in pain; Tom Hornbein who succeeded John Bonica as Chair of the Department of Anesthesiology and Pain Medicine; Richard Chapman and Dennis Turk, successive heads of pain research at the University of Washington; and Lee Glass, mentee. Even more pleasurable were my in-person meetings, which often came with generous hospitality and always came with enjoyment. There were the boat trips on Lake Washington with John’s sons, sitting on their decks talking about their father; a memorable trip to Martha’s Vineyard to meet John’s cousin Tony Levy; and a trip out to Doug Granum’s magical estate in Port Orchard cloaked in artworks, both his own and from his travels. This says nothing of the warm meetings in the homes and offces of John’s family, colleagues, and friends. His children, of course, Sally, Tom, Derek, and David. His neurosurgery colleagues Richard Ellenbogen, Dan Silbergeld, and Alexa Martin. His colleagues and others from the pain world, Linda Bonica, Jonathan Meyer, Steve Butler, Rolf-Detlef Treede, Supranee Niruthisard, Michael Nicolas, David Tauben, and Judith Turner. Last, but by no means least, Karen, John’s wife of 46 years, who patiently tolerated my appropriation of her husband, who cooked me many a lunch and dinner, and who flled in many a feminine detail of John’s story and her own.
Chapter 1
They Came from All Over the World
They were all part of a pain revolution. Chronic pain was destroying lives, livelihoods, economies, and families, and a solution was within grasp. They had heard that an innovative pain program at the University of Washington, Seattle, was achieving remarkable results. They came from all over the world to see how it was done. They were greeted by the avuncular fgure of the Center’s chief, John Loeser. Tall, imposing, warmly welcoming, and delighted by their interest. He was in his element. There was nothing he liked better than to interact with like-minded colleagues, to discuss their shared belief that there was a way out of unrelenting pain and to proudly promote the methods used in his pain program. He also welcomed the chance to make lifelong friends. The visitors were treated not only to a view of a program that was helping turn lives around for people with pain, they were also invited to the Loeser home. It was not unusual for John’s wife Karen to be told to expect dinner guests. In fact, on one occasion, Karen was told on a Tuesday to expect a busload of 60 Italian visitors for dinner the following holiday Monday (luckily the sun shone, given the size of the house and Seattle’s common state of rain). Those visits to the Loeser home in Madrona, with a gorgeous view from the deck over Lake Washington, cemented the visitors’ memories of their trip to Seattle.1 They never forgot the hospitality, nor what they were inspired to develop once they returned home. They became leaders in the pain feld in their own countries and became hosts for John and Karen’s subsequent world travels. As momentum built and pain medicine became an established medical discipline worldwide, John Loeser became a central fgure in its evolution.
It was another John, John Bonica, who is given credit for being the founding father of pain medicine, and John Loeser will be the frst to say that John Bonica deserves that credit. Bonica was Loeser’s senior. Bonica moved to the recently
1 The fact that the Loeser home in the 1980s was small and unpretentious helped embolden return hospitality because it was a real American home, not the sort of large pristine American home depicted by Hollywood that was so unlike their own homes.
J. C. Ballantyne, John Loeser, https://doi.org/10.1007/978-3-031-39047-0_1
opened University of Washington Hospital from down the road in Tacoma2 in 1960 to become the frst Chairman of the new Department of Anesthesiology. John Loeser graduated from medical school in New York the next year. One of the frst things Bonica did as Chief of Anesthesia was to develop a multidisciplinary pain clinic, as he had in Tacoma. Meanwhile, Loeser received his training in neurosurgery, also at the University of Washington. It was during his neurosurgical training that Loeser began to attend Bonica’s pain rounds in the University Hospital.3 This brought him into the then separate worlds of John Bonica and another person who was to become a giant in the pain feld, Wilbert (Bill) Fordyce.4
The multidisciplinary pain clinic developed by Bonica in 1961 was run on a model that called itself multidisciplinary but was quite unlike the multidisciplinary clinic that became famous in the 1980s.5 Two patients were evaluated as outpatients each week. On Mondays the two patients were seen by a primary care physician who decided which specialists the patients should visit during that week. If the patient might beneft from an injection or medication, an appointment was set up with an anesthesiologist in the pain clinic. If the patient might beneft from a neurosurgical procedure, an appointment was set up with the specialist neurosurgeon— latterly John Loeser. Some were sent for a psychiatric evaluation, and some to rehab medicine, which had its own pain program. On Fridays, all the specialists met to discuss the two patients and decide next steps. Off the patients went to pursue the recommended treatment, never to be discussed again in conference. The patient was the passive recipient of whatever the gurus deemed the right treatment.
