ࡱ> e rbjbjJJ (_b(_bj&6 6 6 6 6 $Z Z Z P l!LZ 5fb"b"("""e#e#e##5%5%5%5%5%5%5$ 79I56 _%e#e#_%_%I56 6 ""^5333_% 6 "6 "#53_%#5333"{035t5053f:1 f:3f:6 3<e#Z#@3#43$,e#e#e#I5I52$e#e#e#5_%_%_%_%f:e#e#e#e#e#e#e#e#e#B : John C. Liebeskind History of Pain Collection Oral History Interview with John D. Loeser Ms. Coll. no. 127.24 Conducted: 12 July 1993 Interviewer: John C. Liebeskind Duration: ca. 4.0 hours Pages: iv, 54 History & Special Collections for the Sciences UCLA Library Special Collections Los Angeles, California 90095-1798 2000, revised 2016 Biographical Sketch John D. Loeser was born in Newark, New Jersey, in 1935. He graduated from Harvard in 1957 and earned his medical degree from New York University Medical School in 1961. Following a surgical internship at the University of California San Francisco and a neurosurgical residency under Arthur Ward at the University of Washington, he spent two years in the Army Medical Corps (1968-70), serving in Vietnam and at Fitzsimmons Army Hospital in Denver. Since 1969, Dr. Loeser has been a member of the Neurosurgery Department at the University of Washington Medical School. He was appointed to a full professorship in 1981 and has held a joint appointment in Anesthesiology since 1989. From 1983 to 1997, he was Director of the Multidisciplinary Pain Center founded by John Bonica and brought about important changes in its operation. He also served as Associate Chief of the Neurosurgery Service at Childrens Hospital in Seattle from 1974 to 1986, and as Chief from 1986 to 1993. He is a Past President of both the American Pain Society (1986-87) and the (1993-96), and a founding member of both organizations. Interview History Dr. John Loeser was interviewed in his office at Childrens Hospital in Seattle by John C. Liebeskind on July 12, 1993. The interview lasted approximately 3 hours. The transcript was audit-edited by Marcia L. Meldrum and reviewed by Dr. Loeser prior to its accession by the History of Pain Collection. The tape and transcript are in the public domain, by agreement with the oral author. The original recordings, consisting of two (2) 90-minute audiotapes, are in the Library holdings and are available under the regulations governing the use of permanent noncurrent records. Records relating to the interview are located in the offices of History & Special Collections for the Sciences. Topical Outline (Scope and Content Note) The interview is organized chronologically and then topically, beginning with Loesers early influences and education; neurosurgery residency under Arthur Ward at the University of Washington; and continuing with his relationship with John Bonica and experiences at Issaquah and in IASP; and administration of the University of Washington Pain Center. Loeser goes on to discuss contemporary problems in medical education, pain management, and the progress of the pain field; and the interview closes with comments on his family, his personal rewards and achievements, and his experiences in Vietnam. Major topics of interest include: Loesers early work with deafferented neurons; the variant definitions of pain and types of clinical pain problems; the relationships of Bonica, Loeser, and Wilbert Fordyce; and the economics of pain clinics. Access to the Interview This oral history interview, in its audio and transcript forms, is held by History & Special Collections for the Sciences, a division of UCLA Library Special Collections located in the Louise M. Darling Biomedical Library. Those wishing to use the printed transcript or the audiocassette version (which is available by appointment only) should contact: History & Special Collections for the Sciences, UCLA Library Special Collections, Louise M. Darling Biomedical Library, Los Angeles, California 90095-1798. Phone: (310) 825-6940. Terms and Conditions of Use By agreement with the oral author (interviewee), the contents of this interview are placed in the public domain and are made available for use by anyone who seeks to broaden the understanding of pain. However, users must fully and properly cite the source of quotations they excerpt from this interview (see Citation Information). Citation Information The preferred citation for excerpts from this interview is: Oral History Interview with John D. Loeser, 12 July 1993 (Ms. Coll. no. 127.24), John C. Liebeskind History of Pain Collection, History & Special Collections for the Sciences, UCLA Library Special Collections. Editorial Note The interview transcript has been annotated -- with notes offset in [square brackets] -- to clarify and enhance the readers understanding of the concepts and events described, but as sparsely as possible, so as not to interrupt the flow of the oral authors thoughts. By and large, the transcript is a record of the oral authors ideas and recollections in his own words. Related Materials in the Liebeskind History of Pain Collection Researchers are referred to the following related materials: oral history interview with John Bonica; oral history interview with Wilbert Fordyce; records of the American Pain Society. Acknowledgments Support for the John C. Liebeskind History of Pain Collection and its Oral History Program came from the American Pain Society and the . . [PHOTO PORTRAIT NEEDED] John Loeser, MD Neurosurgeon JOHN D. LOESER INTERVIEW TAPE ONE, SIDE ONE JOHN LIEBESKIND: Let me note that it is July 12, and it is 8:30 in the morning, and we are sitting in the office of Dr. John D. Loeser at Childrens Hospital in Seattle, Washington, and we are getting our interview. John, I have a series of questions here that I have made up that I am asking everyone. I have made some slightly different ones for Louisa [Jones], but they are not meant to limit what we talk about, or shape too narrowly what we talk about, but first I want to ask you how you got into the field of pain. Where did that all come from? JOHN LOESER: It was really all serendipity, to be perfectly honest. I had no particular interest in, or knowledge of pain in any way when I began my training. Indeed, my undergraduate days were marked by the fortuitous chance to write a thesis for Jerry [Jerome] Bruner on cognitive psychology. I was a Harvard Soc Rel [social relations] major, the same year you were, but my interest at that time was really in the opposite end of human behavior, so to speak; that is, the processing of information. I was certainly interested in the brain -- I chose to go into neurosurgery when I was 13 years old and my father, who was a neurologist, took me to an autopsy. The patient had mysteriously died and in those days, before angiograms and CTs and things...he turned out to have a brain tumor. I remember at that time saying I was going to be better than my old man ever was; I was going to be a neurosurgeon so I could look inside the black box. LIEBESKIND: So you could do something about it. LOESER: So I ended up -- LIEBESKIND: That was quite a bar mitzvah -- an autopsy. LOESER: Yeah, it took the place of a bar mitzvah -- good line, I like that one. But I went to college thinking you had to major in sciences and found, much to my delight, in the middle of my freshman year, that Harvard didnt give a damn about what you majored in. Just then LIFE magazine had a big article on the Navajo Indian, and it was written by Clyde Kluckholm, who was one of the professors at Harvard at that time, so I realized that I could do my inorganic chemistry requirement in one semester, and I had a free semester then because I didnt have to do two semesters of chemistry. I took Kluckholms course on the Navajo Indian, got very interested in, really, social anthropology. He sent me off to take a course with Roger Brown, who is a social psychologist. Roger Browns course I found fascinating -- from him I learned ESP may be good, but if you want to talk to your mother in Chicago, use the telephone, its more reliable. [Liebeskind laughs.] He sent me off to work with Jerry Bruner, which was just the privilege of a lifetime. LIEBESKIND: By the way, I just had a student in my office the other day who had a letter of recommendation from Brown. Is he still around? LOESER: He must be pretty senior now -- but he was a very young man, he was assistant professor when I was there. LIEBESKIND: Yeah, he had just retired, I think he said. LOESER: So I damn near went into cognitive psychology. Bruner did his best to deflect me from medicine. But I went to medical school and during medical school I spent a year at Stanford, when it -- the first year they moved down to Palo Alto, in the pharmacology department, of which Avram Goldstein was chairman, working with Keith and Eva Killam, who were very good psychopharmacologists. We had -- my job was doing behavioral studies of pussycats that had been instrumented with multiple electrodes in the nervous system, and in addition I did a little project on the effect of, I think it was Librium, on thalamocortical or thalamoreticular relations, and at that time the Pharmacology Society was meeting here in Seattle. Keith Killam said to me, If you are so stupid as to want to be a neurosurgeon, there is only one place for you to train, there is only one academic neurosurgeon in the country, and that is Arthur Ward in Seattle. So he brought me up here to give a talk at this meeting, marched me into Arthurs office and said, Arthur, this is the best applicant youll ever have -- you better take him. [Liebeskind laughs.] Much to my delight, a year or two later, I was accepted in the residency here. LIEBESKIND: Where were you in medical school? LOESER: I was then a third-year medical student. I took a year between my third and fourth years. LIEBESKIND: You were a medical student... LOESER: ... At NYU [New York University]. LIEBESKIND: ... At NYU, but you had spent this year at Stanford? LOESER: Right. NYU was very flexible. What I did was, I did my entire first three years in two and a half years by taking no vacations. Then there were only six months of required courses in the fourth year. So without losing a chronologic year, I got a one-year block that I went and worked with Keith Killam. LIEBESKIND: How did you hear about that? How did that come about? LOESER: Well, that goes back even further. I mean, all of life is serendipity to some sense. My mothers brother was a psychoanalyst, is a psychoanalyst, in Beverly Hills, who lived in L.A. [Los Angeles], moved out there after the war. His name is Norman Levy. Anyway, he offered me, when I graduated high school, the chance to come and live for a summer in L.A., and...was that high school? It must have been graduated college, not graduated high school. Must have been graduated college, definitely. LIEBESKIND: 57? LOESER: Around 57, yeah, I think thats what it was. To come spend the summer with them. He had some contacts with some people at the Brain Research Institute. LIEBESKIND: Killam was there then? LOESER: Yeah. And he would arrange for me to meet them and maybe I could learn something because I was interested in the nervous system, of course. And so I met Keith and Eva Killam then when they were doing their research in the old church that overlooked the Bullocks department store on the edge of the UCLA campus. LIEBESKIND: Really? LOESER: Yeah, we had this old altar that we used as an operating room table. [Both laugh.] An interesting guy, name of Roy John, was with them then. LIEBESKIND: E. Roy John. LOESER: E. Roy John, yeah. So anyway... LIEBESKIND: Those were the good old days for the Brain Research Institute. LOESER: Yeah. I did my internship at Cal [University of California], in San Francisco, and came up here to be a resident in neurosurgery. And at -- LIEBESKIND: Thats a picture of Arthur [Ward], isnt it? LOESER: Yeah. Arthur is still around. Hed still look like that -- he doesnt look much older than that. Thats 20 years ago. Anyway. At that time Bud White -- Lowell E. White, Jr. -- was one of the faculty members here in neurosurgery and he was interested in pain. This is the era when neurosurgeons were doing a lot of rhizotomies, cordotomies -- it was before aggressive use of systemic opiates, it was before intrathecal opiates, it was before antidepressants, anticonvulsants, and there was a large role for ablative neurosurgery in cancer pain, and it was used a lot in other things too. He was one of my four attending physicians, and because of him...and he was actually the cofounder of the Pain Clinic at the University of Washington, with John Bonica. LIEBESKIND: Really? LOESER: Yeah. LIEBESKIND: Now that name has never come up before in four or five years of talking to John Bonica. LOESER: Really! Well, you go back and ask John Bonica and hell tell you that, yes, Bud White was one of the cofounders, quote unquote. LIEBESKIND: Thats not White of White and Sweet, is it? LOESER: No, no, thats J. C. White, who was a Boston general surgeon, became neurosurgeon and a clear-cut pioneer in the field of pain management. Lowell E. White, Jr., was not of that status. He did decent pain-related surgery and he was one of the few neurosurgeons willing to take on the problems of pain patients. His research was not in the area of pain, except he and Eldon Foltz were the first to do cingulamotomies for pain. Thats Foltz and White, that is Bud White, and so in a sense he did some innovative surgical stuff. Now at the same time all of the research in the Department of Neurosurgery was epilepsy research. That was where the funding was, that was the chairmans interest, and Arthur had a wonderful strategy for research. His idea of research was, you bring in good young faculty and residents and you provide them with a resource to do what they want to do -- he didnt meddle, at least with those of us he thought had the capability to accomplish something themselves. I joined the department right after Les Westrum had demonstrated on Golgi stains that cortex in epileptogenic regions was devoid of the dendritic spines. Now the dendritic spines were thought to be the source of afferent input. So Arthur came up with the concept that deafferentation was the cause of epilepsy. And that was the hot idea at the time we were doing it. We sat there and we said, how can we see if this hypothesis is correct? At that time Larry Halpern was doing a lot of research and he would come to the University of Washington from, I think it was SKF, and he had used a cortical slab preparation in research... LIEBESKIND: Wow, thats early. Using cortical slabs? LOESER: Yeah, talking about mid-60s. The problem with the cortical slab was, it was epileptogenic as hell -- of course, there werent any cell bodies in it, which was one problem, and the second one was, when you made a cortical slab you de-efferented as well as deafferented, and you damaged the vascular system. So we didnt like