Modern Musicians Pay Tribute to the Founder of Bluegrass.

DATE August 21, 2000 ACCOUNT NUMBER N/A
TIME 12:00 Noon-1:00 PM AUDIENCE N/A
NETWORK NPR
PROGRAM Fresh Air

Interview: Dr. Frank Vertosick, neurosurgeon and author of "Why
We Hurt: The Natural History of Pain," discusses the book and
the management of chronic pain
TERRY GROSS, host:

This is FRESH AIR. I'm Terry Gross back from vacation. Thanks to Barbara
Bogaev for hosting while I was gone.

Well, now that I'm back and rested, what's our subject of the day? Pain. My
guest, Dr. Frank Vertosick, is a neurosurgeon and the author of "Why We Hurt:
The Natural History of Pain." It examines the biological nature of chronic
pain and the best ways of treating it. Dr. Vertosick has treated many
nightmarish pain problems during his career, including traumatic amputations,
ruptured spinal disks, fractured vertebrae, diabetic neuropathy, migraines and
belligerent kidney stones. He says that when he's alone with a patient, it
feels as though three entities are in that room: the patient, the doctor and
the pain.

Dr. FRANK VERTOSICK (Neurosurgeon): When you're dealing with a patient,
particularly a patient with chronic, severe pain, the pain becomes almost a
personality in itself, that it becomes almost an alter ego for that person.
It begins to control their lives, tell them what they can do, what they can't
do, whether they can work, whether they can't work, and so you almost feel as
if it becomes a separate personality that you have to deal with. And that's
not so much true for the person who comes in with an acute pain of one or two
weeks' duration but somebody who's lived with pain for months or years.

GROSS: And it sounds like a lot of the patients who you work with are
terrified that they will live their whole life in pain, that the pain is never
going to stop.

Dr. VERTOSICK: Yes. I think that's the human dimension of pain. I
differentiate between pain and suffering. Animals feel pain. Humans impose a
psychic dimension on their pain, which we know as suffering. And suffering is
pain coupled with hopelessness, despair, the feeling that you may never be
well again.

GROSS: Now as you point out in your book, pain is not something we can
empirically measure. And all you can do to understand your patient's pain and
the source of the pain, you have to ask for descriptions of the pain: How bad
is it? What kind of pain is it? And so your understanding of a patient's
pain is going to have to depend on their ability to describe it well.

Dr. VERTOSICK: That's correct. There have been a number of attempts to try
and quantify pain. You show people a scale, a bar graph and say, you know,
`This is no pain, and that's maximum pain. Where would you fit?' But the
bottom line is that we cannot objectively measure the degree of physical pain
that someone's having, at least not yet, if it's something that may be on the
horizon in the next 10 or 20 years. But right now, you're right. We're
totally at the mercy of the person to tell us how bad their pain is and how it
affects their lives. I cannot go and do a test or run their head through a
scanner or do some other blood work or something to say, `Yes, you are having
a large degree of pain' or, `No, you're not having the degree of pain that
warrants this treatment or that treatment.'

GROSS: So what are the things you're listening for when someone's describing
their pain?

Dr. VERTOSICK: Well, you're listening for not only the magnitude of the pain,
but you also have to find how that pain is impacting their lives, and so
someone, for example, may tell you that I have a severe degree of pain, and
when you question them, you find that they're not taking pain medication.
They're golfing four or five times a week and so on, and you see that perhaps
the level of that complaint does not seem to be impacting their lives enough
for you to embark upon what might be more dangerous or risky therapies to cure
that pain. And likewise, other people may minimize in the office their degree
of pain and say, `Well, I'm not bothered that much,' but then you ask them,
`Well, what are you doing?' `Well, I used to golf all the time. I stopped
doing that. I have to go to work part-time now.' And you begin to realize
that this pain they may verbalize in the office as not severe is really making
a major difference in their quality of life and may warrant a more aggressive
therapy to try and get them back to a more normal quality of life.

GROSS: Let's talk about some of the techniques of dealing with pain. You
say, for instance, that during the late 1800s and the first half of the 1900s,
many physicians thought that chronic pain could be cured by cutting the nerves
that were transmitting the pain. Why was that the theory and what happened in
the practice?

