Dr. Fanestil is board-certified in Internal Medicine and has practiced as both a primary care internist and as a hospitalist for most of his career. In 2017, he began researching and learning about new theories in neuroscience - largely supported by functional MRI (fMRI) data - that are beginning to explain the emotional connections between mind and body. After watching many patients improve or resolve their chronic pain problems, he works now at The Center for Mind-Body Medicine, which draws upon these new theories to treat chronic pain and other hard-to-treat medical symptoms - without the use of medications.
Q: What motivates you to study pain and how did you first get interested in it?
A: Chronic pain is a part of any primary care practice. I realized many years ago that most patients with chronic pain had a problem with the way their nervous system was processing pain signals (as opposed to some sort of ongoing wound or tissue damage that was not healing), but until I learned about recent advances in neuroscience I did not have much to do for these people other than try more medications. And while medications can sometimes help, I rarely saw them actually “cure” chronic pain. And they often had side effects. More often, they just didn’t help all that much. But using the ideas behind what is now being called Pain Reprocessing Therapy, I started to see patients get better. Sometimes people in severe pain on lots of meds would get better. And they would get pretty much ALL the way better. Their lives changed. This was very exciting to me, so I decided to spend the rest of my career using these new ideas to help patients, and try to start educating the physician community.
Q: What challenges in treating chronic pain patients stand out to you and how can we start to solve them?
A: The biggest challenge is helping doctors and patients shift their perspective from a biomedical model to a biopsychosocial model.
There is nothing “wrong” with the biomedical model. Vaccines and antibiotics and dialysis machines and ventilators and modern surgery can at times seem almost magical. This way of solving problems starts with the idea that diseases are best “cured” by putting yourself in the hands of a competent doctor and letting him use his skills to heal you. This is a fantastic idea if you have an acute heart attack or appendicitis. In these situations I willingly give up my own agency, and allow the “expert” to fix me.
But this idea that disease can be “fixed” by an expert or by something outside myself (such as a medication) simply does not apply to about 30% of what walks into a primary care office. Pills and procedures simply do not work for chronic pain. New technologies like gene mapping and fMRI are allowing us to use the scientific method to start to explain how biology, psychology and the social environment interact to cause very measurable changes in the brain and the body. The physiology of my brain and my body may depend on my genes and my cells and the chemicals floating around in my system, but it turns out that those genes and cells and chemicals are directly impacted by my thoughts, by my feelings and by my social environment. And for many problems like anxiety and chronic pain, we do patients a disservice if we ignore these very important contributors to disease.
As we acknowledge the importance of psychology and social environment, we can teach patients how to “be their own expert.” Instead of looking for a cure from the outside, we can use our new understanding of neuroplasticity to help patients learn how to change their system “from the inside out.” The newest neuroscience tells us that we all have the ability to cause very real changes in our brains and bodies, and Mind Body Medicine is about giving people the tools to effect those changes. The agent for change becomes the patient, not the doctor. This can be really liberating and hopeful for patients who have been struggling first-hand, often for years, in a system that has been treating them more like a car than a whole person. The human body is an amazing healing machine. Once a patient starts to feel empowered, a whole new level of healing begins.
Q: Your pain clinic has started providing a “Neural Reprocessing for Anxiety” program. What does this curriculum involve and how can it help people with this condition?
A: Chronic pain and anxiety are “alarms” coming from a hypervigilant brain. This mindfulness-based class helps people start to understand how they can start reducing this hypervigilance. It is a 4 session class that gives people a roadmap to start changing their brain. The first session is called Cognitive Reframing. This involves helping people understand that their anxiety or hypervigilance is not a disease or a disorder, but the natural and normal reaction of a brain that has had certain past experiences. Session 2 is called “Mindfulness: why your own brain is stronger than Valium.” Session 3 is called “What are you saying to yourself all day long, and how is that working for you? Let’s talk about Self-compassion.” And in session 4, “Looking Under the Hood,” we discuss what I consider to be one of the central precepts of Mind Body Medicine which is “getting OUT what is IN.” Many people with anxiety have fantastic coping skills. I am sometimes amazed by just how much adversity they have dealt with, often by “shoving problems under the rug, gritting their teeth and moving forward.” But if your main strategy for dealing with adversity is to shove it under the rug and move on, there will likely come a time when you have shoved so much stuff under the rug that you won’t be able to walk across the room. So we practice mindfulness-based techniques that help us go TOWARDS uncomfortable feelings and thoughts, rather than covering them up or ignoring them.
Q: One popular topic in the medical field is Long COVID. If you have had any experience with this in your clinic, can you describe some of the symptoms you’ve seen and if you’ve found any mind-body techniques that can help cure the condition?
A: I started telling the pulmonologists and the Infectious Disease docs and the primary care docs in my community that I wanted to see patients with Long COVID because they reminded me so much of many of my patients with Chronic Fatigue Syndrome. And I have seen enough of these patients get better, that I thought the same ideas could be applied to Long Covid. And I do have several Long COVID patients with significant improvement or even resolution of symptoms.
Once again, the new neuroscience gives us a framework for understanding how symptoms like shortness of breath or chest pain or fatigue or brain fog or joint pains can persist even when there is no longer any actual tissue damage. The patients i see with persistent cardiopulmonary symptoms or persistent pain usually have been seen by one or more specialists who have told them that their chest xray or their heart tests or their joint xrays do not show any ongoing severe problems, but the symptoms (sometimes quite debilitating) persist. Once the patient is educated in what is going on in the Autonomic Nervous System, and once he is given tools and exercises that actually change the Autonomic Nervous System, I believe most patients can heal from Long COVID. My success rate is not 100%. I do have a couple of patients that were severely impacted and whose progress has been minimal so far. But even in these patients it is apparent that a major part of the problem is in the nervous system, yet imaging does not show any damaged areas of the brain. This gives me hope, because neuroplasticity tells us that we all have the ability to build new neural circuits in our brains.
Q: Are you working on anything else these days that you’d like to share?
A: I sometimes joke that I am in year 4 of a self-imposed 5 year residency in Mind Body Medicine. So I am always reading something new and looking for new ideas to incorporate into my model of understanding. Right now I am taking a class taught by Jud Brewer, and MD/PhD psychiatrist and neuroscientist at Brown University who has developed an app to help people with anxiety and with changing behaviors. I hope to incorporate more of his ideas into my clinic. (By the way, his Unwinding Anxiety app can be a great product for people who are committed to the idea of Self-Care, and who understand that putting in just a few minutes per day can result in long lasting changes in the brain.)
Q: When you are not helping people manage their chronic conditions, what do you do for fun?
A: I live in Boulder, so not surprisingly I like to ski and bike. I like to fiddle on my guitar. And I love hanging out and being a home-body around the kitchen and garden with my wife of 31 years.
Looking to find more of Brad? Check him out at the Boulder Community Health Clinic.