It was at the Friday meetings that John Loeser got to know and befriend Bill Fordyce. This was more important than it might seem because Loeser became the catalyst between Bonica and Fordyce. Bonica and Fordyce did not really understand each other. As Loeser has said, they spoke different languages. Bonica addressed pain from the perspective of pain pathways. Pain was carried along a system of nerves that could be blocked, cut, or quelled using medication or exercise. From his perspective, the pain that could not be so eliminated was a psychiatric problem. Fordyce, on the other hand, believed that pain could be changed by behavioral conditioning and that such conditioning was so powerful that it could obviate the need for doing things to nerves. The Friday meetings could be fery affairs, not
2 Prior to his move to the newly opened University hospital, Bonica had been chief of anesthesiology in Tacoma and started a multidisciplinary pain clinic there.
3 Later, in 1969, Loeser was offered a faculty position predominantly in pain and pediatrics to take over the subspecialty practice of two neurosurgeons, Lowell E. White Jr (pain) and Eldon L. Foltz (pediatrics). Upon this appointment, Loeser became the offcial neurosurgeon in Bonica’s group.
4 Bill Fordyce was a psychologist and a behaviorist. When the University of Washington Hospital opened in 1959, Fordyce moved to the new hospital from the Seattle Veterans Administration (VA) Hospital, where he had worked for the previous 5 years. His appointment was in the Department of Physical Medicine and Rehabilitation (PM&R).
5 Strictly, the Loeser/Fordyce clinic would be called interdisciplinary since it links the disciplines into a coordinated and coherent whole, whereas the Bonica clinic did not and is correctly called multidisciplinary. However, throughout this manuscript, I have called both multidisciplinary to avoid confusion. 1 They Came from All
The Clinic to Which They Flocked
only because the Freudian psychiatrists at the table did not understand Fordyce’s emphasis on behavior and conditioning but also because most of the specialists were looking at peripheral causes of pain that fell into their own specialty area. Pain was still considered a byproduct of disease.6 There was considerable discomfort with the concept of a behavioral approach to pain management. There was a lot of open debate, deliberate taking of extreme positions to provoke comments. The relationship that developed between Loeser and Fordyce during those meetings was key to what happened next—the multidisciplinary pain clinic became the multidisciplinary pain clinic as we understand it today, which is a team effort with the patient being an active participant. This was the model of a pain clinic developed at the University of Washington that was visited from all over the world in the 1980s and early 1990s.
The Clinic to Which They Flocked
Fordyce tells a rather self-deprecating story about how it all began.7
“We had on our ward a chemist with rheumatoid arthritis, disease in remission, the sed rate was down; but there was a lot of residual immobilization. He had been referred to rehab for reactivation. He had been there for a couple of weeks, whatever. On Thursday, he announced with great feeling to the nurses and everyone else that the pain was so great that he could not even tolerate the touch of his sleeve on his arm and that he could not get out of bed to go exercise. That was on Thursday. I was on the ward that time, in those days with Justus Lehmann, the chairman of the department, and Barbara Delateur, his senior resident. We’d made walking rounds each day. Friday Jack Michael (who would qualify as a radical behaviorist I guess) gave a lecture and pointed out what seems so obvious now but didn’t seem so obvious then, that social feedback has a lot of infuence potentially.