that as a model. I cant -- to this day I cant tell you who it was thought it up, me or somebody else, and we said, well gosh, lets look at the spinal cord, because you can cut the dorsal roots and you wont affect the blood supply and you wont affect the output. So what I started out doing was epilepsy research on spinal cord, and we showed that purely deafferented, without any histologic vascular lesion in the dorsal horn, without any change in the efferent system, deafferented neurons became epileptogenic, and indeed we used to sit there and play games with each other, showing -- these were all extracellular recordings at that time -- that the firing patterns -- you couldnt tell whether you were looking at cortex, rat, monkey, cat, whatever, spinal cord -- Dick Black, who was with us at the time -- deafferented trigeminal system and you got this markedly epileptogenic cortex -- epileptogenic dorsal horn. LIEBESKIND: Madame [Denise Albe-] Fessard was working on something similar too at that time, wasnt she? She was looking at thalamus -- LOESER: Wasnt she looking at ... she was looking at deafferenting thalamus by cutting ascending tracts. I think we were the first to look at dorsal horns and I think we were the first also to say, hey, this could be the model for central pain states. Now, the problem with that was, to go one step further in the research end a second, not only did we... LIEBESKIND: Now youre a resident at this time? Youre still a resident? LOESER: Yeah, I was a resident. I had a year of research during my residency. This would have been around 65, 66, something like that. The other model that Arthur and his associates had used in the cortex was the injection of alumina cream, and that was considered the standard chronic epilepsy model, but we also sometimes played with other epileptogenic agents, penicillin, tungstic acid, cobalt. Alumina cream takes a long time to produce an epileptic lesion in the cortex. Furthermore, there was a 1946 article by Margaret Kennard that said that if you put alumina in the subarachnoid space, you got hyperesthesia over the cat body wall and it had nothing to do with putting the alumina in the spinal cord. Well, at the same time or soon after we did the deafferentation stuff, we also were able to show that if you put the hot epileptogenic things, tetanus toxin, cobalt, tungstic acid, into dorsal horn, you produced terrible pain syndromes in the animals. Dick Black may still have the movie that we photographed -- you dont ever want to see this. You couldnt do this research today, it is not acceptable, I wouldnt want to do it, but were talking about in the mid-60s and were talking about just looking to see what would happen. We euthanased lots of animals real fast when you saw what happened. LIEBESKIND: They would scratch at themselves or something -- LOESER: They would just eat the dermatome clean of skin and hair. However, there was some fascinating research that came out of that that has basically never been published because it is unpublishable. But we can talk about that if you want. LIEBESKIND: He was doing that with trigeminal, wasnt he, Dick? LOESER: Right. Well, we did it with trigeminal and spinal. But the issue was... LIEBESKIND: You know, I have heard that story. Maybe I heard it from you, and so forth, but I seem to recall -- tell me if this is true -- that you actually, and this led to some of the use of anticonvulsant medication for trigeminal neuralgia, I mean, wasnt that where that idea... LOESER: Well, the anticonvulsants came, but the trigeminal neuralgia has been thought of ... long before there was any data on neurons, people commented that tic douloureux looked like epilepsy in the trigeminal system because of its explosive onset and offset and so forth. LIEBESKIND: So that led to the use of -- LOESER: Dilantin was used for tic, and carbamazepine was used for tic long before we did any of this stuff. LIEBESKIND: All right. LOESER: But the thing ... I mean, if you want to get into that in a second ... you see, the problem was, deafferentation surgically produced epileptogenic neurones, but in cats, at least, never produces a behavioral change. You can deafferent the cats hind leg and cats do not get autotomy, sorry. They dont get it whether you cut their sciatic nerve and they dont get it if you do dorsal rhizotomies. Yet their dorsal horns were exceedingly electrically active. If you take tetanus toxin, which is not nice stuff to work with, but we played with it for a while, and inject it into the sciatic nerve of the cat, it flows centrally at the rate of retrograde axoplasmic flow, and in the appropriate number of minutes later, it hits the dorsal horn and the cat develops the worst pain syndrome youve ever seen an animal get, and will literally denude the dermatome, wont touch anything but the dermatome, but it will -- Tetanus toxin will eventually spread out of more than one segment. If, however, you do a peripheral nerve block, pain stops instantaneously. Now thats an interesting concept as to what goes on. The same thing is true with tungstic acid or cobalt, which you inject directly. LIEBESKIND: So the deafferentation wont do it, though it makes the cord epileptic, but the epileptic agents will. LOESER: Thats right. But the epileptic agents will do it, and the only way you stop the pain is by deafferenting it pharmacologically. Anyway, I have not studied the papers to prepare for this discussion, so I am not exactly sure on the chronology and things. But the message is, I got into pain research because it was epilepsy research when it started, but the observations we made and the fact that my chairman said, Thats very interesting, why dont you go ahead and pursue that, rather than saying, No, wait a minute, you got to do epilepsy research. LIEBESKIND: Thats not epilepsy research. Right. LOESER: Then I was exceedingly fortunate in that some first-class physiologists were part of our department, I mean, Bill Calvin, whom I worked with for many years, and we had a wonderful electronics engineer who created the first negative capacitance amplifiers that were around, and we did -- made our own little microprocessors, so we were doing burst firing analyses and things like that... LIEBESKIND: Well, this was a hotbed of neuroscience really, wasnt it? LOESER: Right. And our department was tremendous in that regard. So having the basic scientist support, having the chairmans support...I was not doing high-budget research, but the money was there to do what needed to be done; in fact, the lab was there, I mean, Arthur gave me a lab when I was a resident; when I came back and joined the faculty in 69, I was given a lab. It was fully equipped. He had the money ... the truth be known, from 1969, when I came back on the faculty, until Arthurs retirement, I never applied for an individual grant, an RO1, because it was just a waste of time. I always was part of the epilepsy program project and the Epilepsy Center grant, and I sent in my proposals as part of that, but I was spoiled rotten. I mean, this was the heyday of the NIH, this was one of the premier places, and we got money to do our research. So that was the research side. LIEBESKIND: Thats the way research ought to be done... LOESER: Yeah, well, you and I are dinosaurs. LIEBESKIND: ... Not individual people struggling, but dynamic groups like that. LOESER: You and I are dinosaurs. I finished my training in July of 67 and had the sword of Damocles hanging over me as I had been deferred from the Korean War to go to college, and managed to squeeze through all of my education, but when I finished my residency, Uncle Sam made me an offer I couldnt refuse. LIEBESKIND: Caught up with you. LOESER: I actually left the UW [University of Washington] and took a job as the first neurosurgeon at UC Irvine when they moved from L.A. down to the Long Beach V.A. LIEBESKIND: That was as in satisfying your service requirement? LOESER: No, no, that was my job from which I got drafted. LIEBESKIND: Oh, I see, you didnt last there long. LOESER: Spent a year in Vietnam, then a year at Fitzsimmons in Denver, and then Bud White had left and Arthur was looking for a new faculty member, and so I got the job. And in fact, Bud White, who did the pain, and Eldon Foltz, who did the pediatrics, had both left, and therefore I ended up with a job. That was pain in pediatrics, which is why we are sitting here in Childrens Hospital. LIEBESKIND: ... Talking to the incoming president of the IASP []. LOESER: I picked up -- I ended up then with a clinical practice where my associates were delighted to give me all the peds and all the pain stuff that came along, and that too was part of the serendipity of the environment. Had Bill Kelly left and not Eldon Foltz, Id have been stuck doing pituitaries instead of pediatrics, so it is a lot serendipity, I think. LIEBESKIND: Well, this has come up in all the interviews, I mean, there havent been so many, but the same theme came up strongly; talking to Bill Fordyce, we were talking about how, you know, these things just, theyre not planned, they just happen that way, and I guess thats just life. LOESER: Then, of course, if you go to the clinical side, I in a sense inherited the position in the Pain Center that Bud White had, and John Bonica was still quite active in the pain business locally when I was a resident and a junior attending, but he passed on initially to Stefano Brenna, but he didnt last long, and then to Dick Black, and then to Terry Murphy, the job as director of the Pain Clinic. Actually, I guess it was ... yeah, I think thats right. Then when it became a Center, that is, the medical school upgraded the thing, Terry was the director for a while and then it passed on to me. LIEBESKIND: When was that, when did you become the director? LOESER: 83. LIEBESKIND: So its been 10 years, now. LOESER: That was contiguous with, I mean, they tried to get me to do it before then, but I took another side track in my professional life and I was the curriculum dean here at the UW from 77 to 82, and there wasnt any way that I was going to pick up anything else for that era. But having Bonica here, I mean, and the Pain Clinic here, and then when the IASP got conceived and born with the 73 Issaquah meeting ... I mean, John Bonica ... I love John, he was great for me in many ways -- not the smallest way was that I didnt work for him and I was, in a sense, always a free agent. I think some of the people who worked for John sometimes found him overbearing and pressured, but John wasnt ever my boss. He always seemed to respect me even though I was a young man and he was much more senior, and we developed a very good working relationship. And come the time to set up the Issaquah meeting, he drafted a certain number of local people to be his worker bees, and I was one of them; and the reward for that was he saw to it that the worker bees got the chance to meet people, to be involved in things, to be in on IASP and APS [American Pain Society] at the earliest stages. It wasnt because I was a great man by the time of 1973 -- hell, I had been on the faculty four years -- its because John Bonica said, youre doing work to help me and I will help you. I mean, thats what happened. So thats what came to that. LIEBESKIND: Thats kind of my next whole area I wanted to get into, is Issaquah. LOESER: [Laughs.] Oh, there are things that happened at Issaquah I wont even talk about. Issaquah was an amazing event. I mean, John Bonica, and Louisa was involved in that, they can tell you more of the facts. I had a relatively peripheral role. I was given certain jobs and tasks to do, and things to accomplish. It was a marvelously organized meeting when you realize the absence of external resources; that is, John Bonica personally, with Louisa and another secretary, invited the people, hustled the money from the drug companies, from the government, everything else; it was a one-man show, there wasnt any question about it. Had this ingenious idea of having it out at this former nunnery which was 30 minutes out of town. There was no transportation -- only if you had a car could you get out of there, and most of the people didnt have a car and couldnt get out of there, and he had the damn meeting running from eight in the morning till ten oclock at night, but it was a nice facility in terms of the meeting hall. The beds were built for miniature ladies ... LIEBESKIND: Small nuns. LOESER: ... Small nuns. Your feet hung out the back, but it was, I mean, it was the most spectacular meeting I have ever been to. Now in part it is because I was young and impressionable. In part it is because I knew who some of the great people were and I realized that they too put their pants on one leg at a time. Ron Melzack showed that movie of trephining in Africa and somebody fell off his bench and fainted and hit his head on the stone floor. I remember that head injury -- we had a head injury at the meeting. But I can remember sitting around in the evening, talking with Pat Wall and Ron Melzack and other people that were great names when you and I were nothin, buddy -- we were just beginning -- and it was astounding, because Bonica managed to have not only formal lectures and formal discussions, but time for sitting around talking. I met Ron Melzack for the first time there. We had some letter-writing, Im sure. Then in 74, when we held the Congress ... 