Dr. VERTOSICK: In that era, the era of the 19th century, early 20th century,
when all we had was aspirin and morphine, there really weren't many modalities
to treat severe pain, other than some, like, drastic surgical methods. And
so, for example, if someone had facial pain or chronic dental pain, the
treatment was to just cut the nerve that went to the face or cut the nerves in
the jaw that supplied the teeth, in the feeling that, well, it was better to
have numbness than pain. And the physicians and patients knew that they were
trading complete sensory loss for the theoretical removal of their pain.

What they learned and what we still see today when people try those therapies
is that two things: one is that the numbness often isn't better than the
pain. It becomes worse than the pain in terms of just the feeling of numbness
that you get. And the second thing is a more dreaded complication, which is
known as anesthesia dolorosa or painful numbness in which your body plays a
very cruel trick on you and replaces the sensation of numbness with pain. And
so you get pain in a body part that you no longer can feel, so example,
phantom limb pain, where you don't have a limb at all and you still feel
severe pain in that limb.

GROSS: One of the case studies that you write about in your book is a man who
you treated who was in a bad motorcycle accident, and it was the nerves to his
arm that were severed...

Dr. VERTOSICK: Yeah.

GROSS: ...and he had terrible, like, excruciating pain in an arm that he
could no longer use or feel. And as you say, it's such a cruel irony. Can
you explain a little more why, when nerves are severed, the pain should be
excruciating as opposed to you feeling the absence of anything?

Dr. VERTOSICK: The nervous system is wired in such a way that you don't have
just a nerve go straight from the skin, say, to the brain. There are several
intermediary nerve cells in between, such as in the spinal cord and in the
brain stem, so it's almost like a bucket brigade type arrangement where one
nerve passes the sensation from the skin to the spinal cord. The spinal cord
nerves then pass it on to the brain stem, and the brain stem pass it on into
our consciousness.

The problem when you cut a peripheral nerve is that you're only removing one
nerve cell in that chain of command. And so subsequently, the nerve cells
that are upstream, such as in the spinal cord or the brain, suddenly find
themselves without anything to do. And sometimes they don't like that. They
don't like being deprived of anything to do, and so they begin just making
things up, hallucinating, so to speak, and feeding static upstream into the
brain.

I use the analogy of a television set that, if you have a cable television
set, if the cable goes out and you're deprived of a meaningful input to the
set, the screen doesn't go blank. It still projects a staticky, white picture
because that's what it's designed to do. It's designed to keep working even
without an input. And in the spinal cord, when it does that, it transmits
static to the brain, and unfortunately, that static is perceived in our
consciousness as terrible pain. And so it's really a form of sensory
hallucination that's manufactured within the higher centers, particularly in
the spinal cord.

So the brain does not like and the spinal cord does not like a vacuum. They
will fill it up with something. And if you cut a peripheral nerve and you
have no meaningful input from a limb, it will replace it with pain, and it's a
misfortunate way our body is wired, that pain is sort of a default sensation
when there is no other meaningful sensation to perceive.

GROSS: What technique do you have as a surgeon to deal with this kind of
phantom pain?

Dr. VERTOSICK: Well, it depends on where the pain is coming from. In the
example of the case study in the book, coming from the upper extremity, the
arm, a procedure was used on him known as a drez lesion, a dorsal root entry
zone lesion, in which the nerve cells in the spinal cord that are
hallucinating or producing the static are physically destroyed with a hot
electric probe. It's a very risky operation, but for people who have
experienced this type of anesthesia dolorosa, their pain is so severe that
they're willing to take the risk and actually let somebody enter their spinal
cord and attempt to destroy the pain-generating neurons inside the spinal cord
itself.

GROSS: How do you find which are the right neurons?

Dr. VERTOSICK: You know anatomically where the right neurons are because of
their location in the so-called dorsal root entry zone where the sensory nerve
enters the back of the spinal cord. Right at that level approximately two
millimeters or so deep to that level, there are located the pain-generating
neurons and so you have an electrode that basically just has two or three
millimeter of active probe exposed at the tip. The rest is insulated and you
just manually insert it into the spinal cord at that location, and you use an
electric current generator to actually coagulate that part of the spinal cord.
It's delicate surgery. It has risks, but again, the fact that people are
willing to undergo this procedure shows the magnitude of the pain that they're
in.

GROSS: So it doesn't work to sever a nerve to stop pain but it can work to
destroy the nerve that's causing the pain.