The following Monday—now our chemist friend had been in bed Thursday and Friday and Saturday and Sunday—the following Monday we came walking around the ward and came to his room on ward rounds. I don’t know where the idea came— I got this hairbrained idea. “What do you say, if he says anything about pain, let’s look out the window.” It was crass, it was cold, it was whatever. But we did it. We walked into the room ……. and began talking with him at the bedside. He was lying in bed, and immediately, he began to tell us how bad his pain was. So all three of us looked out the window, turned our heads ninety degrees or whatever it was. It was just crude. And he stopped. So then we turned back to him and he started talking about pain again—looked out the window again. We went through this little charade 2 min, 3 min, something like that, and then left. The darndest thing happened. He
6 JDL to JCB, interview 11th May 2022.
7 Oral History Interview with Wilbert E. Fordyce, John C. Liebeskind History of Pain Collection, Louise M. Darling Biomedical Library, UCLA.
got up and got dressed. He hadn’t been out of bed since Thursday, except to go to the bathroom, I guess. He got up and got dressed and went to PT and OT and did his exercises. He never missed another session of treatment. I was just fabbergasted.”
The idea that social feedback could change pain behavior had taken root. The effect of social feedback on activity and exercise had been dramatic. They continued the experiment, not with anything as “crass” as ignoring the patient, but just not fapping around, instead encouraging positive behaviors. This continued to be successful. If exercise could be affected by social feedback, what about medication? Many of the patients in rehab at the time were weighed down by dependence on medication, so maybe a behavioral approach could help that too. Within days of the chemist friend story, Fordyce sat down for coffee with one of his psychology colleagues, Roy S. Fowler Jr., and within the course of 1 h had come up with the “timecontingent”, “pain-cocktail” gambit. The patient would no longer be given or be able to request medication at will; all the medications would be given at set times during the day (“time-contingent”) and would be disguised by being mixed together in syrup.8 The idea of calling this a “pain cocktail” came later, intended as a joke, but it stuck. Again, they were astonished that when given in this blinded timecontingent manner, the medication could be tapered relatively easily, even though the troublesome medication might include both opioid and benzodiazepine,9 each notoriously diffcult to taper.10
More patients followed, and they continued to be astonished at the results they were achieving. “A man who hadn’t worked for 2 years came in with canes and addiction and walked out whistling. And hell, our eyes bugged and we thought, well gee, let’s try it again. So we tried a second one and that worked and then tried a third one and she set all kinds of records, so that by the time we got the third one—hey, we’ve got something here. We were opportunistic enough, Roy and I, we wanted to establish ourselves academically—so we’re going to write this up right now. So the next week or so we wrote that frst paper.” That paper is now considered seminal.11 However, perhaps the most consequential aspect of the way it all developed was that the frst patient, the man who went out whistling, had been referred by a downtown psychiatrist who suggested rehabilitation for his patient for no
8 It was the pharmacologist Larry M. Halpern PhD who formulated the “pain cocktail” that they used for their “time-contingent” idea.
9 Initially, all sedatives were converted to phenobarbital. Later, Mark Sullivan convinced them to convert clonazepam.
10 The so-called “pain cocktail” gambit became a key component of the pain program under Loeser’s leadership. From Fordyce’s perspective, it was a behavioral intervention designed to reduce the patients’ focus on the next dose of medication. However, with hindsight, getting the patients off their opioids and benzodiazepines was likely helpful in itself, even though the doses used in the 1980s and 1990s would rarely reach the levels used today.
11 Fordyce, Fowler and DeLateur. An application of behavior modifcation technique to a problem of chronic pain. Behavioral Research and Therapy 1968;6:105–107.
other reason than being disabled by pain. The team had never heard of this before, but they found a bed and so began pain rehabilitation.
