St. Olaf Magazine | Winter 2019

The Pain Managers

The patient was a young man, an assistant at a school for troubled youth. One day, a situation at the school got out of hand. A student attacked him, crushing his left hand and breaking his fingers.

The man’s fingers healed, but month after month, the pain remained. Eventually, he simply stopped using his hand. St. Olaf College alumnus Peter Stiles ’05, medical director of the pain program at TRIA Orthopedic Center, recalls not just the man’s injury but its impact. “He just kept his hand in a glove and put it in his pocket,” he says. “He couldn’t lift his daughter.”

When the man came in to see Stiles, he thought he’d exhausted every possibility: medication, physical therapy, behavior modifications. Stiles, who makes his living helping people with seemingly incurable pain, offered another option: a high-tech spinal cord stimulator.

The stimulator, developed by Boston Scientific and supported by a team that included fellow St. Olaf alumnus Ben Fetters ’05, would act something like noise canceling headphones for the pain. It wasn’t a guaranteed fix. But the man, who continued to struggle with raging pain, understood that it might just be his best shot. He agreed to try the procedure to implant the device.

His turnaround could hardly have been more dramatic. “I saw him back one week after the implant. He was holding a can of Coke with his left hand,” Stiles says, still astonished.

Not every patient that Stiles sees experiences such a striking improvement with this device. But for some, the technology is truly life-changing.

Ben Fetters ’05 (left) and Peter Stiles ’05, photographed at TRIA Orthopedic Center by Tom Roster

There’s no question that the country is in dire need of good solutions for chronic pain. Studies suggest that one in three Americans suffer from chronic pain, defined as pain lasting three months or more. And some of the most common treatments, including opioids, are both addictive and potentially deadly.

The comprehensive pain management plans that Stiles offers, paired with the kind of advanced technology developed by several medical device companies, including Boston Scientific, may be a big part of future treatments at TRIA. For those experiencing extreme chronic pain, the work that Stiles and Fetters pursue might just be the one-two punch that can knock out pain’s debilitating effects for good.

The path to pain management

Long before Stiles and Fetters were collaborating to support patients with chronic pain, they were hallmates in Ytterboe. They knew each other casually, and each had separate ambitions. Stiles planned a career in medicine. Fetters, who focused on economics and financial management, planned to pursue a business career.

Stiles started out as an anesthesiologist, a fast-paced position in the operating room. “I was responding to crises and rescuing airways,” he says. “It was front-line lifesaving.”

He made a real impact on patients’ lives and enjoyed this work, but he felt as though something was missing professionally: a lack of durable relationships with his patients. “I missed the interpersonal piece. I missed coming up with a plan and seeing it through.”

Stiles completed additional fellowship training and was recruited to TRIA, where he built a program capable of designing individualized pain management plans. These plans typically include a combination of medication, physical therapy, behavioral support, interventions, and even mindfulness techniques and acupuncture. Sometimes, they also include technology.

As Stiles was getting his bearings at TRIA, he heard from his long-ago hallmate Fetters. After a stint in commercial real estate, Fetters had landed at Boston Scientific, where he was a manager focused on spinal cord stimulators.

In the complicated world of chronic pain management, Stiles appreciated his relationship with Fetters, a trusted voice who could serve as something of a translator, helping Stiles understand the best uses for the cutting-edge technology. The more that Stiles understood its capabilities, the more likely he would be able to match the right patient with the right spinal cord device. Stiles is careful to note that while he appreciates his relationship with Fetters, he is always a doctor to his patients first: with similar devices from several medical device companies, he makes his choices based on what’s best for a patient, not his relationship with a classmate.

Tiny but mighty

There’s no question the technology feels a bit like science fiction itself. For something that can have such a major impact on pain, a spinal cord stimulator is small (imagine an Oreo cookie with a couple of small wires attached to it).

Implantable devices such as the spinal cord stimulator are one way to provide real relief without the danger of opioid addiction.

The device is surgically placed underneath the skin of a patient, with a pair of wires implanted just outside the spine, so that it can deliver electrical signals to specific spots on the spine. These electrical currents can help alter a person’s excruciating feeling of pain to something that’s more tolerable.

Think of the experience, says Stiles, like the moment you hit your head on the corner of a cabinet. Your first instinct is to rub your head. That simple motion doesn’t actually make the pain go away, but it does overwhelm the pain signal your body is giving you with an alternate sensory signal. Stimulators work in a similar way.

The goal of pain management should not necessarily be absence of pain. It should be increasing function with less pain, or in spite of pain.Peter Stiles ’05

Such devices, relatively new in the field, are among the most promising developments for those who have had unrelenting pain that is not relieved by other treatments.

“It offers hope for a whole class of pain and patients that, as recently as five to ten years ago, were completely hopeless,” says Stiles. And while spinal cord stimulators may not completely erase someone’s pain, they can greatly improve a person’s quality of life. “As funny as it seems, the goal of pain management should not necessarily be absence of pain,” he says. “It should be increasing function with less pain, or maybe in spite of pain.”

A Collaborative Effort

The process of implanting and managing the spinal cord stimulator is a collaborative one. It begins with a doctor like Stiles, who implants the spinal cord stimulator in a person’s body. Experts and scientists from Boston Scientific are closely involved.