75, rather, when the Congress was in Firenze, Ron and I spent ... he had lived in Italy for a year and he was high, he was great then, and he and I spent some time talking and meeting, and out of that came a piece of work we did on spinal cord resections for pain. And the friendship with Ron Melzack -- thats just been professionally and socially fabulous. That all started -- Bonica managed to get it going in a way that not only was this a group of professionals who were pursuing information or patient care, but it instantaneously started out as a family of people with shared goals -- unbelievable. LIEBESKIND: Family. That word keeps coming up, and you know, its true. LOESER: I remember my main reaction to that meeting was it was an amazing privilege for a young person to be there and be part of it. I think I must have given a talk on dorsal rhizotomies --I dont even know, I mean, Bonica must have the program -- I dont remember what I said or did. I might have talked about the research -- I dont know, even... LIEBESKIND: Well, its in the book, there was the volume that came out. LOESER: Yeah, thats right, there was, and in fact I remember there were some people who were really pissed off at me because I had to edit the neurosurgical section, that was one of them, and you couldnt put everything in the book, and you had to leave some people out. To this day, there are some prominent neurosurgeons scattered throughout the world who dont like the name Loeser because I edited their contributions out because Bonica told me I had to have fifty pages, but I had a hundred pages of stuff ... I remember that. But it was a great, great meeting. LIEBESKIND: Did you have a sense at that meeting of what the field was about, that you were coming together, that this was an initial, you know, a kickoff. I mean, of course, Bonica at that meeting announced that he wanted to have an IASP, that he wanted to have a society and a journal. Had he talked with you ahead of time about that? LOESER: Yeah, John, but it is too far back for me to give you any meaningful thing. Yes, it was definitely described to those of us on his local organizing committee, that the purpose of this meeting was to start an international pain organization that would have scientific meetings and publish a journal and so forth, and we were all asked to, in our own disciplines, give him a list of the people who should be invited, and he had this committee and I was on it and Fordyce was on it and I dont know who else, I mean I cant tell you, I just remember Bill and me, Dick was certainly on it. LIEBESKIND: Dick Black? He would have been on it, certainly. Was Dick Chapman here then? LOESER: No. Wait a minute, now let me just say...I am not sure whether Dick Chapman was here then. Id have to check things. I dont remember Dick as a member of the group, but I may be wrong. We met and we gave him names of the people from our field so that he would have a broader participation than just the people he knew. In those days, of course, the premier pain-related neurosurgeon active in the world was Bill Sweet. J.C. White was still alive, but I think was older and I dont remember him coming to the meeting, but Sweet certainly. [William K.] Livingston was gone by then. LIEBESKIND: Blaine Nashold? LOESER: That was before Blaines heyday. I dont know if Blaine was there. Really, it was before the DREZ [dorsal root entry zone] lesion thing. Again, you have to go look it up. LIEBESKIND: Its all a matter of record. Give me some more specific recollections; I mean, that was a wild meeting. I remember Bill Mehler going off and sneaking out and coming back with a fish. LOESER: [Laughs.] Now, I dont remember that. No, I remember there was a swimming pool there, and I can remember some episode of Louisa in the swimming pool, and there was somebody in hot pursuit of Louisa, I remember that. [Liebeskind laughs.] I dont know if you want to quote that one, though. Somebody was pursuing Louisa and she didnt look with favor upon it, I remember that. LIEBESKIND: She told me about having a swimming race with someone ... LOESER: Maybe that was it. LIEBESKIND: ... And beating him. He challenged her to a race. LOESER: That could have been. [PAUSE] LIEBESKIND: Issaquah, were still talking about Issaquah. Well, it was such a milestone, it really was; it was where things got started, wasnt it, I mean professionally, in terms of bringing things together. LOESER: Oh, lots of things got started there. LIEBESKIND: The journal. LOESER: I think the idea for the journal...I think what went on was towards the end of the meeting, I remember a group of people sitting around dividing up the pot, so to speak -- who was going to take on what tasks, and Pat Wall agreed to take on the journal. There was a great deal of discussion about how to share the obligations and the planning. There was a committee set up to plan the 1975 program thing and all sorts of stuff like that. Again, its all very vague to me. LIEBESKIND: Well, Im sure Bonica has records on all this, or Louisa does, you know, in any case. LOESER: Louisa may have some. I think there isnt any question that it must have been one of the most unique meetings of any of our lives; first of all, it was put together by one person. Secondly, it had an amazing purpose. Most of the meetings you and I go to dont have a focus or a purpose the way this thing did. Thirdly, it worked so damn well. I mean, it just was beautiful in terms of how it worked. LIEBESKIND: Absolutely right. And one of the questions -- there is obviously a question of being the right idea at the right time, and so forth, but there must have been some advance politicking by Bonica. Its hard to believe he came to the meeting and no one there had the idea that there was going to be this society and it would have a journal and Pat Wall would be the editor. LOESER: Oh, I think youre wrong. I think the letters went out that said that. I mean, you ought to get the letters, if they are available. I am almost certain that the letters that were sent inviting people talked about. LIEBESKIND: This is what I am saying, that he must have done that advance planning to have it work well. Pat Wall must have been the anointed editor-to-be prior to the meeting. LOESER: I dont know if thats true. But I do remember that in the invitations, in the planning thing, time was set aside in the meeting for discussion of the future; and people were told, this was not only a meeting to come and tell us what you are doing and what your thoughts are on these issues and share the thoughts, but be prepared to discuss what is going to be the future and how we are going to organize ourselves and so forth and so on. The other thing I think is interesting is that he started out with an international organization, not a national one, and if you look at most professional societies, the international ones, they are in fact some sort of an agglomeration or federation of national ones. He did it the opposite way around -- that the international association would be direct-membership -- it would not be a federation, it would not come through national governmental chapters and things like that. I think that was very unusual and innovative. It shows you that he was... LIEBESKIND: He needed it to be international in order to get enough people, to get a critical mass, probably. LOESER: Oh, I dont know if thats true. Because it was only four years later that the American Pain Society was founded. You were at that meeting in Chicago. That was the craziest day of my life. LIEBESKIND: Why? LOESER: Well, because I left Seattle at 6 oclock in the morning and got back to Seattle at midnight, so I went nowhere and traveled 3500 miles. [Both laugh.] No, I think you could have started ... you could have said, Bonica could just as easily have said, well, were going to have an American chapter, he could have lobbied with his friends in different countries, to set up national chapters, but thats just not the way he did it...his viewpoint was so international that we started with a direct-membership international organization. And I think that its prospered. LIEBESKIND: Tell me, apart from its internationality, the other rare if not unique feature to it was its interdisciplinary nature, and at least at that time my own familiarity was with, you know, guild meetings -- Im a psychologist, I went to the psychology meetings. LOESER: Well, thats because he picked a topic. LIEBESKIND: Thats what Im saying. LOESER: Thats unique. LIEBESKIND: In your familiarity with this, do you know of other organizations that were highly interdisciplinary like that? LOESER: Not to the extent that this was, but, I mean, for example, within my own field I can remember when pituitary surgery started to blossom again because people rediscovered the transnasal route and better imaging techniques, and so there were organizations where there were endocrinologists, neurosurgeons, radiologists, but nothing as broad. LIEBESKIND: That goes back to that period? LOESER: Yeah, roughly that period, but nothing as broad as pain to covering all kinds of basic scientists and health care pros. And John Bonica, I think, one of his other great strengths was even though he is a clinician and not a research scientist, although he certainly has done some clinical research, but you would not look upon John as a research person per se. LIEBESKIND: Not a bench person... LOESER: Well, not only that, but not a clinical researcher either in terms of comparing him to, lets say, someone like Michael Cousins, who spent a lot more time doing clinical research. John clearly recognized that this was an area that required basic science- clinical interaction, and he believed in it, and he hired people in his department ... LIEBESKIND: ... As few clinicians would have. LOESER: Oh, he was way ahead of his time. [PAUSE] LIEBESKIND: Just to editorialize for a minute, the reason that I am doing this, apart from the fact that it is terribly amusing running around the world talking to fun people, the reason I am doing it is I do have a little sense of history in respect to our field, that -- maybe were not unique, but that we are at least rare in the annals of the history of science and the history of medicine, of the bringing together of these different kinds of disciplines to focus on a single subject matter. There probably are no other fields that have done so with such great benefit, mutual benefit, to clinical practice and science, and certainly the promise of a lot more. LOESER: On the other hand, some of that may be because, to take the example I was using, pituitary surgery, if you say what are the sciences basic to that, well you get into endocrinology, biochemistry, certain aspects of pharmacology, and although it is true hormones have an influence on personality or something else, there arent any psychologists working on that. The role of nurses in the management of pituitary tumors has not been something that anybody...vocational counselors, PT, OT, you go down the list. I use that as an example because I think it happens to be uniquely related to pain, and I am sure there are others. For example, you could use epilepsy as an example, where there indeed is this huge multidisciplinary array that is just as broad as the pain one, and it might be an interesting avenue to explore to see what has happened in that area. LIEBESKIND: Sleep is another example there -- thats a big field, the sleep field. So there are other examples like this. But, you know -- LOESER: But its not quite as medical in a funny sense. LIEBESKIND: Although there is a sleep pathology issue, but its not as compelling, I agree. LOESER: Yeah, yeah, but its not central. The World Health Organization is not likely to have a mandate to improve the management of sleep. LIEBESKIND: So this is why, John, I have this sense that now is the time to get the story from those who made the story, because I think that the history of medicine and the history of science one day will take an interest in what has happened. LOESER: I agree with you. It is interesting, and to me also its sort of hard to separate American Pain Society and IASP, because things came along so closely one after each other, and people like myself who were interested and involved in both, as you were also, it was an interesting tightrope, because... LIEBESKIND: Thats right, there was competition between the two. LOESER: Oh, without question, but also there was mutual support. The other thing that I think was relatively unique and indeed may to some degree have been the right place at the right time is the very strong support for the nonmedical; that is, the psychological, nursing, PT, OT, etc. -- people who are involved in the pain world. LIEBESKIND: Who are always a minority, in terms of the raw numbers, and they still are, I mean, what is it, 25%? LOESER: Well, in the early days... LIEBESKIND: But there is always a respect from the scientists and they felt like they were wanted, they werent token. LOESER: Oh, well, we tried damn hard. Now part of that also came out of Seattle, came out of the fact that Fordyce was establishing the behavioral approach, he was highly respected by John Bonica. I worked very closely with Bill. I think also, at the risk of tooting my horn a little bit, there isnt any question that it is the Seattle model of pain management and multidisciplinary approach that has been the cornerstone for IASP; and that is not a total accident either, because the group that Bonica established and brought together was good enough, strong enough, developed its own legs to stand on, that we became the model clinical, and research to some degree, facility. People came and spent time with us, particularly IASP people, because again this tremendous network of people -- Ron Melzack could come out and would spend some time, Ulf Lindblom came out here and spent some time with me. I cant say which came first; was it IASP, was it shared professional interests, was it friendship -- I dont know the answer to that. LIEBESKIND: It was a growing, a mutual growing together. LOESER: The original IASP council was really a family. I mean, it was very different from now. LIEBESKIND: Were you on the first council? LOESER: I was on the first council, because again this was Bonica appointing me, or had me nominated -- I dont remember what, I mean, I was a nobody, but I was on council with a three-year term, 75 to 78. I was then off of council from 78 until -- Id have to work it out. LIEBESKIND: A couple of terms, and then came back... LOESER: I was off the council for like six years or something like that, and then I came back on. But the original group was really a family type thing. Now there were some bad sheep in the family [Liebeskind laughs] and things like that... LIEBESKIND: Not bad, just difficult. LOESER: Oh no, there were some bad seeds too. But the original group... END OF TAPE JOHN D. LOESER INTERVIEW TAPE ONE, SIDE TWO JOHN LIEBESKIND: Michael Cousins was not part of the original group... JOHN LOESER: ...But got elected to council and became President and is now out the back end as Past President. But I think Im the only one, other than Pat Wall as editor of the journal Pain, Im the only one of the original council members who is still involved, active, on the officer level. I mean, Louisa, obviously, but I think if you go back to that original council ... LIEBESKIND: Well, theres been a turnover, you know. LOESER: I remember it met in Milan and Igls [Austria] ... anyway, those were the two council meetings prior to -- the 78 meeting was in Montreal. Thats when I went off of Council, at that time. LIEBESKIND: I even remember the picture we have of that; youre in a sweater. LOESER: Geez, if I think back on that original group, Bill Noordenbos is dead, Dieter Gross is dead, Ron [Melzack] is still around, Pat is still around, you were there at that meeting in Igls, I remember. LIEBESKIND: Im still around. Not so many dead though. I think Council was bigger then, wasnt it? LOESER: Well, we had vice presidents -- I dont know if it was bigger, but we had five continental