John Paggioli

Dr. John Paggioli graduated with honors from Columbia University, then attended New York University School of Medicine. His residency was in Anesthesiology at the Columbia-Presbyterian Hospital followed by two pain management fellowships, the first at Brigham and Women’s Hospital, Harvard Medical School, and the second at Texas Tech University Medical Center where he trained under Dr. Gabor Racz, known throughout the world for his innovations in interventional pain treatment. After finishing his training, Dr. Paggioli was appointed Co-Director of the St. Elizabeth’s Hospital pain center in Boston, and assistant professor at Tufts University School of Medicine where he taught residents and fellows. Following his career in academic medicine, he went into private practice and established the Eastern CT Pain Treatment Center in Norwich, CT. He is expert in numerous interventional pain-relieving techniques including spinal cord stimulation and radiofrequency ablation.

Where did the idea for your career come from?

I called my medical practice “Eastern CT Pain Treatment Center” because I was the first fellowship trained pain management specialist in Eastern Connecticut. I called it pain treatment because the techniques I learned in my two fellowships taught me how to reduce the pain, rather than just manage it, although both pain reduction and pain management are necessary.

What does your typical day look like and how do you make it productive?

A typical day at work involves evaluating new patients, often referred by spine surgeons looking for more conservative treatment to be tried before considering surgery. I also have referrals from spine surgeons when surgery fails to reduce the pain. Treatment for patients with ongoing pain after spine and orthopedic surgery involves first figuring out the source of the pain through a careful examination of the patient’s MRI imaging, and a thorough physical examination. Then inflamed nerve roots, often from scar tissue can be injected with steroids which reduce inflammation and possibly shrink scar tissue. The use of fluoroscopy allows for pin point accuracy to help guide the injection and reduce the chance of complication. Sometimes ongoing pain is related to arthritic joints near the area of surgery: radiofrequency can reduce spinal joint pain for an average of eight months. There are instances where a neighboring disk to the one that was operated on can be a source of ongoing pain; if the MRI shows only a mildly degenerated disk, whether the disk is a problem can be tested with discography, where contrast is injected into the disk to look for tears not obvious on the MRI. Medical Management is an option, but many patients do not respond to the medication available for nerve pain and arthritis. The use of opioids is controversial: while these reduce pain in the short run, there is no proof that they continue to reduce pain in the long run. Referral to a psychologist for treatments including cognitive behavioral therapy can help the patient manage the pain that does not go away. When all else fails, spinal cord stimulation can be an effective option that can reduce the pain by 50-75%. Spine and joint surgery that fails to reduce pain involves one third of my patients. Having great staff that help me and are thorough and responsive to my patient’s needs is important in making my day productive.

How do you bring ideas to life?

I bring new ideas to life by doing a lot of reading, attending medical conferences where new information is presented, and thinking about past patient successes all combine to help me treat patients whose pain problem is different than usual. Patients with a common underlying condition do not always have the same pain pattern. For instance, spinal cord stimulation is approved for failed back surgery syndrome and complex regional pain syndrome where a limb can become swollen with severe pain to light touch. Spinal cord stimulation, and the newer dorsal root ganglion stimulation can work for more complicated pain locations including chronic severe angina, chronic abdominal and pelvic pain, and peripheral vascular disease. Unfortunately, the need for a treatment such as spinal cord stimulation for a condition that is not FDA approved will usually mean that the insurance company will refuse to pay, even if there is a great chance that the treatment will work. New technology can be expensive.

What’s one trend that excites you?

A trend that excites me in the field of pain management is regenerative medicine. The procedure is in widespread use on professional athletes with tendon tears. Blood is taken from the patient, spun with a centrifuge, and the portion that floats up is “platelet rich plasma” which contains growth factors. The growth factors stimulate stem cells near the tendon tears to form new tendon cells, repairing the damage without surgery. An important unmet need is ongoing pain after spinal fusion or disk replacement from mildly degenerated disks with small tears adjacent to the fused disks. Disk degeneration involves a loss of disk cells called chondrocytes which make important proteins that keep the disk moist. A dry disk, which occurs with age, is more likely to tear, and tears are painful. A repeat fusion has a low success rate. Pain specialists are removing stem cells from the patient’s bone morrow or fat, concentrating them, and injecting them into dehydrated torn disks to regenerate chondrocytes. This process is not cheap, and unfortunately to save money and make higher profits, insurance companies refuse to pay for expensive quality of life treatments. Hopefully in the future drug companies will obtain FDA approval for disk regenerative techniques that will be proven cost effective compared to fusion, making the insurance companies more likely to pay for the treatment. As with any FDA approved drug or treatment, insurance companies have the power to deny coverage for anything that is more expensive than existing but less effective alternatives.

What is one habit of yours that makes you more productive as an entrepreneur?

I am more productive as a physician through leaving private practice and becoming employed as the majority of physicians are now in the country. One reason I left is the cost of running an office which involves many employees to follow the ever-increasing prior authorization requirements of insurance companies despite their cuts in re-imbursement. Having a private practice necessitates the physician having an extensive role in running the office. Large groups and hospitals can hire the necessary staff including office managers so that the physician can focus on patient care.

What advice would you give your younger self?

I would develop and trust my intuition more. Racking one’s brain to find all possible facts and angles before making important life decisions is usually fear based. Facts are important but the belief that some have not been found and considered is a waste of time and demonstrates intolerance of uncertainty. Intuition and letting go of the ultimate outcome is important in making decisions in order to have a more peaceful life.

Tell us something that’s true that almost nobody agrees with you on.