“We actually bring the devices to be implanted to the surgery,” says Fetters. “Then we stay with the patient after the surgery to educate them how to use it.” He adds that he or his team members come to follow-up appointments to program the device, and they’re always available beyond the surgery: “All patients get our cell phone numbers.”

At a patient’s request, Boston Scientific scientists can use their own technology to fine-tune the anatomic location of the stimulation. They can make sure that the stimulation affects the foot rather than the knee, for example, or the left foot rather than the right.

From there, patients themselves control the device with a remote control, using one of more than a dozen settings. They might choose one setting during a workout, another as they prepare for bed, and a third as they sit at their office desk. The battery, which has a 12-year-life, can be charged through the patient’s skin.

As medicine advances, such collaborations among doctors, medical device experts, and scientists will become more common. For his part, Stiles says that working with an Ole he’s known for nearly two decades makes a meaningful difference as they work with patients.

“As a doctor, you have to have strong trust in the team you’re working with,” he says. “When Ben tells me something, it’s coming from someone I know and trust.”

Fetters, meanwhile, appreciates the chance to support the work of doctors and surgeons who want to help people with debilitating chronic pain. He believes that implantable devices such as the spinal cord stimulator are one way to provide real relief without the danger of opioid addiction. The FDA has approved spinal cord stimulators as a safe and effective, drug-free therapy for people suffering from debilitating chronic pain, Fetters notes, adding that for more than four decades, these stimulators have brought pain relief to hundreds of thousands of individuals.

For Stiles, the larger pain management work is about developing a plan that makes a real impact on people’s lives. He’s watched as wheelchair-bound patients regain the ability to walk and as patients debilitated by pain go from an hour or two of sleep per day to uninterrupted nights. “I like to work with patients to come up with a plan together that makes their lives better,” he says. “When I can walk with them through that, it’s very rewarding.”

So You Want To Be A Doctor

An internship supported by doctors Peter Stiles ’05 and Marc Tompkins ’99 lets students dive deep into the joys and challenges of medicine long before they apply to medical school.

Eliza Thompson ’17 had known for years that she wanted to go into medicine. She’d even spent some time — an afternoon here, a day there — shadowing physicians. But when she landed one of the two coveted spots for the TRIA Orthopedic Center internship through St. Olaf’s Piper Center for Vocation and Career, she knew she’d get an unparalleled view of the world she soon hoped to join.

Colten Yahn ’17 and Eliza Thompson ’17, the first two students in the TRIA Orthopedic Center internship, are both now in medical school.

She wasn’t disappointed. Over the course of 160 hours in 2016, she observed physicians, nurses, physical therapists, and radiology technicians. “I got a sense of what each of these professions contributes to patient care,” she says. “After this experience, I knew I wanted to go to medical school.”

Thompson is now a second-year medical student at Washington University in St. Louis. That outcome — not just a spot in medical school but Thompson’s clear-eyed knowledge about the road ahead — was exactly what Peter Stiles ’05 and Marc Tompkins ’99 hoped would come from the internship they developed in partnership with St. Olaf.

It all got started at the TRIA Orthopedic Center holiday party. Tompkins, an orthopedic surgeon, and Stiles, medical director of the pain program, were chatting about their St. Olaf experiences, including the internships they had done as undergraduates. Both men realized that those internships had been invaluable in their own paths to medicine. “[My internship] opened my eyes to different areas of medicine,” says Tompkins. “It was the first time I had exposure to orthopedic surgery.”

Marc Tompkins ’99 (left) and Peter Stiles ’05 teamed up with St. Olaf through the Piper Center for Vocation and Career to design a structured internship at TRIA.

The pair teamed up with St. Olaf through the Piper Center for Vocation and Career to create similar opportunities for students by designing a structured internship at TRIA. Thompson and fellow classmate Colten Yahn ’17 were the first two students to go through the internship program, which selects two students each semester. The seventh and eighth students, Abhinab Kc ’21 and David Domnick ’21, will wrap up their experience this July.

Stiles says that even the most committed and knowledgeable students gain new insight during the internship. For example, they might be surprised by the time gobbled up in tussles with insurance companies, or in learning the nuances of electronic medical records.

“You can read about what doctors do. You can watch medical shows. But until you actually show up before the sun comes up and stay until the sun is down — until you learn what it’s actually like to interact with patients, both the good parts and the challenging parts — you probably don’t have the real flavor of what a career as a physician is like,” he says.

Yahn, for his part, says that while he expected to be wowed by Tompkins’s and Stiles’s skill as surgeons and professionals (he was), one of the most useful parts of the internship was having weekly, meaningful discussions with the two about what a career in medicine really meant. “They were extremely open about some of the sacrifices they made for the sake of their profession,” he says.

Yahn, now a first-year medical student at Eastern Virginia Medical School in Norfolk, says the conversations made a real difference. “The internship at TRIA was my confirming moment. It was when I completely bought into the idea of going to medical school,” he says. “The conversations [with Stiles and Tompkins] pushed me to explore my true motivations.”

Most of all, say students, the experience gives them a model for who they can become as doctors.

“Doctor Stiles was graceful, kind, and smart — words that I hope will describe me in my future career,” says Thompson. “[The experience] helped me see that I could become the kind of physician I want to be.”