vice presidents and then I think six or eight council members. The original idea was to get geographic representation out of the vice presidents and the disciplinary thing out of the council. That idea didnt work so well. LIEBESKIND: You mention family, and, you know, this word keeps coming up everyone you talk to, and outsiders see us that way. LOESER: Well, it has been a double-edged sword. I am very concerned about that, I mean, my appointing committees and chairpersons, trying to get new people and stop self-regenerating the same people, its a difficult task. LIEBESKIND: But there are plenty of them out there -- weve seen this with the American Pain [Society] -- there are a lot of good young people coming along. The field is -- LOESER: Well, you always worry about young people, you know [laughs]. LIEBESKIND: You cant trust them if theyre under 50. LOESER: The age keeps going up, doesnt it? LIEBESKIND: All right, let me see here, where are we? Oh, I had one little question that I wanted to ask you that came up in a comment you made. You mentioned at one point that you had a little tangent aspect of your career when you became a curriculum dean here, and I wondered -- you know, one of the big problems that we feel we face as a field is getting pain taught in the medical schools. LOESER: Umm-hmm. LIEBESKIND: I wanted your take on that whole problem. I ask you in two capacities, one as a former curriculum dean, which is what brings it to my mind, but also as, you know, a part of the worlds largest university medical school pain program. I mean, heres Bonica, heres you, and on and on, and if you couldnt get pain properly taught here in the medical school, who could, with all the power you guys represent. So how is that -- ? LOESER: But we represent no internal power, and thats, I think, a very interesting story. Again, life has its things that come along. In 1977, the dean of our school was looking for someone to be curriculum dean. It was deemed to be a half-time job. It was an interesting challenge and I had recognized that neurosurgery was a wart on the backside of medicine and if you wished to play any role in medical education, and I was interested in it, you got to get out of neurosurgery. So my associates were willing to let me reduce my departmental activities to fifty percent and I went down to the deans office fifty percent. I had a wonderful time, I loved it, but I was much too assertive and strong, as an individual with beliefs and policies, to succeed in the deans office in a school like ours, which is departmentally organized. I scared the shit out of the department chairmen because I stood for something. What the department chairmen at the University of Washington want is a deans office that is passive, that takes no initiative, and threatens them in no way. My belief was that I was the only person paid to see to it that the medical students got a square deal and that they often werent. So after my five-year term was up they made it very clear that I had been very successful and so forth and so on and everybody thought I did a good job and would I please leave. [Liebeskind laughs.] They are still running the programs I set up, and I certainly am laughing last in terms of what our school changed in the process of change. Now, on the other hand, the medical school curriculum at our institution is owned by departments. What is taught has no relevance whatsoever to what is needed and I despaired of changing it. We are awful when it comes to pain education for our students, as are almost all American medical schools, because almost all of them are saddled with the same issues. It starts in the first two years of medical school, where the hard scientists -- the professor of anatomy gets up and belittles the course in Medicine, Health and Society, the course in Human Behavior. The students learn that these are soft courses, the fact that you cant examine knowledge with multiple-choice, short answers, and the basic science faculty, most of whom dont have any idea what the practice of medicine is all about, fail to recognize that half the people who go to a primary care physicians office do not have physiologic or anatomic abnormalities to explain their symptoms, and for that reason our medical school education is totally out of proportion towards anatomy, physiology, pharmacology, and the fact that the number one complaint for common -- for primary care docs is the common cold, the number two complaint is back pain -- the fact of the matter is, pain is not considered part of somebodys discipline in the basic scientists realm. Therefore what is taught in pain management, pain issues, tends to be trivial. Now having said that, there is a very nice unit in every medical school course on the pharmacology of opiates. Whether or not they are taught anything relevant to clinical practice is another matter, but theyre -- almost everybody gets opiate pharmacology. Some of them get it out of textbooks that are wrong, but they get it at least. Almost everybody in their first or second year has a human behavior course like we do, and there is one two-hour afternoon session on pain that I and one of our psychologists will put together. In the nervous system course, which is a very good course here, beautifully constructed course, there is one neuroscientist who gives a lecture on pain, not somebody who has done any particular research in pain, and then I get to give one hour of clinical correlation and what I did that devastated them one year, that I am still laughing about, is I brought in a man who described his pain in great detail, let the students ask him about his foot pain, his leg pain, what made it worse, what made it better, what medicines worked, what didnt work, and everything else. After they got all done, I had him take his leg off. [Liebeskind laughs.] And I said to them, You see, there isnt anything theyve taught you about pain that explains this mans problem, and then I left. [Both laugh.] Then I left. LIEBESKIND: Ron Melzack must have loved that. Somebody should have videotaped that one. Thats a wonderful story. LOESER: So, I have despaired of doing that. Now, there are some other things going on that are important in this area. For example, the American Cancer Society has finally made pain an issue and I know one of my associates is the ACS professor at the UW [University of Washington] and he has a written mandate that he is to implement pain education in cancer pain. LIEBESKIND: Do you assume that that has come from the pressure put on by the WHO group, Kathy Foley and people of that sort? LOESER: I am certain that plays a role. I mean, just as we discussed before, ideas have their time. People have their energies. The cancer pain group, of which Kathy Foley is certainly one of the most visible leaders, but people in Texas, M.D. Anderson, Stratton Hill [C. Stratton Hill, Jr.], the World Health Organization and its various members, the whole cancer pain initiative thing, it all snowballs. LIEBESKIND: The Wisconsin group -- LOESER: Its hard as hell to go back and say it started here. So in the cancer pain area, I think there may be some changes in curricula because of the fact that oncologists are being forced, reluctantly I might add, forced to do something more than the molecular biology as an educational thing. LIEBESKIND: Is it true, by the way, that part of that change is coming about because in order to get Boarded (I dont remember the language here), but in order to get Boarded in oncology or whatever, now you have something, the exam poses questions about... LOESER: I dont know if thats true or not. I am not aware of the oncology situation. LIEBESKIND: Well, thats certainly a good way of effecting change. LOESER: Yeah, but its too late. I think the issue is American medical education is a dinosaur. I know of no rational basis for saying that chairmen of basic science departments are equipped to know what is important and not important. I think that American society has made it perfectly clear over and over again that we dont like the physicians we are getting in terms of their interest. They all go into specialties. Why do they all go into specialties? Because of what happens to them in medical school. I think that on the clinical side, other than anesthesiology, that has made dramatic changes of now requiring pain education in the residency and establishing a special certification in pain management, most of the other specialties have not adequately done the job, and its a matter of ... I hate to say it because, as you well know, I am not a religious person and I feel that religions in general have been a detriment to human society ... the pain movement is a religion and hopefully we wont be a detriment to human society. Well, we were talking about family or something, huh? LIEBESKIND: We were talking about a lot of things. This has been very good. Youre cutting across all my questions, which is fine. Thats just delightful. LOESER: I see, okay. LIEBESKIND: I am very pleased with the way this interview is going in terms of getting at the important points. LOESER: Okay. The issue of education is a very important one to me, which is why I chaired the task force on desirable characteristics for pain management. I have written the guidelines for fellowship training, I mean through the IASP task force. I did the same thing for the American Academy of Pain Medicine, for the American Pain Society, because I really believe that we need to do something about the education issues. But to be very honest, I despair of altering American undergraduate medical education until we manage to do something to replace the faculty that we now have and, to be perfectly honest, in reference to my own institution, I just thought there were more important things for me to do. LIEBESKIND: Yeah, well, you must have been hitting your head against the wall. LOESER: The other thing was, as curriculum dean you cant have your own agenda; thats not fair. So when I was the curriculum dean, even though I was very interested in the pain world and so forth and so on, and even though personally I looked at what we were doing in the pain world and tried to subtly make some improvements in our system, I dont think you can use an administrative position as a bully pulpit and do it that way. So I feel much more at liberty now, for example, if I wanted to try to do it. But I think that the last vestige of the feudal system is the American medical education scheme. I think that you would waste an awful lot of energy trying to do it from the school level on, and I think what you need to do is get each of the disciplines, the recognized disciplines, to say, hey, pain management is an important part of this and we want our students to have a basic understanding so that when the policy-making department of an institution gets together, they say, you know, weve got to do something more about pain, just like they said weve go to do something more about molecular biology or something like that. But the way our school is put together, youd have to it through departments, I mean, because although we have what are called human biology courses that supposedly are run out of the deans office, the fact is the deans office has basically given those courses back to departments and the deans office does not play a role in content determination, and it isnt going to be done centrally in our place with the present system. But I think it is symptomatic of the general issue in at least American medicine and probably all of Western medicine, that the status lies in specialty, not in primary care medicine, and most medical schools do not in fact educate on the basis of what the health care needs are, they educate on some other historical basis. So when you go talk to basic scientists and say, wait a minute, fifty percent of the people who go to the primary care doctors, who were supposed to be training out, dont have a physiologic or anatomic abnormality, they have a symptom that is preoccupying them and worrying them and youre not allowing us to teach the sciences basic to the understanding of that, theyll look at you as if youre crazy, and thats what the issue with pain is. In my opinion, weve reached the point where we need to separately look at different facets of pain. Acute postoperative, post-traumatic pain, is an area where the knowledge is around if people would only use it -- not all the knowledge; I mean, Christ, theres more to learn, thats for sure; but the issues in the developed countries relate to failure to use available technology and knowledge in the main. And here my policy would be to do it by standard-setting; that is, you do...Of course, we have... LIEBESKIND: Well, with these new guidelines, for example. LOESER: ...Except we have a good example of what happens then --the AHCPR comes out with guidelines on acute pain management and the Medicare system says we arent funding pain management. So it takes obviously more than guidelines, it takes funded guidelines, but nonetheless in that area, in my opinion, the issues should be like infection. I mean, we are talking mainly about hospital stuff. There is some outpatient stuff that we need to get addressed. But the main issue is a hospital policy issue. It should be dealt with just the way we deal with infections, and we should not tolerate inadequate care. LIEBESKIND: So how are we going to change that? Where are the buttons to push? If you had infinite resources, if you had three gazillion dollars? LOESER: Well, it depends again on where you feel you have your leverage. For example, almost all the pain is created by surgeons of some sort. So you might think it important to try and get into the surgical education system. Bonica used to go around the world saying that in twelve thousand pages of textbooks there is not four pages of pain management. So one area to change, and its gotten better but it still stinks, is in the standard texts and in the standard examinations and in the standard what do we teach our core -- whats our core curriculum, so to speak, for each discipline. I think thats an area of addressing it. I think that if National Boards, which almost all Americans take, or similar fellowship type examinations included significant things about pain, that that would put a pressure on the system, so -- LIEBESKIND: Well, let me ask you a very pointed question on this, and Im drawing here on your years of experience in the field of pain, but also your background in psychology, because it seems plain that this is not just a matter of lack of information, its not, you know, I used to think education was putting ignorance and knowledge together in the same room -- thats not what we are talking about here. Were talking about