Dr. VERTOSICK: Yes. You will notice a temporary reduction in pain. Just
like when we have a shot of Xylocaine or Novocain in our jaw to have a root
canal, we don't feel that pain. We do have an uncomfortable sensation of
numbness in our jaw. You will get a temporary success, say, of cutting a
nerve and feel better for perhaps four months, six months, nine months before
eventually the static information begins to rise and provide the sensation of
anesthesia dolorosa or painful numbness. But the fact that you do get a
temporary relief means that severing nerves is still an option in people who
have types of malignant pain where their life expectancy is less than a year,
and they're not likely to develop the anesthesia dolorosa. Those sorts of
nerve severing operations may still be useful, but they're not useful for a
type of benign pain like facial pain in somebody who has a normal life
expectancy. You're just asking for trouble down the road. You're going to
get a temporary success and a potential long-term disaster.

GROSS: My guest is Dr. Frank Vertosick. He's a neurosurgeon and the author
of the new book "Why We Hurt: The Natural History of Pain." We'll talk more
after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: If you're just joining us, my guest is neurosurgeon Dr. Frank
Vertosick. He specializes in treating chronic pain. His new book is called
"Why We Hurt: The Natural History of Pain."

Let's talk about the cause of a very common form of back pain: herniated
disks and degenerated disks. First of all, maybe you could describe the
difference between these two disk problems.

Dr. VERTOSICK: A degenerated disk is a normal aging process within the disk
itself. The best way to understand what's happening in a disk is to consider
what's happening in the lens of our eyes. It seems funny to compare the two,
but structurally, they're very similar. The lens of the eye and the disk in
the back, they're basically a fibrous capsule with a watery gelate in the
center. And as we get older, the elasticity of those structures and their
water content tends to go down. They basically start drying out and become
stiffer. We see the same thing happening in the skin. That's why as people
get older they use moisturizing creams and so on.

So you're seeing a general water loss, increased stiffness of the tissues
which in the eye is manifested as difficulty reading and needing reading
glasses. In the lower back, you will see it on an MRI scan that certain of
the disks actually begin to lose water and they begin to lose height and lose
their elasticity and balge(ph). So you will hear the term a balging disk(ph)
or degenerated disk or a deteriorated disk applied to that normal aging
process. In most people, vast majority of people, it is a painless process,
so that most people with degenerated disks will not have pain, and in the
general population over the age of 40, fully 50 percent of people will have
those on an MRI scan if you just pulled them off the street or off the tennis
court and say, `We want to do an MRI scan for a study.' That has been done,
and they are very ubiquitous in the population.

A herniated disk is a different matter altogether. It's when the disk has
become so dried out and so stiff that some event actually leads the disk to
fracture and part of the disk to displace or to herniate out of its normal
position in the spine and impact the nerves, causing nerve pain or a condition
commonly known as sciatica.

GROSS: So you say that when you have a herniated disk, part of the disk can
actually break free and wedge itself against a nerve, and that could be what's
responsible for the serious pain?

Dr. VERTOSICK: In people with leg pain, that's the case. There's a great
misconception that if you have back pain--and back pain is so common in the
population, 50 to 70 million people at one time are going to be complaining of
back pain. Back pain alone is not a sign of a herniated disk. It's nerve
pain--pain in the leg, numbness in the leg. Those sorts of symptoms are going
to be what you see with an actual herniation of the disk. So there's a lot of
confusion. Most back pain--just pure mechanical back pain is not really
related to anything going on in the disks itself. It is the syndrome of
sciatica with the pain shooting down the leg that is more indicative of this
disease.

GROSS: What kind of back problems do you most often see in your practice?

Dr. VERTOSICK: Well, in a general neurosurgical practice, you see just about
all types of back conditions because a lot of the internists are under the
same misconception that if somebody comes to them with severe back pain, that
they should be seen by a specialist and go to a neurosurgeon. Really, the
only surgically treatable conditions are the ones in which the disk is
actually displaced and impinging the nerves. So in most surgical practices,
we will see a heavy preponderance of people with an actual herniated disk, but
we still see a fair number of people with non-surgical mechanical back pain.

GROSS: Who do you recommend surgery for? Like, what are the problems that
are fixable now with surgery that you're most confident about?