In fact, there were several portentous developments in clinical medicine underway that combined to enable the development of the University of Washington’s model multidisciplinary rehabilitation pain clinic. The Second World War not only changed the philosophy of human rights and healthcare provision but also sent home scores of injured and fragile men. The suffering of those men was a trigger for the rapid development of pain medicine, rehabilitation medicine and clinical psychology, none of which existed as established clinical practices until the Second World War. However, during and after the war, these three new healthcare disciplines developed in parallel. Bonica had been moved by the terrible pain and suffering of the injured military, which was what drove him to dedicate his life to the study of pain and the development of pain clinics. There had been fedgling rehabilitation programs even before the great wars,12 but the growth of this specialty accelerated under the continued leadership of Frank H. Krusen after the Second World War. The specialty was eventually codifed by the American Board of Medical Specialties in 1947. Clinical psychology, although not new, was newly asserting itself into psychiatry’s dominance within healthcare, by Fordyce’s record, “trying to establish itself not only within psychology, but even more pointedly within the mental health/mental illness domain. The warfare, open and otherwise, with psychiatry was profound.” Feeling undervalued within the sphere of mental health, when Fordyce was recruited to the new University Hospital in 1959, and the chairs of both Psychiatry (Herbert S. Ripley) and Rehab Medicine (Justus F. Lehmann) offered him a position, he chose Rehab Medicine. It was vision and leadership in the new University of Washington medical program that led to its rehab program being, in Fordyce’s admittedly biased opinion, “the strongest medical rehab program in the world for most of his 30 years in the program”. In the 1960s, the University of Washington program was one of only three rehab programs in the entire United States. The Dean of the medical school, George N. Aagaard, was strongly committed to setting up rehabilitation medicine in a way that was “broad-gauge”, in other words, multidisciplinary. When they appointed Fordyce to Rehab Medicine, it was a frst for clinical psychology within rehab medicine and a brilliant move on the part of the leadership.
The only person around the table at the Friday meetings who truly understood Bill Fordyce was John Loeser. Loeser’s childhood, education and experience had prepared him for an open mindedness and intellectual curiosity that meant that rather than skepticism about Fordyce’s ideas, he embraced them. Being a neurosurgeon was his life’s ambition and pride, but when he became drawn into the pain world, he found intellectual satisfaction that simply was not present in day-to-day neurosurgery. His relationship with Fordyce would provide exactly what he sought and become one of the most fruitful intellectual partnerships in the growth of pain medicine. The two men truly liked each other. They were open to learning from
12 Frank H. Krusen founded the frst Department of Rehabilitation at Temple Hospital in 1928.
each other. They had the same values and the same political leanings. When in 1976–1977, they were selected, together with Terry Murphy,13 to teach on a Circuit Course in the WAMI region,14 visiting a total of 46 regional towns over 2 years, their evenings spent eating, drinking and talking cemented their friendship. Fordyce’s success in his two designated beds in the inpatient rehab ward in the University Medical Center convinced both men that if only they had more inpatient beds, they could work miracles.15 However, for a while the hospital leadership was not ready to give the multidisciplinary pain clinic the space it sought. Loeser and Fordyce were so frustrated that they talked about setting out on their own and building exactly what they wanted outside the university. But this idea was quickly dismissed, especially by Loeser, because he wanted to continue being a neurosurgeon, and he valued being an academic. However, in 1982, Loeser became director of the Pain Center,16 and as fortune would have it, the hospital fnally came forward with the space needed to fulfl the Loeser/Fordyce vision, just as Loeser was taking over leadership. The hospital had built a new wing that had more beds than allowed by their certifcate of need, so it suited the hospital to give a whole ward to the Pain Center, knowing that the Pain Center could use inpatient beds on one side and provide outpatient services on the other, thus reducing the bed capacity of the space by half. What they went on to create in this space is the program that attracted visitors from all over the world, not in small part because John Bonica, who was no longer running the Pain Center, was traveling and proselytizing about the revolutionary work going on at the University of Washington. The people back home were rather amused by this because they had created something quite different from Bonica’s own clinic!
The outpatient side of the new space ran like any other outpatient pain clinic. If physical therapy or injections were indicated, these were carried out in nearby preexisting areas. Many of the patients coming to the center could be managed on the
13 Terry Murphy was one of the anesthesiologists in the pain clinic and later ran the pain center. He is reputed to be one of the funniest individuals ever, which added to the fun they all had on the Circuit Course.
14 A four-state medical education initiative of the University of Washington, states being Washington, Alaska, Montana and Idaho. (Wyoming joined in 1996, making it WWAMI, a fvestate endeavor). The circuit course was a pride of the medical school, and being invited to take part was considered an honor. The visits spanned 2 years, and they spent 1 week at each state, often speaking in 5 or more towns that week.
15 Fordyce had only two beds through the Rehab Medicine Department, but the multidisciplinary pain clinic initially had no proprietary space until 1977, when pain clinic space was created next to the emergency room with 4 exam rooms, a nerve block room with recovery room, an offce and a conference room. Even later, the anesthesia department was given 6 inpatient beds to which pain patients could be admitted for pain triage by the anesthesia residents (similar to the outpatient triage by primary care physicians). These beds were no longer needed after 1982.