attitudes, were talking about a willingness or a lack of willingness to understand, to hear, to remember, to change behavior. I always think of Fordyce, and he has so many of these ... LOESER: Information is a low-power way to change behavior. LIEBESKIND: And thats so true. So what are the attitudes, whats preventing this information -- its out there, we could get it in the textbooks, we could get it in the lectures, we could get it, but theyre not going to accept it, you know, what is ... LOESER: Whos the they? The medical students enter, I feel, as a tabula rasa -- they dont have any preconceived ideas about it. Yes, its not only knowledge. I mean, lets go down the list. There are three things, knowledge, attitude and skills, okay? And you need all three to effectively deal with medical problems. We have a Christian ethic. The Christian ethic says in certain situations, pain is of value. Maybe the Judaic ethic says that too, I dont know -- I dont worry about that. Christ, it may be the Muslin ethic, Confucianism -- Im not an expert on religions, but the issue is, I have heard good surgeons, I mean, technically good, morally concerned people, say having pain after an operation is good, it lets the patient know that they have had an operation, that they lived through it, it teaches them how to be a man or whatever the hell else. Well now, thats a big problem. Youve got to change that attitude. Youre not going to do it with just knowledge, I agree with you. LIEBESKIND: Lets try and focus on what some of the issues might be that there are attitudes and wrong attitudes about -- I mean, we hear a lot about the use of drugs, narcotic drugs -- thats obviously a big attitude issue. If you remember our IPF [International Pain Foundation] days together when Chuck Winner took his national survey, the one thing that came out of that was he said, look, whatever else, I can assure you that the American public is not ready to accept the proposition that narcotic drugs can be used safely to manage pain. I mean, that for a hundred thousand dollars worth of survey, that was what we got out of that. LOESER: Well, I think its flat out wrong, okay? Do you think its wrong that -- Theres another issue, which is it the best alternative we have in managing pain. But the issue of -- I dont know if we want to spend time on the issue of opiates, I mean, its a politically charged issue. LIEBESKIND: I dont want to argue -- Im just trying to say -- Im trying to focus on what are some of the difficult issues for people to understand. LOESER: The main difficult issue is that pain matters. That to the surgeon -- see, its a whole concept shift. Anesthesiologists have this cockamamie idea that theyre paid for seeing the patient once before the operation and conducting the operation, and when the guy gets out of the recovery room they have no more responsibility. Now thats the way our current fee schedule works in the United States, and in other countries it may not be on a fee-for-service basis, but its on a session basis, and the definition of the place of work of the anesthesiologist for his or her session is in the operating room. Well, God didnt say that. So the first thing you could do is come along and say, wait a minute, thats an inadequate definition of the specialty of anesthesiology. Youre responsible for pain management -- LIEBESKIND: -- post-operatively. LOESER: -- throughout the entire thing. All that is is a concept shift, thats an -- its in a sense an attitude thing. The same way with surgeons -- the surgeon wont let the medical student hold the knife, he doesnt let the medical student stitch. The medical student stands there holding the retractor. But when they make rounds and the patient is having a pain problem, the surgeon lets the medical student write the pain orders. So that too is an attitude problem. Weve got to get the pain management issue right up here on the top and make it like the goddamn Army made venereal disease a command function, that when a commanding officer had a bunch of guys with the clap, his command was in trouble -- he was not an adequate leader if that happened. LIEBESKIND: So if you have surgical patients -- if your surgical patients are not comfortable and are in pain, thats your problem. LOESER: Right. LIEBESKIND: Were going to make that your problem. Make the pain your problem. Or the anesthesiologists. LOESER: Yeah. Or you do it with the surgeons or the anesthesiologists. And thats an attitude. Again, we are talking about acute pain now. That I think should be accomplished. I see that as the easiest of the issues. It could be collaboratively done, it could be done by policy, one or the other, but it needs to be part of a basic surgical/anesthesiologic education. Only anesthesiology, to my knowledge, has mandated that the anesthesia board requires -- it doesnt specify how much. LIEBESKIND: Thats just in the last few years. And thats presumably -- LOESER: Thats correct. Our residents all get three months of pain in their three years of clinical anesthesia training, so its one-twelfth of their education. So its become a significant piece, but in the surgical specialties, none. LIEBESKIND: Its not there. LOESER: Now, maybe what we ought to do is make the surgeons take a rotation on the acute pain service; that is, you take an R1 in surgery and say, youve got to spend a month on the anesthesia pain service. We often have had surgery R1s spend a month on anesthesia because we think they should know the emergency things. However, the problem you are going to face now is specialty residency slots are going to get smaller and smaller and smaller, there are going to be fewer and fewer bodies. And the chances of taking people off of their parent discipline are going to get smaller and smaller, because once again we dont educate people on the basis of education. A resident is an indentured servant, and we use them almost as much as we educate them, so thats a big problem. Now, when you are talking about cancer pain and chronic nonmalignant pain, I think the issues become totally different. Cancer pain, the single impediment is the oncologist. Now, not all oncologists are impediments, but if you talk to the people interested in cancer pain and go around to their institutions and see what they say and then see what they say by going to other institutions, and I emphasize -- what Im talking about now is mainly secondhand information, because I dont go around pretending to be a cancer pain expert. The issue is, oncologists see themselves as primary care physicians, and they consider it an insult to their integrity as a physician to think of asking for external help. If you have an oncologist who is sophisticated in pain management, they can do every bit as good a job as anybody else. But what the pain people see over and over again is patients inadequately managed on inadequate treatment strategies who near the end of their lives are referred for a definitive pain procedure and you look at their record, a guy has been hurting for a year without adequate pain management. So there isnt any question in my mind that if you are talking cancer pain, the problem has got to be getting to the oncologist, because they are the issues. It wasnt so long ago that the chief of radiation oncology at this institution said his patients didnt have pain, his x-rays cured them of their pain. So that I see as a separate issue. I think weve got to get into oncology training, weve got to focus it right there. The chronic pain due to benign diseases needs a totally different approach. First of all, there are some of those that are clear-cut neuropathic pain problems that we dont understand the biology of, we have lousy treatments for most of them, not tic douloureux, which is why all neurosurgeons love tic as a specialty, because the pills or the operations cure it ninety-nine percent of the time. But you got to be able to identify those pains associated with injuries to the nervous system, the RSDs, the sympathetically maintained pains, the causalgias, the phantom stump, postherpetic neuralgia, thalamic syndromes, etc., etc. And here the issue is, it isnt attitude, or it isnt skills, we just dont have effective treatments for the vast majority of people. LIEBESKIND: But wait a few months, were working on it. Nine out of ten papers in the basic science section are addressed to these neuropathic pain models. So theres a lot of activity. The NMDA receptor hasnt solved the problem yet. LOESER: Im waiting, Im waiting. Ill tell you, dextromethorphan does not stop pain in the majority of the central pain states we have tried it on. I have no great research project going on, but Im waiting. I have a few people who swear that it stops their pain and a large number who say it didnt help a bit. I dont know what your experience or someone elses is. Its more complex than meets the eye. But clearly this is a subset where it isnt attitude -- well, Ill take it back. It is an attitude because of Russ Portenoy -- thats another matter. In terms of the truth of the issue, the truth of the issue is we dont have good treatments. We are dependent on basic science, or maybe clinical science, to come up with a better understanding of whats going on and how to deal with it. Then you have the largest number of chronic pain patients, who in fact, in my opinion, are best described as people who have a disability ascribed to chronic pain. I am coming more and more to the conclusion that this is not a medical issue. This is a social, political, economic issue and I doubt that science, by that I mean biology science, is going to have an answer to this problem. I think that science, meaning psychological or economic or social or political, may have an answer to the problem, and I believe that it is one of the contributors to the massive health care expenditure in the United States that doesnt seem to improve the health of anybody, and I am not at all sure as to whether in the long run a hundred years from now, they wont laugh at us as if we were the guys putting the leeches on the patients, because Im not sure its got anything to do with medicine as we traditionally define it. So here again, I think that we are dependent on a better understanding of human behavior. Its -- in a sense also needs more research, but it is not neurobiology, its neuropsychology, its economics -- its gotten -- I mean, there are so many things that fascinate me about this. You know, economics, as John Galbraith said, is a dismal science -- but why should it be that you can show that the wage replacement ratio, i.e., how much money you get from disability payments versus what you were getting, is a determinant of how long you will be disabled from an injury or the likelihood of your submitting a claim for disability? How does that get into the pain system? LIEBESKIND: Not by the spinothalamic tract. [Both laugh.] LOESER: And I dont wish to argue that thats the only determinant. I mean, you know, claims incidence goes up when the unemployment rate goes up in your community. Now think about that. You cant submit a claim unless youre working; I mean, youve got to be employed. But if you take the group of people who are employed and ask, what is the rate of submission of a claim for back pain injury, it goes up -- one-third of the variance is explained by the unemployment rate, which is the other guys. How the hell does that get into it? So I think that we need to do a much better job recognizing, in the chronic pain situation, recognizing that in fact health care is not delivered to people who have pain, it is delivered to people who claim a disability due to pain, and that the issue really revolves around what society declares is a compensable disability, not is there a difference in somebodys back or arm or something else. So I try and discriminate what I think the issues are. In this area the issue is concept. Conceptually what is it that society is plagued with? Its disability, not back pain. Two-thirds of the population has back pain; two percent seek health care. In the neurologic issues, the problem is understanding the basic mechanisms. In the cancer pain issue, the problem is getting to the oncologists and also other primary care people who manage people with cancer pain to use available information and knowledge. And in the acute pain issue, the problem is getting into the anesthesiology, surgery and ultimately back down into the medical education system. LIEBESKIND: Maybe in a very real sense we are ill-served by having this one word pain which is trying to cover these things. Youre saying pain one is not pain two and its damn important that people understand that pain one is not pain two. When they dont understand that, they screw things up. LOESER: In the very first issue of Pain, the first year, Dick Black and I wrote an article using the concepts of general semantics to try and get at the fact that what Joe meant with pain is different from what Sam meant with pain, which differed with what Pete meant, calling for a pain sub one, pain sub two -- that was the first conceptual work that I did in thinking about it, and it is what led to the scheme of nociception, pain, suffering, and pain behavior, because it became perfectly obvious to me that nobody was going to say pain sub one, pain sub two, pain sub three -- that was almost an eponym, and I hate eponyms. On the other hand, in spite of their ambiguities, as having many different connotations, the terms nociception, pain, suffering, and pain behavior stuck a lot better. So I think the first time I wrote that was back around 1980, 79 or 80, and it stemmed out of that thing that Dick and I did, which actually we wrote while sitting in an airport waiting for a plane someplace. We had come from a meeting and were very disturbed by the fact that one guy stood up and said pain and was talking about acute pain, and the next guy was talking about something totally different. LIEBESKIND: Well, these incredible fights that Pat Wall and Ed Perl used to have -- they were both using the word pain and they werent talking about the same thing. LOESER: Thats absolutely true, and unfortunately, Ed Perl impeded the progress of pain by his definition. Now Ed Perl has done brilliant, wonderful research, but his research has been on nociception, not pain. LIEBESKIND: Absolutely. LOESER: I think thats been a very important issue and the field, particularly in the beginning, was totally confused by the many meanings of the word pain. LIEBESKIND: Yeah. As a psychologist, of course, I am very interested in the psychology of things, and I feel that is without question the most difficult concept for people to understand, even, maybe especially within the pain field. You know, you cant get two people to talk