To allow that a lot of hard work and time spent in developing one’s career is acceptable in order to have a meaningful and therefore enjoyable career. Many people are afraid of becoming physicians because of the years spent and hard work involved. All meaningful careers involve time, focus and sacrifice. One is still living along the way, and there is always time for a family later. It is a mistake to pick something that one likes less in order to save time, because that can lead to either a lifetime of regret, or having to start over later with something more enjoyable, with more time spent in the end.

As an entrepreneur, what is the one thing you do over and over and recommend everyone else do?

Exercise. Exercise on a near daily basis increases endorphins and energy, decreases depression and anxiety thereby improving mood, decreases the need for excess sleep, make’s one more comfortable in one’s body (experiencing less aches, pains, and fatigue), and allows one to be happier and more productive.

What is one strategy that has helped you grow your business?

Teaching my colleagues and the public through lectures and newspaper articles. The local newspaper ran several articles on me with pictures of my patient’s undergoing spinal cord stimulation implantation when spinal cord stimulation was a new and unknown technique to the public.

What is one failure you had as an entrepreneur, and how did you overcome it?

Failure to be successfully involved in managing my private practice when I could no longer afford a nurse-manager. I gave my trying to mange an office long ago when I became salaried and could completely focus on patient care. Most physicians are now salaried; this was caused by insurance payment cuts and ever-increasing insurance company requirements to get treatment approved.

What is the best $100 you recently spent? What and why?

$100 doesn’t buy so much anymore. The best $300 I ever spent was for a ticket to see Paul McCartney in concert. He is 80 years old, and gave the best concert I ever saw. His voice is still great, and better than the other rock stars I have seen. Most importantly, he cares about his audience, plays his hit songs unlike some rock stars who play songs from their latest album or keep their eyes closed and play mostly blues music (I won’t name names). He is very active with the audience, and tells jokes stories about the old days. He spent a lot of money on special effects including fireworks during Live and Let Die, and at the end of the concert. He doesn’t need the money, and performs because he loves it. He also is in great shape and likely eats well and exercises regularly. He is my role model. I hope at 75-80 years old I am still working, alert, and loving what I do.

What is one piece of software or a web service that helps you be productive?

I can’t say the computer systems that doctors are forced to use to document patient care makes us more productive: dictating in the old days was faster and more thorough. Therefore, the most important computer for me is my I-phone. For instance, when I am waiting for my car to be fixed with nothing to do, I take out the phone and look up topics or people I want to read about. I use Wikipedia often. Learning in this way is relaxing, enjoyable and I feel like I accomplished something rather than wasting time watching TV or staring into space.

What is the one book that you recommend our community should read and why?

Any book by Eckhart Tolle is helpful. In the Power of Now he recalls how he was miserable throughout his life, he one day thought about the statement “I feel miserable” and felt that he was two persons: the miserable person, and the conscience that noticed it. His books are about the spiritual theme that ultimately, we are not a miserable self, that this is conditioned by genetics and events, and is therefore impermanent. The miserable self is made up of past traumas stored as memories that with great frequency bubble up into consciousness as unwanted thoughts and day dreams. These thoughts and daydreams are often about regret, anger, and feeling hopeless about past events, worry over imagined future events, and such thoughts induce fear and anger as if the past or imagined future is actually occurring. These feelings lead to a flood of fight or flight hormones and neurotransmitters including cortisol and norepinephrine which are important during actual danger but not in daydreams of past or imagined daydreams. Such chemicals reinforce negative memories and thoughts making them more likely to occur, such as in the case of post traumatic stress disorder. Tolle prefers to be a peaceful observing presence who is alert and can watch such thoughts come and go, knowing that they are impermanent. That one can be alert and in control of their thoughts by not clinging to them is a Buddhist idea.

What is your favorite quote?

I have many, but I’ll mention a few that support the ideas of Tolle and cognitive-behavioral psychologists. In Hamlet, Shakespeare wrote “There is no good or bad but thinking makes it so.” People with chronic pain will sometimes ruminate and catastrophize over their pain and the effect on their life, leading to misery and hopelessness; such thoughts can make pain worse. Having pain, anxiety and depression is difficult to control, but being miserable over it is more a matter of excess thought, where there can be some control once one realizes it is in part a choice. The Buddha has many similar quotes: “Do not dwell I the past, do not dream of the future, concentrate the mind on the present moment.” “Holding onto anger is like drinking poison and expecting the other person to die.” “Your worst enemy cannot harm you as much as your own unguarded thoughts.” “Happiness does not depend on what you have or who you are. It solely relies on what you think.”

Key Learnings:

• Treating pain starts with finding the source of the pain through a thorough physical exam and careful examination of MRI imaging.
• There are many ways to reduce pain including medication and interventional pain techniques including fluoroscopy guided steroid injections, spinal cord stimulation when all else fails, and newer techniques including regenerative medicine, dorsal root ganglion stimulation, and percutaneous discectomy and spine decompression (done with sedation and no incision). Unfortunately, insurance companies will often refuse to pay for newer treatments by calling them “experimental” even when available studies and the consensus of expert opinion is that they are safe and effective.
• Psychiatric and psychological treatment is important for people who have problems that existed before chronic pain such as anxiety, depression, post-traumatic stress, and for people disturbed by pain that cannot be reduced and recurrent thoughts over their situation. Negative thinking causes a flood of unneeded toxic hormones and transmitters meant for actual danger, and these sensitize the nervous system further to make pain worse. Worse pain leads to more negative thinking and a vicious cycle is born.