16 Bonica stopped being chair of anesthesia in 1978 and stopped seeing patients in the mid-1970s. He appointed a succession of people to run the Pain Center (a designation agreed upon by the University in 1978), which did not work out. However, he had his eye on John Loeser, who agreed to take over the leadership of the Pain Center once his term as Assistant Dean for Curriculum (a half-time position that he loved) was over in 1982.
outpatient side, while patients selected for inpatient treatment were a special group, selected on the basis that rehabilitation might be the most successful approach. The two sides worked together, but it was the inpatient program that engendered the most excitement because no one had previously seen the success that was being achieved with intractable cases. John, speaking years later, commented that the gift of space “gave us the chance to start a truly multidisciplinary inpatient treatment program. And Bill and I literally out of thin air created it. I mean, we decided that this would be a 3-week treatment. Why 3 weeks? Well, because four was too much, two was too short. So that was the way we picked that.”17 Many of the practitioners who would be involved in the new pain program were already involved in the multidisciplinary pain center under the direct management of their own various departments. However, in a stroke of genius, John persuaded the various services to assign named practitioners through the pain program. In this way, they could accrue training and experience in the management of pain specifcally and thus become pain specialists. John insisted that they all become equal partners in the care of the inpatients, regardless of discipline. Understanding the strains of looking after patients with complex pain problems, they were limited to 3-week duty periods on the inpatient service, and duty meant 24 h per day. Despite the anesthesiologists’ fears that the psychologists would be unhappy about being on call, the psychologists valued being on equal terms with the physicians.18 Once a true sense of team had developed, all those involved came to appreciate the satisfaction that arose from the teamwork that was changing their patients’ lives. Regular conferences to discuss the patients’ progress were critical to the success of the program, and it was at these conferences that John demonstrated his extraordinary leadership skills. He made everyone around the table feel valued and heard, so they became united in the crusade to fnd a way to help people out of pain’s vicious cycle.
The vision had come from two minds—Loeser’s and Fordyce’s. But John Loeser was the person who made it happen. Naturally, not every patient admitted to the program walked out whistling like the frst patient described by Fordyce. However, it would be rare if they were not helped, largely by being provided with the tools needed to manage their own pain at home. And there were, indeed, some miracles. Steven Butler, one of the anesthesiologists in the Loeser-Fordyce program, recalls one such patient.
We had this woman who was a secretary for a rheumatologist out in Eastern Oregon. She had developed some sort of chronic pain, and he was convinced it was rheumatologic. He tried her on many medications, and he sent her to a professor of rheumatology in a teaching hospital in Portland, Oregon. The professor said clearly this wasn’t rheumatological. But the rheumatologist, her boss, continued to insist
17 JDL to JCB 11th April 2022.
18 Decisions under Loeser’s leadership were team decisions (at least ostensibly). One of the strongest dissenters of this idea was anesthesiologist Peter Buckley. One of the strongest supporters was psychologist Kelly Egan. One day, Kelly took Peter into the back offce, sat him down and said, “Sit down, you little s***”, you need just do it. It always amused John that Kelly and Peter later married.
that it was. He had her on low-dose steroids and something else, but she was confned to a wheelchair. They revamped the house so that it had wheelchair access. She had a hospital bed in the living room, and she was completely incapacitated. The only thing that she did socially was play bridge. However, she had so much problem with pain that someone else had to deal the cards. She did our course for 4 weeks and went from being completely incapacitated to being able to walk 100 m, do a 25-m speed walk in under 25 s, do aerobics on an exercise cycle, target heart rate for 20 min, walk up and down 8 fights of stairs.