about that in the same way. You listen to Fordyce, he talks about it in one way and others in others, and they dont really understand. I interviewed Bill the other day and I love the way he talks about it. Its a very hard message to get across. He was telling me about... LOESER: Well, it tends to appear dehumanized, but it isnt. LIEBESKIND: Yes. I think youre probably one of the very few people in the world who understands what Bill Fordyce is really talking about and appreciates it, and I know about your appreciation not only from Bill, but from your own writings, from my activities with Bristol Myers, and so forth, and I completely agree with you. But I dont think its an easy case to sell, somehow. People, even psychologists... LOESER: Well, again, part of it is disciplinary and part of its attitude and knowledge. That is, psychology, perhaps more than many of the other fields I interact with, is riddled with the need to identify yourself as something within psychology, you know, Im a behaviorist, Im a cognitive behaviorist, Im a mentalist. LIEBESKIND: We used to give ourselves names, Im a Hullian, Im a Spencerian, Im a Skinnerian ... LOESER: Thats right, I remember those. And I remember back -- I took a course at Harvard, as you did, with Robert Solomon on learning theories -- remember that? As if that was relevant to something real. LIEBESKIND: [Laughs] They sure as hell thought it was then. LOESER: Thats right. And the issue was that, of course you can pretend that there are no emotions and that might be useful for looking at certain aspects of behavior. But even, you know, Fordyce has never been a radical behaviorist. And in the last decade he has been a cognitive behaviorist. So hes very -- I would say he has been very pragmatic about it. LIEBESKIND: Very eclectic and very pragmatic. He started from, not theory, but from people with pain problems. He was very clear on that -- I think it was very telling. LOESER: Yeah. LIEBESKIND: But that message is hard to get across. One of the things that came out in my interview with him, which I wouldnt have known beforehand -- I should have known, but I didnt -- I would have assumed that, you know, you think of Seattle, you think of John Bonica and I would have assumed that there was lots of interaction, lots of appreciation and so forth; thats not true. When Fordyce talks about his relationship to John, he is not speaking of Bonica, hes speaking of Loeser. [Both laugh.] LOESER: Well, Ill make some comments on that for you. LIEBESKIND: And youre one of the people who really appreciate him. I dont think Bonica -- in fact, Bill said something about this, without any bitterness, but when John and Emma were back in New York for the eye surgery, they were out -- Fordyce and Bonica were in Brooklyn giving a talk somewhere, a few weeks ago, and Bill said something about, he did his usual thing. Bonica was there, and he thought John was sort of angry with him for what he was saying. LOESER: He is. LIEBESKIND: After all these years of hearing Bill Fordyce and of seeing what the impact of Fordyces ideas are in pain management at his pain clinic, I dont think he has a clue as to what -- I dont think he really understands Fordyce. LOESER: Well, I would phrase it somewhat differently. First of all, I think John has respect for Bill and vice versa. They dont like each other in any way. And I dont mean that they dislike each other personally -- Im talking about professionally. It goes way back to the fact that Bonica was difficult to educate, that there was a human behavior component. I mean, after all, John Bonica started out doing nerve blocks to people. LIEBESKIND: But this is the man who just an hour ago, half an hour ago, we were lauding for his broad vision, for his acceptance of science, for his understanding of interdisciplinary method, and here hes got a blind spot. Here hes got an attitude problem. Thats what Im saying. And it has to do with psychology. LOESER: No. Ill tell you what the issue is, I think. John Bonica is very proud of not only himself but his discipline, and it is hard for John to accept the fact that there are a lot of anesthesiologists who are horses asses. Fordyce emphasizing the behavioral thing, I think, and John recognizing that there is some truth to it, puts John in a conflict situation. LIEBESKIND: Fordyces -- yeah, his message is so clearly anti-medical. He keeps saying, all we have to do to really solve the problem of chronic pain is get the medical profession out of it. LOESER: Well I just said that too. But I was a little more specific -- I wasnt talking about neuropathic pain and I wasnt talking about cancer pain. But you see, there are several separate issues here if you want to look at the Bonica-Fordyce thing. First of all, Bonica has great respect for Fordyce as an expert in this area. He did not have to ask Fordyce to be the editor of the clinical psychology section of the textbook. He did so because he recognizes that Fordyce has had a major impact, that his thinking is relevant to the area, that he is well-recognized in the field, etc., etc. So I think that there is considerable professional respect. But the issue is that within our own local institution, for years Fordyces suggestions fell on deaf ears. You see, the pain service didnt have an inpatient component. Fordyce ran a one- or two-bed behaviorally-managed service up on rehab medicine. Patients would be screened in the pain clinic and only after the nerve blocks had failed would they allow the patient to be sent to Fordyce. Fordyce was not -- see, there is another set of stories in here, and I dont know if I want to talk about this -- Ive go to think about it a second. Where will this end up? You have to be very discreet. LIEBESKIND: Let me interrupt you a second. May I interrupt you a second? This is not a question of Bill Fordyce and John Bonica. We are couching it in the terms of these two men. But it has to do with -- I think, one of the key issues in the field of pain, and I think, as people are going to look back fifty years from now, whatever, twenty years from now -- theyre going to recognize that one of the big issues is this issue that you started talking about a little while ago, having nothing to do with Fordyce and John Bonica, of the whole question of disability versus pain and so forth and so on, the psychological management approaches. I mean, what is Fordyce doing? Fordyce isnt curing pain. Hes getting people to walk. You know, this is nothing to do with pain. And hes the one who says that. LOESER: But you see, Bonica sees -- see, the problem you have is, there are two levels of problem. One of them is a practical -- END OF TAPE JOHN D. LOESER INTERVIEW TAPE TWO, SIDE ONE JOHN LOESER: The Fordyce-Bonica thing is perhaps emblematic of anesthesia vis a vis psychology. But youve got to recognize that it has two components. One is the day-to-day practical interactions between two people in a specific institution, and the other is this big broad general thing. On the specific level, Fordyce was part of the Department of Rehabilitation Medicine. He was one of the people interested in pain. The Pain Center started out -- it was all in anesthesia. Bonica owned it; he hired a couple of GPs who saw the patients on a Monday and these GPs organized their assessment, which took place over the next four days; that is, nobody met in one place. The Pain Clinic was not a place. The Pain Clinic was -- okay, were going to have you see the neurosurgeon, the orthopedist, the cardiologist, get an x-ray, get a nerve block, get a this and a that, and then on Friday the patient was presented to the assembled group, each of whom had seen the patient, and some other people. What would happen would be, Bonica was in charge, so to speak. So Fordyce would say this patient should have a this or a that and Bonica would say hes going to get a nerve block or whatever the case may be. Or the decision was made, well try this first. Well, as the Pain Clinic evolved, Fordyce developed a separate empire; that is, the Rehab Medicine - Behavioral Medicine service was upstairs. And he got patients not only from the Pain Clinic, but from external referrals. And -- JOHN LIEBESKIND: So, in some sense, was he a competitor? LOESER: Oh, in many ways. But he was unwilling to do a lot of work. By that I mean -- I love Bill [Fordyce] dearly, but Bill was one of these guys who wanted to control what he was doing and not doing. And his chairman wanted to control how many beds hed give to the pain service. So Bill could be hard to find when you needed him for a problem because he was otherwise occupied. The number of patients they could treat was limited, and you might have a patient you wanted treated but they couldnt get to it for a period of time -- it was not a very practical system. On top of that, Bonica heard the wrong message. Bonica to this day doesnt understand that the man who has increased financial reward from being ill hurts. Bonica still thinks that Fordyce believes the guy is malingering, lying, cheating or something else. The only way you can accept Fordyces viewpoints as a physician, at least my perspective on it, is if you recognize that the patient hurts just as much. You start from that premise, then you can ask the question, why does he hurt? LIEBESKIND: What can you do about it? LOESER: Because the simple fact is, dollars do alter the gate. But John doesnt understand, in the past at least, had difficulty grasping that. So John would get very angry because he would hear a message that made him think that we were saying the patient didnt have a pain or was in some way not a real pain or something else. I dont personally believe that at all. I cant prove it, obviously, because I cant climb inside somebody elses head, but I honestly believe that when a man says, Doctor, I hurt, he is, and it probably doesnt matter whether thats because he has osteomyelitis of his femur or all the other factors that alter the gating mechanism are playing a role. So on a local level, then, what went on was Fordyce got to develop a service on the rehab medicine thing. In the early 70s the pain service for the first time got inpatient beds. This was a huge fight because anesthesiologists do not normally have admitting privileges. It was still the Pain Clinic, it was still part of anesthesiology, and they got the right to admit up to four patients on a particular floor. Mainly those were used for drug detox. Then sometimes a patient -- once in a while the system would work perfectly. Hed have a drug detox on the anesthesia service and then get transferred up to the Fordyce service. Then sometimes they were doing both at the same time. OK? But it was clearly two separate services. The thing became a pain center instead of a pain clinic in, I believe, 1977 -- I may be off a little bit a year or two in dates. At that time Terry Murphy was asked to be the director of the pain center. The clinical pain center had assigned space. Thats because one of the jobs I had that you havent asked me about is in 1974 to 76, I was the chairperson of the University Hospital expansion committee and Dick Black and I put in a pain clinic. It was four exam rooms, a conference room, a block room, a waiting room -- that was the first time that we had our own space, and there is no question about it, we got it because I was the chairman of the space committee. Dick and I designed it, put it in. LIEBESKIND: Its the testicles of the medical school, the space committee. You have your control, your hands on that... LOESER: Well, thats sort of a sexist remark. I dont want to be quoted as saying that, thats for sure. Make the record indicate that Dr. Liebeskind said that. [Liebeskind laughs.] At that point, Fordyce would physically come down to the pain clinic to interview the patients. Thats the first time we owned our own space. We had our own secretary. There was a huge lot of shit going on that I couldnt cope with -- I wasnt in charge of anything at that time. When I finished my stint in the deans office and agreed to run the pain center, they had done an internal review on the pain center, which had panned the organization comple -- badly. LIEBESKIND: It must have been a tough time. LOESER: It was a tough time for Terry; it was awful for Terry. Bonica neither gave him free rein nor let him do anything. The institution put no resources in it. I was in a much stronger position. On top of that, Bill Fordyce was very unhappy in rehab medicine because they wouldnt give him beds, wouldnt give him space -- it was not going well. So he and I made the dean an offer the dean couldnt refuse, and we really were in a position of negotiating as if we were outside the institution and not in. At that point we got ten inpatient beds on a designated floor. Plus they wanted the space on the outpatient side. We knew that was going to happen, so we got a guarantee theyd move us from our outpatient space up to the same place and wed have our unified clinic that we now have. Plus Fordyce would spend a hundred percent of his time in the pain world. Plus I got an endowment. Plus we got lots of other things, and it was truly interdisciplinary with an advisory committee of four different departments -- it really wasnt part of anesthesiology. Thats when it got going the way it now is. Thats when the great leap forward occurred, and Fordyce and the psychology end became truly integrated in every way. Now John Bonica and Bill Fordyces interactions personally were bothered by this Bonica idea that somehow Fordyce was impugning the validity of the patient and on the other side of the coin, John could be a very difficult person to deal with. On the wider level, the interaction between psychology and medicine is of a course much more interesting one. John Bonica, although he had reservations about things, he was quite capable of saying yeah, theres a -- this is important, I may not believe in it or understand it but -- because you go back, its not only Fordyce whom he supported, its Merskey, who has a totally different thing. Bonica went out and found Dick Chapman, brought Dick Chapman, gave Dick Chapman really an opportunity. Now again, it took a little manipulating on my part because Dick was being offered twice as much money to be chairman of a department back east and the University of Washington has a general policy of not giving tenure to people in departments unless they are in that discipline; in other words, anesthesiology can hire a psychologist, but they didnt have tenured chairs. I got Dick a tenured position. Dr. [Thomas] Hornbein was chairman and he, bless his heart, he was the one who agreed; but that was also one of the great strengths of the pain center, was Bonica hired Dick Chapman and then we