Dr. VERTOSICK: The standard indications for back operation--and those are
evolving somewhat, depending upon which speciality you talk to--the standard
indication is for somebody with a displaced disk, where the disk is actually
ruptured out of its normal compartment in the spine, is impinging a nerve and
is causing a degree of pain and disability which the person who is going to
undergo the surgery considers is worth having an operation for.

And a lot of my patients are taken aback when I tell them that for most
people, having a back operation is similar to having a face-lift in the sense
that they come to me and ask--they say, `Should I have this operation?' It's
sort of similar to going to a plastic surgeon and ask them, `Do you think I
should have a face-lift?' It is really not the surgeon's responsibility or
domain to tell that person if their quality of life is so harmed by this
disease that they should have surgery for it, because most back operations are
a quality of life operation. They're not intended to make you live longer or
be healthier. They're intended to make you better faster from a degenerative
disk condition, and whether you choose to have surgery or not is purely at the
discretion of the person. Some people will have a back operation the day
after they have pain. They don't like even a day or two of pain. Other
people will not let you operate on them even if they're incapacitated for 9 or
10 months. And neither person is right or wrong. It's a matter of personal
preference.

GROSS: I was surprised reading your book that smoking can worsen spinal
problems. Why is that?

Dr. VERTOSICK: Because smoking, in general, is an insult to the small blood
vessels throughout the body and tends to accelerate the aging process. And I
think the general lay-public has the idea of smoking affecting your heart and
affecting your lungs, but you can tell in the skin of somebody who's a
long-term smoker. If you look at somebody who's 65 or 70 who's been a heavy
smoker all their life and compare that to a person who has not been, you can
see a definite acceleration of the aging process in the skin. And that is
true in all the connective tissues of the body. That's not just speculation.
Studies have shown that the rate of disk degeneration in smokers is higher
than non-smokers. The outcome of spinal surgery, particularly fusions, is
much poorer in people who are smokers. The return to work after back injuries
in smokers is not as quick or as certain as people who are non-smokers. So
there is a definite influence of cigarette smoke on the integrity of the spine
as it also affects other tissues of the body just as well.

GROSS: Do you find that people's personalities change if you're able to
alleviate the pain; you know, that pain changes personality and the relief of
pain changes personality?

Dr. VERTOSICK: Oh, I think that definitely. There's probably no worse
effect on someone's psyche or personality to have a chronic background drone
of pain affecting you. I think that -most people know from their own
experience just if they're having the pain of the flu for several weeks, how
that affects their attitude towards life and towards their fellow co-workers,
their family. And, yes, you do see a marked change in people for the better
if you can silence that constant background drone of pain.

GROSS: Dr. Frank Vertosick is the author of "Why We Hurt: The Natural
History of Pain." He'll be back in the second half of the show. I'm Terry
Gross, and this is FRESH AIR.

(Soundbite of music)

(Credits given)

GROSS: This is NPR, National Public Radio.

(Soundbite of music)

GROSS: Coming up, the challenges of adapting the novel, "The Cider House
Rules," for the screen; a talk with John Irving. He wrote the novel and the
screenplay. It's now out on video. Maureen Corrigan reviews two new
collections of essays. And Henry Sheehan reviews the film "The Cell."

(Soundbite of music)

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GROSS: This is FRESH AIR. I'm Terry Gross back with Dr. Frank Vertosick.
He's a neurosurgeon and the author of the new book, "Why We Hurt: The Natural
History of Pain." The book examines some of the latest ways of treating
chronic pain, including alternative therapies and prescription drugs.

What are some of the new drugs on the market that you're most optimistic about
in terms of their treatment of pain?

Dr. VERTOSICK: I think the best medications that I've seen in my own practice
are not new drugs, but their new ways of delivering drugs, specifically the
long-acting narcotics, such as MScont and then a variety of other proprietary
medications that deliver narcotics over a much more sustained release so that
people get a longer duration of pain relief without having to take medications
as frequently and without having the short-term rush or buzz that they get
with taking shorter-acting narcotics. So long-acting narcotic medications,
narcotic patches, which, again, give a better delivery system, a more
long-lasting delivery system, that's been a big advance in the last 10 years.