On her last week, we walked into her room, and she was in tears. We did not understand what the problem was, she was doing so well. She said, Dr. Fordyce, I want to talk to you in private. Bill was her hero. And her problem was that she said, I feel so stupid. What am I gonna tell all my friends when I come home. I was in this program, and they said it was just rehabilitation. And now I have no pain. And it’s as if I did something wrong before. So Bill said to her very quietly, I think you have to say that the problem was due to the healthcare system, and you were just following advice, and we had different advice that you could follow and that’s why you got better. And that woman used to come to Seattle sockeye fshing. They had a trailer, and they drove through Oregon and Washington every summer. Every year she dropped into the pain clinic to see Bill Fordyce. We saw her for 5 years, and she was still at full function after 5 years.”19
Pain that is not an expected symptom of some underlying disease or trauma has never been easy to understand. While pain still has its mysteries, the twentieth century saw enormous advances in how pain could be understood. Why does a fxed cause produce pain in some people and not others? How is pain experienced differently in different circumstances? Is it possible that an injury that looks so terrible, could come with no pain at all? Throughout most human history, lacking any knowledge of pain pathways and pain physiology, pain was thought of as a punishment coming from outside the person. However, the great anatomists and physiologists of the nineteenth century provided the twentieth century pioneers of pain medicine with a concept of pain that was distinctly internal and that could be understood through neural pathways. Nevertheless, some of the very early pioneers— W. K. Livingston, H. K. Beecher, P. D. Wall and R. Melzack—recognized that pain could not be completely explained as a signal from the periphery to the brain. There had to be other factors to explain the mysteries of pain. John Bonica’s perspective was that modern anesthetic and surgical techniques could be utilized to relieve pain as never before. If medications and these techniques failed, then the likely cause of
19 Steve Butler to JCB 9th September 2022
The Loeser Onion
pain was psychiatric. John Loeser could see that what Fordyce and the behavioralists were demonstrating was beginning to explain the “other factors”.
The 1970s was a decade during which the biopsychosocial nature of chronic illness was increasingly recognized.20 Chronic pain emerged as perhaps the archetypal biopsychosocial condition, while heart disease, diabetes and many other chronic illnesses would qualify. Yet there was an important difference between chronic pain and many other chronic illnesses, which was that chronic pain was entirely subjective. Unlike other biopsychosocial illnesses that had objective markers to guide treatment, chronic pain diagnosis relied on a patient report. How was one to understand that whatever pain was expected was not necessarily refected in the patient’s report of pain or the patient’s behavior. The specialists were beginning to understand that the signal (nociception)21 did not become pain until it was processed in the brain to become perceived pain. Without such processing, it was not pain as such, merely a signal that might become pain. Pain itself requires a conscious, processing and learning brain. Pain so understood was entirely personal and internal: there was no way the doctor could access it. And this internal event, pain, was not necessarily refected in suffering. Even if the signal had produced pain, an aversive process by defnition and intent, the amount of suffering associated with the pain could only be based on the person’s experience. In turn, this was dependent on factors such as past events, culture, current circumstances, and the purpose of the pain, to name just a few. These factors were all particularly relevant for chronic pain, which emerges as a biopsychosocial condition. But still, the doctor had no access, could not see the suffering, and could only gain access through the behaviors of the person in pain, including the person’s report of pain. It was the behaviors that unlocked the pain, but the behaviors could only be properly interpreted if the doctor understood the underlying layers and could then use clinical judgment to address the relative role of each to the suffering, behaving individual. How could the specialists explain this to the nonspecialists, who may not have even heard of nociception and probably did not understand that there could be a disconnect between pain and the only thing they could detect—pain behavior? While Murphy, Fordyce and Loeser were touring the northwest (WAMI region) giving lectures to community physicians on an almost daily basis, Loeser was mulling over how to get their concepts across to the primary care physicians. This is when he came up with the Loeser onion (Fig. 1.1).
He did not even think of it as an onion, but he drew it exactly the way it is depicted to this day, with nociception at the core and behavior forming the outer layer. People thought it looked like an onion and have since drawn it as an onion, sometimes adding layers and sometimes adding colors. But to John, it was just a
20 The promotion of the concept and term biopsychosocial is attributed to George L. Engel “The Need for a New Medical Model: A Challenge for Biomedicine” 1977. However, the term biopsychosocial was coined earlier in 1954 by Roy Grinker.
21 Nociception is the transmission of a painful stimulus to the brain via the spinal cord. Many factors can alter nociceptive input, including continued pain generation, infammation and descending modifers.