were able to keep Dick Chapman by creating a tenured position for a psychologist in an anesthesia department. Come on, where has that happened before? Thats been a unique thing. Bonica supported Fordyce externally. Now the other thing that happened had nothing to do with Bonica, and that is Murphy, Fordyce and Loeser have been in 56 communities of the Pacific Northwest on this one-day circuit course on pain. Weve run the pain course in Hawaii three or four times. We ran it when the Huskies went to the Rose Bowl in 1978. Weve run it in Seattle umpteen times. We are about to run another office management of chronic pain course next year here. LIEBESKIND: These are one-day courses? LOESER: Yeah, one-day things for physicians, and thats independent of Bonica and that has really put Fordyce and the behavioral approach on the map, and we have done this at national meetings and the Family Practice Academy. And, you know, and thats independent of Bonica too. So I think that if I personally, clinically, have made any contribution, it is the fact that I have really made Bill Fordyce part of the system by incorporating his thinking into everything Ive said and done and theres no question that its his thinking; I dont deny that for one minute. But probably more than any other physician, I have really pushed the multidisciplinary, the cognitive behavioral approach, and that has legitimated Bill and given Bill exposure, not that he didnt deserve it or couldnt have gotten it himself -- Im not trying to take credit for Fordyce, but he and I hit it off personally. I mean, its very interesting because hes a decade older than I am, we have very different interests -- I dont play golf, the thought of taking a vacation and going out and lying on my butt on the beach at Kauai, which is where they have a little condo -- I couldnt do that for three days, you know -- but Bill and I really hit it off intellectually. Weve been a wonderful duo of passing ideas back and forth and thinking about them and then adding Terry to it in terms of all the talking, and going places. Bill and I managed to accomplish something that I think was pretty unique. We started this pain thing in 83, and we had the physicians saying to us, it will never work, the psychologists are gadflies, they dont want to stand in the trenches, they only want to be consultants. We had the psychologists saying, it will never work, the physicians wont treat us as equals, and so forth and so on. I can vividly remember the first time Kelly Egan got into a fight with Peter Buckley on exactly this, and in two weeks theyre getting married. [Liebeskind laughs.] So that is without a doubt the symbol of the Fordyce-Loeser ... LIEBESKIND: Ones an M.D. and ones a psychologist? LOESER: Absolutely, and Peter Buckley is an Englishman, very much not, when he joined us, of a psychological bent. Kelly Egan is a psychologist, very much not of a medical bent -- and we banged heads together. We said to the physicians, if you cant treat psychologists, nurses, PTs, OTs, as equals, you cant be on our team. And we said to the psychologists, if youre the attending inpatient psychologist, you are going to carry a beeper, you are going to be available all the time, you are going to make rounds, and by God, weve done it. LIEBESKIND: Well, you see that Bill Fordyce credits you for this, for great managerial skills in pulling this together, by the way. LOESER: Well, itd never worked with just me. I mean, in a sense, Im the guy who was the head and Im the guy who called the meetings and Im the guy who would use my usual lack of subtle approach and just said to people, Hey, you know, you got to play the game my way or youre out. But the approach was a lot Bill. He and I spent many hours behaviorally engineering the behavior of our health care providers. LIEBESKIND: Well, youve set a template here in Seattle and its been exported, its being exported, its not the same one, and I think I now appreciate that more than I used to, much more than I used to. Its not the same template that John Bonica created -- no, thats a very different one. Thats what we call the multidisciplinary approach. Not to give labels here, but that approach, I gather, by the way, is in a lot of trouble nationally -- its not paying off, and -- LOESER: But youve got to watch out. Youre talking about John Bonica starting at the end of World War II, doing something through the 50s in Tacoma, coming up here in the 60s, and youre up to 1975. Up to 1975, the mere fact that you had a neurosurgeon talking to an anesthesiologist talking to an orthopedist and had a psychiatric or psychologic consultant was so far ahead of the rest of the world it was unbelievable. LIEBESKIND: Right. I understand that. LOESER: And that was John Bonicas contribution. LIEBESKIND: Im not trying to denigrate it, dont get me wrong. LOESER: Now in 1975, behavioral medicine became applied to pain -- a little before that, but it grew in that era. That meant that the old Bonica model was no longer sufficient and what we have been able to do is evolve from the old Bonica model into the multidisciplinary behaviorally-based concept. Now thats a very interesting philosophic issue, because one of the questions I ask myself and those of my associates who are willing to think ahead in this way is, okay, we were on the cutting edge in 1960 because Bonica set up a multidisciplinary pain clinic. In the mid-70s we were on the cutting edge because Fordyce got the behavioral thing going. In the 80s we again got on the cutting edge because Brian Ready set up the acute pain service and we led the world in the management of acute pain. Whats the 90s? Because you cant just rest on your laurels and maintain the front edge. Well, maybe youre on the front edge thirty years, you cant maintain the front edge for a hundred years -- I dont know. My belief is the 90s is behavioral principles applied to not only things called pain, but symptoms, because as I read the issues in managed health care, again the issue is, half the people have symptoms and only a fraction of those is the complaint of pain. They have palpitations, they have fluttering, they have bowel distress, they have this, that and the other, but theyre all pain, and we have learned how to deal with them when we call them pain, and it is my personal belief that the issue is going to be treating other kinds of symptoms. Now whether I can pull that off, I dont know, because, I mean, what the hell is a neurosurgeon doing in this area? LIEBESKIND: How about a soc rel major? LOESER: But every specialty has it. You know, theres nonspecific prostatitis -- that means you dont have any inflammation in your prostate, you never did, but you complain of pain in your perineum. There is nonspecific gastritis -- what does that mean? They gastroscope you, you dont have inflammation, they biopsy it, there is nothing wrong with your gastric mucosa, but you complain of pain up here so they call it nonspecific gastritis. Its a bunch of shit -- theres nothing wrong with your stomach, or your prostate. Then theres a whole -- theres functional bowel disorder, postcardiac pain problems, cardiac neuroses, tinnitus, you go all down the list, all of these are non-diseases. I think weve learned -- Fordyce was the leader in this -- weve learned enough dealing with pain in this way, that my belief is the pain center is going to evolve hopefully into a symptom management center, and pain will continue to be one of the symptoms. Now there is no question that the nerve block method, which actually, interestingly enough, I am just reading the English translation of Leriches book on pain. I do not read French well enough to read it in French. It was Leriche who was the first one to use Novocain -- he called it novocainization -- to do diagnostic evaluation for pain. Bonica was probably the first to make a big deal of that, at least in the English language -- again, God knows what was written in Romanian -- I cant handle that -- but he goes back to Leriche, no question about it. Leriche, who was a surgeon, still did use regional anesthesia and blocks. Bonicas great contribution, one of them, was the recognition that regional anesthesia or local anesthesia can be used in the diagnostic process and perhaps sometimes in the therapeutic process. But whats happened now is, we are having people who have been trained to do nerve blocks who are doing inordinate numbers and amounts of nerve blocks that have benefit only to the doctor and not to the patient, and thats a real problem. [BEEPER GOES OFF; PAUSE] This issue of whats happened -- its not only American, by the way -- I ran into one anesthesiologist from Delft. This woman I met in another country while on sabbatical. Now the population of Delft -- I dont know -- its 40,000 or something like that -- geez, I dont know how many people live in Holland -- but this lady assured me that she did five thousand lumbar sympathetic blocks a year. And they always cured people. You go on down the line, its unbelievable. I dont know if this country is the worst, but I certainly know were not the best. Im a little bit concerned because I think that there is a role for both diagnostic and therapeutic blocks, but some people lose all perspective. Now they lose all perspective for a variety of reasons. One of them is -- Years and years ago, I wrote an article on dorsal rhizotomies dont work. Luckily for me, the same issue of the Journal of Neurosurgery, the Mayo Clinic, Burt Onofrio, published an article that said that dorsal rhizotomies dont work. Talking about 1972, I think it was. I got a poison pen letter from J.C. White, who had done a million dorsal rhizotomies, that basically gave me three reasons why I made my observations: I was stupid, I didnt know how to do operations, or I didnt know how to pick patients. LIEBESKIND: You got your choice! LOESER: I assume Burt Onofrio got the same letter. Years later, I found out that Dr. White was one of these surgeons who really was devoted to his patients and his patients to him, and no patient would ever want to disappoint Dr. White by telling Dr. White that the operation didnt work. So theyd tell him it was successful and go on to the GP and get their morphine. Now I think a lot of thats going on in the needle sticking world. LIEBESKIND: Does Bill Sweet know that? Does he appreciate that, by the way, today? LOESER: Well, hes the one who told me. Be careful with this, come on, John. LIEBESKIND: Im going to interview Sweet, I hope. I got a letter out to him. LOESER: Well, you should. But dont -- this episode -- I dont want to -- Im sure White was his mentor -- I dont wish to make light -- the man made a wonderful contribution. But nobody since has ever gotten the good long-term results that he described. But the issue is, I think, patients want to get -- want their doctors pleased and they often tell their doctors one thing and another thing happens. Two, we get nonsensical things -- there was a physician here in town at one point who was running a pain clinic and every patient got a differential spinal when they walked in the front door, even though everybody who had ever looked at it knew that it was a totally useless diagnostic step, it also paid a handsome fee, so that goes on. Then, I just testified in a medicolegal case about a lady whos had 47 epidural steroid injections. Now what the heck is that guy doing, doing 47 epidurals. So I think that I do not wish to come across as saying there is no role for blocks. There is a real role for blocks. There are some people who have disease that are well-treated, optimally treated with our knowledge today, with a nerve block. But on the other hand, there are vast numbers of people getting facet blocks and epidural steroids and the frequency of those is so high that we should pass a law that says you cant do them unless you are doing research to show that it works. Because right now there is no data that it works. OK? Thats not something Bonica ever did. Bonica never did an epidural steroid. Never heard of them. They werent done then. And thats the most common nerve block done today by anesthesiologists in the management of pain. So you dont want to tar and feather Bonica with that. Bonica was doing diagnostic regional anesthesia, what nerves are involved in transmitting his pain, so that we can do the definitive operation or look for the compression syndrome or something else. But you go back, I mean, in his original textbook, he talks about using IV procaine in the treatment of neuropathic pain syndromes. It does stop it transiently, but not permanently, and so, well okay, thats the best they had back then. So needle stickers are a big menace, oh my God, and in this country we got a few, but we have them all over the world. LIEBESKIND: You know, again, its not just a matter of knowledge. I gave a talk up at Davis a few months ago and was met by a young man named Brian Tsang, an anesthesiologist who went to medical school at Yale, I think, and got his residency at Stanford, very well-trained. He is in anesthesia there, in charge of their pain center, their small center, and he said, You know, its a real problem, because I know these nerve blocks dont work very well, but you know Im getting pressure from on top to do them because thats whats paying the bills. LOESER: Thats right. LIEBESKIND: He said, I dont know how to handle that. This is a young guy. He said, I dont know what to do. LOESER: Its a terrible problem. We are about to have a new chairman of anesthesiology here who may in fact do that to us, my friend. Its a real problem. See, there isnt any funny money in the system anymore. Anesthesiologists used to make enough money that they could support that limb of the department, doing the pain clinic, because the pain clinic doesnt make money. But now, when the money gets tighter and tighter, theres less ability to support these other things, and I think thats a big problem. LIEBESKIND: Is there a way to make the pain center here pay off, make it in the black? LOESER: Is there a way? Now is that a theoretical or practical? What do you mean? LIEBESKIND: Is there a way, while still providing good medicine ... LOESER: Well, the answer to that is to divide the question up into two ways... LIEBESKIND: Im asking that, coming from UCLA, where the pain center went under ... LOESER: Yeah, but why? LIEBESKIND: Because it wasnt making any money. It never made any money for ten, twelve years in a row. Finally -- LOESER: John. Im sorry. The pain center went under at UCLA because of Teresa Brechner. LIEBESKIND: She didnt help. LOESER: Okay, pain centers dont make money in large academic institutions... LIEBESKIND: They fired her; they could have fired her and gotten somebody else. They fired Ron