Of course, the more recent development of the so-called COX-2, or
cyclooxygenase-2 inhibitors, proprietary names such as Vioxx, these are
medications that are like aspirin, but they target only the pathways that deal
with pain. They do not affect the stomach as severely, and in my practice,
that has been a big benefit for a number of patients. Anti-inflammatory
medications come out--new ones are coming out all the time. It becomes
difficult for most practicing physicians to keep up with the different brand
names. And people are always coming into my office saying they're on this
medication or that medication, which I have yet to hear of. But I think
what's most important is new ways of delivering the old medications rather
than the development of new medications.

GROSS: One of those new ways, I think, has to do with, say, certain pain
medications delivered through a nasal spray. Why is that effective?

Dr. VERTOSICK: Well, that is effective because, again, these are ways of
delivering quickly higher doses of medication, especially for diseases such as
migraine, where speed is of the essence; or tragaminoralga(ph), where people
may have a sudden flare-up within a matter of 30 minutes to 60 minutes of
their pain, and so taking conventional oral medications might take too long to
work, may take two or three hours to reach their maximal effect.

So, certainly, for entities such as migraine, where you may get a warning that
you're going to have a headache and you need to obtain relief or a level of
drug faster than what an oral pill might give you, things such as internasal
sprays or even carrying injectable medications with you are going to provide
you faster relief than taking a pill.

GROSS: Some doctors say now that we should be more liberal in our use of
narcotics for people who are terminally ill; that there's no reason to worry
about them becoming addicted because they're not worried about the future, and
there's no reason that they should die in pain. What are your thoughts on
that?

Dr. VERTOSICK: Well, I think that there's a general trend to be more liberal
with narcotics in general. And the term `addiction' in pain medicine doesn't
have the same meaning as it does, say, in recreational drug use. If someone,
you're clearly convinced, is in severe pain, their addiction--and you're using
narcotics to treat the pain, their chance of addiction is not that high. So
people have been more aggressive, not only in malignant pain syndrome, such as
cancer, but also in benign pain syndrome, such as chronic back pain after a
failed back operation and so on.

My own belief is, yes, your first obligation as a physician is to ease
suffering, even perhaps a higher calling than prolonging life, and so that's
your main goal. The problem is that there's a misconception in the public
that we have achieved the level of technology that allows us to ease someone's
pain completely and yet not obtund them or cause an alteration in their mental
status. And so, yes, we can take almost anybody in severe pain and render
them pain-free, but at a cost that they may not want to pay, mainly being
completely obtunded.

So we have to continuously walk that fine line of giving them pain relief and
yet reducing their quality of life so severely that it's just not worth using
the medications. And that's where different means of narcotic delivery have
been developed, such as instilling the narcotic directly into the spinal fluid
itself, for example, or using the more long-duration narcotic pills or
narcotic patches instead of conventional high doses of oral narcotics.

But, yes, I believe that we need to be more aggressive, but I think the public
is still under somewhat of a misconception that we can take away all the pain
of a terminally ill patient without causing them to have severe mental status
problems. And we're just not at that level of technology yet.

GROSS: Now you mentioned some of the new drug delivery systems that you're
optimistic about. Well, what about some of the alternative approaches to
dealing with pain? Let's take something like acupuncture and magnetic
therapy. Starting with acupuncture, have you seen much success with that?

Dr. VERTOSICK: I've had a few patients see success with that, that's true.
And there's acupuncture and its needleless cousin, acupressure. I think the
latter is probably more widespread use. In terms of--yes, I have seen results
from that as well as from a variety of alternative treatments. I think that
the main thing--and, remember, you're dealing with alternative
treatments--that if you have a chronic benign pain, if it works for you, it
works. And I give an example in the book of a man who came to me convinced
that wearing magnets in his back brace cured him of his back pain. I can't
argue with him. I can't quote him any study or any scientific treatise on the
role of magnetic fields in the human body that's going to convince him
otherwise. And I told him that if magnets made him better, I'm happy for him.
Use them. If they work for you, if they take your pain away, then use them.

And some people will say, `Well, that's just a placebo effect,' but the bottom
line is if somebody's in pain and they employ a therapy that is not
particularly dangerous, is not going to bankrupt them and it helps them, then
I don't think I or any other physician should criticize them for seeking that
out, but particularly if I don't have anything else to offer them, short of
potentially dangerous surgery or narcotics.

GROSS: No, I mean, acupuncture has a very long history that many people have
read about. What about magnets? You're saying these little magnet kits sold
in even department stores now--is there anything behind it medically that can
be explained?

