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Provide Care for Patients Like a Fox Not a Hedgehog

June 8, 2018 • Practice Leadership • Kory Zimney

Pain, especially persistent pain, is complex and usually a multifactorial problem. Because it is multifactorial and having a number of factors and causes involved it is very rare a single intervention will solve it. Sure, we will hear the stories from individuals who report that a single intervention was what fixed their back pain or fibromyalgia symptoms – just read the testimonials from anything or anyone that claims to be the fixer of persistent pain problems.

However, the reality is that acupuncture alone was not what made their back pain better. Most likely they also had a positive expectation that they were going to get better, actually started to become more active and engage in positive social activities, started or had been working on other healthier habits, interacted with a health care provider that developed into a strong therapeutic relationship, and a slew of other things that an individual might not even be aware that is happening through subconscious thoughts and emotions. It most likely wasn’t just that they started a B12 supplement that made their fibromyalgia symptoms better, but again they had many of the other things mentioned such as positive expectations, increased activity, more social connections, increased many healthy habits, and others.

As humans, we love simple straightforward cause and effect. When we throw a ball into the air, gravity causes it to fall to the ground. This makes understanding the world we live in easier. Each time we throw a ball up; we know it will come down to the ground. Thus creating simple cause and effect helps us navigate through life easier because we know what to expect. If we have back pain just get acupuncture to make it go away. If fibromyalgia symptoms worsen, just increase B12 intake and symptoms will get better. We all love the thought of the “magic bullet” fix. If we just have to do ONE big thing what is it to fix back pain or improve fibromyalgia symptoms?

The Hedgehog and the Fox as written by Isaiah Berlin was not directed at caring for individuals with persistent pain. Although, the idea of the fox knows many things, the hedgehog one big thing might serve as road map for care for individuals with persistent pain. The hedgehog looks at the big picture through a single lens directed at a single problem, whereas the fox is comfortable with nuances and lives with contradictions. Patients wanting a straightforward approach to getting rid of their single problem (having pain daily) often will be more hedgehog in their thinking and actions. Unfortunately, the paradox is that the best care probably lies in the context of the fox. There will be many approaches that need to be explored and worked on to maximize improvement from a persistent pain problem. One will have to become comfortable with nuances of the amazing biology, psychology, and sociology that makes us, us.

As health care providers assisting those with persistent pain, we need to appreciate and respect the hedgehog approach and thinking many patients will take in regards to their pain problem. We also need to consider that our care should take a fox approach and consider multiple areas (exercise, sleep, diet, goals setting, reassurance, pain education, and many other things) to work on. We also need to be careful that we do not get to “foxy” with our multimodal approach. It is easy to over complicate things and provide treatment interventions that may not need to be as complex as we make them. In addition, we need to be wary of providing too many things just in the hope something works.

What are your thoughts about treating like a fox as long as you do not get to foxy, or should we take a hedgehog approach?

Kory Zimney

Kory is a physical therapist with 25 years of experience and a dedication to changing how people in pain are treated. Current Roles: Associate Professor, University of South Dakota Faculty, EIM Research: The efficacy of pain neuroscience education on musculoskeletal pain: A systematic review of the literature The clinical application of teaching people about pain

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