Dr. VERTOSICK: Well, magnet therapy is probably as old as acupuncture, and it
dates back all the way to the 16th century when people, particularly
Paracelsus, the alchemist, felt that magnets would draw out evil humors and
draw out pain. And so it's sort of--magnet therapy has been around for a long
time. Even the school of chiropractic back in the turn of the century started
out as a school of magnetic therapy, and when people didn't really buy into
the magnetic therapy, they began utilizing spinal manipulation in addition to
magnetic therapy.

Is there anything to it? It's hard to imagine scientifically what could be
the benefit of wearing, say, a ceramic magnet. The penetration of that
magnetic field is only about three or four millimeters. That's why, if you
hang up a piece of paper on a refrigerator, you can hang it with a ceramic
magnet. You can put up one piece of paper. You put up two or three pieces of
paper, the magnet will not hold. It just does not have the strength or the
depth of penetration to go more than two or three millimeters. So to wear a
magnet, you're basically not really having much of an effect below the level
of, say, two or three millimeters into the skin.

GROSS: Do you often recommend your patients to chiropractors, and have your
patients had much success with chiropractors?

Dr. VERTOSICK: I do beca--if I think they have mechanical back pain or
mechanical neck pain, meaning that it's not due to a fracture or a large
herniated disk or something that is going to potentially require surgery, they
come in with just back or neck pain of a fairly short duration, there's good
evidence that chiropractic manipulation is every bit as good as conventional
physical therapy or surgery in terms of getting people over an acute episode
of mechanical spinal pain. And so, yes, I will refer them to a chiropractor.
But most of my patients don't need me to refer them to a chiropractor.

I would say that probably nowadays, two out of three to three out of four of
my patients have already been to a chiropractor, and the chiropractor has sent
them to us. So I think that there is a value to chiropractic, but whether
there's a value to long-term chiropractic, people who are going and being
manipulated three times a week for two or three years, there's not good
evidence that that is doing anything. But for pain of say three or four weeks
duration, mechanical pain, there is good evidence that they help people. And,
yes, with my own patients, I've seen a good response with chiropractic if it's
done on the properly chosen person and it's done with a reputable chiropractor
who knows when to treat and when to bail out and send that person to a surgeon
or to an alopathic physician, such as myself, when the chiropractic fails.

GROSS: My guest is Dr. Frank Vertosick. He's a neurosurgeon and the author
of the new book "Why We Hurt: The Natural History of Pain." We'll talk more
after a break. This is FRESH AIR.

(Soundbite of music)

GROSS: My guest is Dr. Frank Vertosick, the author of "Why We Hurt: The
Natural History of Pain."

I want to ask you about cancer pain. I'm wondering if you think that cancer
pain is medically different than other forms of pain, if there's any unique
qualities about it?

Dr. VERTOSICK: Cancer pain is--there's not really a unique physical component
to cancer pain. There's a unique emotional component to it, but the physical
pain is basically similar pain to what you get with any other similar disease.
For example, if you have a metastasis of a breast cancer tumor in your hip
and your hip fractures, you have severe pain. That pain will not be any
different in character or magnitude than somebody who'd broke their hip in a
motorcycle accident.

So there is not a unique physical component to the pain, but there's a mental
component in the sense that people with cancer pain know the significance of
that pain, and that tends to alter their perception of that pain. If you
break your hip in a motorcycle accident, you know you will get better from
that; that that is a treatable, temporary thing. The cancer pain patient
knows that once they begin to have pain, that that may not end for them until
the end of their life, and that does put a completely different perspective on
it that outweighs any of the biological aspects of the pain itself.

GROSS: How will that affect how you treat cancer pain?

Dr. VERTOSICK: People with cancer pain, because they tend to have a shorter
life expectancy, we can be more aggressive with use of certain surgical and
medical therapies that we could not, for example, in somebody with benign
pain. So in that respect, the life expectancy of somebody does factor into
how aggressive you can be. We talked earlier about, you know, you can sever
nerves in people for benign pain. That may lead to problems two or three
years down the road. In somebody whose life expectancy may not be two or
three years, you can be more aggressive with those sorts of surgical
procedures. But I think you just need a different degree of empathy for
somebody who has cancer pain compared to somebody who has benign pain.

GROSS: As you point out, some people try to find meaning in their pain.
Explain what you mean by that.

Dr. VERTOSICK: Humans are unique in that we can find meaning in suffering.
We can tolerate suffering if it has some purpose in our lives. The example I
used was Sir Edmund Hillary. I went to a talk by Sir Edmund Hillary talking
about the night he spent just below the summit of Everest before he made the
final assault, and he said it was the most miserable experience of his life.
They did not have enough oxygen for the two of them. Most of the time they
were short of breath. The temperatures were extremely cold. They had nothing
to eat. And he said it was just absolute torture that night.

And you ask yourself, `Well, why would someone voluntarily do that? Why would
someone voluntarily put themselves in a position of being miserable?' And he
did it because of the reward, which was to attain a goal, to climb the highest
mountain on Earth. So that we, as human beings, will tolerate pain if we
think that there is something at the end of the road that is beneficial or
worthwhile. And so I tell some patients if they don't have any success in
medically treating their pain, try and find some good that come out of it.
For example, to counsel other people who have similar problems, lecture about
their pain, join organizations, do something, anything, to try and find a
positive aspect to their pain, to make it seem like that that is something
that is not worthwhile, but something that has a silver lining. It's very
difficult to do, but some of my patients have managed to do just that.

GROSS: Dr. Frank Vertosick is my guest, and he's a neurosurgeon specializing
in dealing with chronic pain. He's also the author of the new book "Why We
Hurt: The Natural History of Pain."

You've had migraines since childhood. Is that one of the reasons why you went
into pain-related surgery and medicine?

Dr. VERTOSICK: Yes, I have had migraines, and I guess anybody's own medical
background influences them to some degree in becoming a physician. And I
can't say specifically that having migraines made me become a neurosurgeon,
but it has certainly given me an insight of what it's like to be incapacitated
by pain, particularly when you're incapacitated by pain that no one else can
see, and there is no physical correlate to it.

Migraine is probably the epitome of the type of pain syndrome which you don't
get a lot of sympathy for. Everyone feels they get headaches. They just
don't understand why your headaches are so much out of the ordinary from
anyone else. But if you have migraines, you know the degree that you can be
incapacitated by pain, to the point where you're having pain so severe that if
you had to get up and run to save your life from a burning building, you might
have some doubts whether you would even bother to do it at that time. And
that's how severe it can get.

So I think it's provided me with some empathy into how severely incapacitating
pain can be. Fortunately for me, like most men, I have managed to outgrow my
migraines over the last 10 or 12 years so they've not been much of a problem
for me. Many people are not so lucky.

GROSS: Yet you were told when you were starting off in medicine, `What about
if the migraine comes on you while you're in the operating room? What would
you do? Is this really the right choice for your profession?' Did that ever
happen?

Dr. VERTOSICK: No, it's never happened, and I think many migraine sufferers
will tell you that it's not a period of stress, fortunately, that causes a

migraine. It's more a period after the stress. When I went into surgery, I
knew from my past experience that I could count on the fact that I would never
get a headache when I absolutely could not tolerate to have a headache:
during a large, fine-organic chemistry final or during an operation that was
particularly stressful. But I could count on, after a stressful experience,
having potentially a headache afterwards.

And so it's those sorts of things, to be able to learn what affects you and
what doesn't affect you--true of any pain patient, particularly migraine
sufferers--you begin to adapt your life according to what you know from past
experiences how that pain has affected you. I knew from adolescence on into
medical school that the migraines have never affected me during a period of
time when I just could not afford to have it affect me. It would affect me
maybe an hour or two later, but not during the period of time when I needed to
be functional.

GROSS: Well, I want to thank you so much for talking with us.

Dr. VERTOSICK: Thank you.

GROSS: Dr. Frank Vertosick is the author of "Why We Hurt: The Natural
History of Pain."

Coming up, Ken Tucker reviews a new CD paying tribute to Bill Monroe. This is
FRESH AIR.

(Soundbite of music)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * *

Review: Tribute album to Bill Monroe called "Big Mon"
TERRY GROSS, host:

Bill Monroe invented the country music offshoot known as bluegrass music. He
died in 1996 when he was in his 80s and had been inducted into both the
country music and rock 'n' roll halls of fame. A new biography of Monroe
called "Can't You Hear Me Callin'" by Richard D. Smith has just been
published, and there's a new all-star salute to Monroe and his music called
"Big Mon" produced by one of Monroe's musical disciples, Ricky Skaggs. It
features performers ranging from the Dixie Chicks to John Fogerty.

(Soundbite of music)

Mr. BILL MONROE: (Singing) Blue moon of Kentucky, keep on shining. Shine on
the one that's gone and been untrue. Blue moon of...

Mr. JOHN FOGERTY: (Singing) Blue moon of Kentucky, keep on shining. Shine
on the one that's gone and been untrue. Blue moon of Kentucky, keep on
shining. Shine on the one that's gone and left me blue. It was on a...

KEN TUCKER reporting:

John Fogerty's interpretation of one of Bill Monroe's best-known songs
commences with a snippet of a performance by Monroe and his Blue Grass
Mountain Boys. Then Fogerty turns the tune into a chunk of rockabilly that
is, in turn, reminiscent of Elvis Presley's wailing version of the song.
Fogerty combines the meticulous with the passionate in a way that,
unfortunately, drains the life out of the song.

Much closer in spirit to what Monroe was trying to get at is Dolly Parton's
version of "Cry, Cry, Darling."

(Soundbite of "Cry, Cry, Darling")

Ms. DOLLY PARTON: (Singing) Cry, cry, darling. That's what I'll do if you
should leave me with the blues. Cry, cry, darling. That's what I'll do if
you're the one that I should lose. For me, there'll be no moonlight if ever
we should part.

Ms. PARTON and Chorus: (In unison) Cry, cry, darling. That's all I do,
'cause you're the one that's in my heart.

TUCKER: Parton sounds as if she's standing on a mountaintop keening for her
man, hoping he'll come back; her despair steadily overtaking her. That's one
of Bill Monroe's career-long themes, a restless loneliness that cries out for
relief.

Many reviews of the new biography "Can't You Hear Me Callin'" have expressed
surprise that Monroe, in his later years such a figure of stalwart dignity,
was, at his most active, both a womanizer and a vindictive guy who held
grudges for decades. It's as if some reviewers are surprised once again to
discover that a great artist can also be an ornery SOB. But that flinty guy
wrote some beautiful music, rendered best here by Ricky Skaggs, who produced
the entire CD, and Natalie Maines, the best voice in the Dixie Chicks.

(Soundbite of Ricky Skaggs and Natalie Maines singing)

Mr. RICKY SKAGGS: (Singing) Walk softly on this heart of mine, love.

Ms. NATALIE MAINES: (Singing) Don't treat it mean and so unkind. Let it rest
in peace and quiet, love.

Mr. SKAGGS: (Singing) Walk softly on this heart of mine.

Ms. MAINES: (Singing) You say you're sorry once again, dear. You want me to
take you back once more. You say you need a helping hand, dear. But that's
what you told me once before.

Mr. SKAGGS and Ms. MAINES: (Singing in unison) Walk softly on this heart of
mine, love. Don't treat it mean and so unkind. Let it rest in peace and
quiet, love. Walk softly on this heart of mine.

TUCKER: Bill Monroe's formal innovation was to play the mandolin with a fast
precision that broke the melody apart into a series of dotted notes. You can
practically hear him assembling the tune. Just using the mandolin as a lead
instrument was a novelty, one that Monroe emphasized by strumming hard and
using only four strings instead of eight.

This collection doesn't include a single one of Monroe's top 20 country hits,
focusing instead on songs that allow vocalists like Travis Tritt, Charlie
Daniels and Mary-Chapin Carpenter to strut their ostentatious stuff over
Monroe's discreet melodies. But even their preening cannot snuff out the
flame that Ricky Skaggs keeps fanning on this homage, the red-hot flicker of a
man at odds with himself and everyone around him, making beauty out of
plaintiveness.

GROSS: Ken Tucker is critic at large for Entertainment Weekly. He reviewed
"Big Mon," the songs of Bill Monroe produced by Ricky Skaggs.

(Credits given)

GROSS: I'm Terry Gross.

(Soundbite of song)

Mr. SKAGGS and Ms. MAINES: (Singing in unison) Up along the Ohio River, over
on the old Kentucky shore, once dwelled a fair young maiden. Now there's a
crepe upon her door. I'll walk down to the graveyard, down by the Church of
God. I'll look upon the one I love that would soon be covered with sod. Up
along the Ohio River, over on the old Kentucky shore, once dwelled a fair
young maiden. Now there's a crepe upon her door.
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