Katz, the chairman of the department, because the whole department of anesthesiology lost money that year, that last year. LOESER: Ron Katz got fired, huh? LIEBESKIND: Well, he was allowed to step down after many years of service. LOESER: Whats he doing now? LIEBESKIND: Well, hes still there. Hes just not the chairman; we have a new chairman. LOESER: Whos the chairman? LIEBESKIND: Joe Gabel, from Houston or something. LOESER: Well, lets go with that. First of all, there are two components -- professional health care providers and the physical resource. How you account for your costs determines whether a pain clinic will make money or not. If you say that the budget for this institution is a million dollars and we have ten thousand square feet, therefore it is ten thousand dollars per square foot is what it costs, which is what every hospital does, the pain center always loses money, because compared to an operating room, that generates a huge amount of revenue, you cant do it, right? LIEBESKIND: Per square foot. LOESER: So its a pure accounting fiction. Now I can tell you there are private practice pain centers that made very nice profits over the years. Im talking about global profit. A physician I know owns the pain center. He hires the people, he pays the rent, he pays the insurance, he pays salaries, and in addition to that the business makes a profit. So the issue of the pain center making profits, its a function of how you cost account the space. It also is a function of what do you feel you need to have to be a functional institution. I pointed out to you that the ten percent of your institutional space that goes to administrators, the administrators do no measurable productive work. I mean, whats the work product? So the idea that every piece of square footage should make a profit... LIEBESKIND: And God forbid any training or education should make a profit... LOESER: Oh yeah, thats of course... LIEBESKIND: Not to mention [whispers] research. LOESER: So this issue of institutional profit is a very complex one. Now, professional profit -- LIEBESKIND: When you say professional profit, you mean -- ? LOESER: Here the thing that determines it is how you pay your fees, I mean the people, the health care professions. The nurses, of course, are funded through the hospital side; theyre on a straight salary. They are part of your overhead costs. Private practice clinics make their money on their PTs, OTs and vocational counselors, which in our system are owned by the hospital, so the hospital is making a profit that comes out of those people. I never see it. Its not included in my profit or loss statement. Psychologists can make as much money seeing pain patients as they can anyplace else, doing anything else, especially since we do a lot of things in groups, which happens to generate much more revenue per thing. Now the function is, who do you take as patients? If you take the people who dont have any funds or who are funded forty cents on the dollar, you lose money. If you take people who are funded, psychologists can generate enough money, but its marginal. No psychologist gets rich in practice of this sort. If you live in Beverly Hills and charge five hundred dollars an hour or whatever the hell it is, you might get rich, but using standard medical psychology fees, psychologists can generate just as much money in the pain world as elsewhere, and they can pay their salaries. The physicians, its a function of what kind of physician you are. If youre a family physician -- we have a family physician in our pain clinic -- he makes in fact more money per clinical hour than he does in the family medicine clinic because he is billing as a specialist with us and billed as a generalist with them. But if you take a neurosurgeon who can do a one-hour operation and get a fee of fifteen hundred dollars, heck, if I get a hundred dollars fee for seeing a patient in an hour Im lucky. So of course you lose money with neurosurgeons in the pain clinic. Now anesthesiologists, same deal. Right now they get paid best working in the OR. Now if they do a lot of procedures they can make a lot of money in the pain world. But if they are interviewing patients, talking to patients, screening patients, participating in behaviorally based pain management programs, compared to what they make in the OR, they lose money. Compared to a family practitioner, they make money. Now, the question is, whats the salary of an anesthesiologist going to be and who is going to determine it? So the losing money story that you had at UCLA, thats because the anesthesiologists were paid as if they were working in the OR when in fact they were working in a pain clinic. They werent generating that kind of revenue. So the whole thing is a function of how you set your economic system, both for the professionals and for the physicians. In Australia, where physicians are paid by the session and an anesthesiologist is paid whatever hes doing in that session, if the institution allocates a session for pain management... LIEBESKIND: It doesnt matter to him, hes going to get the same as if hes doing a needle stick. LOESER: Right. So the whole thing is a question not of pain management, its a question of the socioeconomic system in which health care is being provided. When we go to a managed care system, it is all going to be very different. Because in our kind of health care now, what you do is, you start with zero money in your pot at the beginning of the year, and at the end of the year the more work youve done, assuming youve priced your services to cover costs, the more profit you have. So you start with zero and end up with a hundred percent of your money. But with managed care it is exactly the reverse. At the beginning of the year you are paid for how many people you are going to manage. And every time you provide health care you lose some of your pot, and at the end of the year you have zero, or if you have used less, you have some profit, and so forth. LIEBESKIND: You use up some of that. LOESER: Now what is going to happen then to pain management is going to be very interesting. The fear that all the physicians have, of course, is that theyll be so concerned with dollars, they, the administrative types, that we wont be able to provide quality health care, and they dont give a shit about quality health care. I think thats a legitimate fear, I really do. On the other hand, there is so much excess health care being given that theres no question that managed care can reduce all the extra nerve blocks and pain management stuff and save money for the system. Now where that line is going to go and who is going to see to it that cancer pain patients get pain management that costs money, where is the top for pain patients? So the Loeser remedy mandates that you never let any institution separate health care costs from wage replacement costs. That is what we have now. Blue Cross couldnt care less whether somebody goes back to work. All they are interested in is their health care costs. The managed care system, Group Health, a very good managed health care system here in Seattle, old, good, but they dont give a damn whether the guy ever goes back to work or not, all they want to do is keep their health care costs down and their health care appropriate to the patients needs. So thats called cost shifting. So thats what weve got to watch out for. We need to have a system, and the way I would propose doing it, and this is something Bill Fordyce and I have been working on for a long time, is basically, everybody who says I cant work because of pain is entitled to a good health care evaluation and one attempt at rehabilitation. When you are done with that, you call them unemployed; thats what they are. You treat them just like you treat all the other unemployed people, whatever you choose to do. Its a social welfare benefit. LIEBESKIND: Not a medical problem. LOESER: But nobody, nobody, is disabled by pain. Thats a bunch of crap and weve got to stop the health care for that and turn the system around. Well, enough of that. LIEBESKIND: Thats going to be a tough act to sell. Its going to be hard for people to understand that distinction. LOESER: Oh yeah. But who said you wanted to do it the easy way -- LIEBESKIND: Yeah, I hear you. Bill talked about that. LOESER: The issue that were getting into in terms of whats happened here is this pain clinic and the pain movement have evolved beyond what John Bonica saw in the early stages. He was way ahead of his time, but eventually the times, at least the people who surrounded him in the pain world, moved beyond where he had gone and the field is, in my opinion, further along than John Bonica brought it in terms of its clinical things. But the other issue that youve got to recognize is Bonica not only worked the professional street but what he did in lobbying the NIH and Congress and government and International World Health and all this other stuff -- I mean, his impact is unbelievable. There will never be anybody like that again in the pain world, and there just isnt the chance because... LIEBESKIND: He did it all. LOESER: He did it all and he got it started and so many other people have taken up and gone further than he did. The field has moved beyond him, which is to his great credit. LIEBESKIND: These are fascinating issues, you know, and the great question is, how do you make these changes? You, I think, have a very clear understanding of what the problems are. I dont know that you or anyone else has a very clear understanding of how to go about changing things... LOESER: Oh, well, thats my old aphorism right now, you know. Here I am, Im fifty-seven years old, and just like when I was twenty-one years old, I know what the problems of the world are. When I was twenty-one I also knew the solutions. I dont now. LIEBESKIND: [Laughs] Life has beaten into you the knowledge that you dont any longer. LOESER: No, I see that as a big problem. You see, to get back to the pain thing, I have not been able to do many of the things I wanted to do because of the exigencies of earning a living as a professor of neurosurgery at the University of Washington. Im over here doing a lot of pediatric work, which is not really what I wanted to do, I mean, I love taking care of kids. My grandfather was a pediatrician -- its in the bones, so to speak -- but it has totally blown me out of the pain world in many of the things I wanted to do. Administering the University of Washington Pain Center, I did it because there wasnt anybody else I could see who would do what needed to be done. I dont like being an administrator. I have heard too many people come and talk to me about their problems, their marriages, their divorces, their gayness, their this, their that -- I have to deal with the petty, immature, childish behavior of the average American working person -- it drives me bananas, but I cant see any place to keep this institution going and I see it is the fountainhead of the pain world. I was very much involved in research at one point in my career and the research arena has progressed so much in my time out that Im a dinosaur. Im totally out of date. If I wanted to get back doing research in animals today, I would need to basically go back to graduate school, and I can tell you, in the 60s and 70s, I was on the cutting edge in neurophysiologic techniques. We were the first people to go into intracellular recordings with negative capacitance amplifiers. They werent commercially available when we were doing that. Ive lost that, and I miss it. It was an important part of my life. LIEBESKIND: Well, join the gang. There are a lot of us who have been a lot closer to research and have progressively ossified as molecular biopsy has taken hold. LOESER: Now on the other hand ... LIEBESKIND: ... For which Soc Rel [social relations] didnt prepare us. LOESER: On the other hand, what Ive gotten into is the population level issues, and we have a wonderful institution here at the UW, namely the back pain outcome assessment team, which Rick Dale chairs, which is AHCPR-funded, and that has perpetuated some interests that I started in, working with a sociologist, Ernie Volinn, a decade ago, to try and look at the other side of the coin, and look at the role of economic, social, political factors. LIEBESKIND: You measure these things, and you look at them, yeah. LOESER: Thats been a very interesting area and it is an area that Bonica pointed out was desperately needed back, and I forget the year, the NIH or the National Center for Health Statistics funded a workshop in San Diego on pain, in which we all screamed that they werent giving us any data. From that there were -- Bonica led that charge, fomented it, organized it. From that they set up contracts -- I and Ernie Volinn had one of them, did research things -- it was a Bonica-ism right down the line to get it going, but it was an area that I went off into and which I think still is just beginning to get a handle on describing the magnitude of the problem in epidemiologic terms, and thats another area of research that interested me, still interests me, but Ill tell you that its not the same as dealing with real things. I mean, dealing with epidemiology is the science of dealing with numbers. Youre not taking care of people and youre not manipulating individual animals in some interesting way, so its a different arena. LIEBESKIND: What do you count as your greatest achievements up to this point? Clearly the Pain Center here is... LOESER: Being the father of four great kids is my biggest achievement to date. LIEBESKIND: I meant outside the home. LOESER: I see. You know, I just came back from a weekend out river rafting with all four kids plus my daughters husband, and the whole family spent a weekend together, and it just proved to me right off the bat that nothing you and I are talking about matters worth a damn. LIEBESKIND: No one at St. Peters Gate wishes they spent more time at work, huh? LOESER: I dont know what the biggest thing is. Well, in terms of the biggest impact, there are two very, very mundane things that you probably wouldnt have thought of. One of them is, I took the finances of the American Pain Society, that were in an absolute shambles, and at the end of four or five years as treasurer we had an investment fund, we had proper finances, the organization was not floundering, was on its feet, was functioning well, and in a sense... LIEBESKIND: I know you did that. I wouldnt have thought of it tonight, but ... LOESER: In a sense, in terms of impact on the pain world, had the APS died, and I thought it was damn close to dying at one point, when the president wouldnt send the treasurer the books and a few other strange things like that. LIEBESKIND: So you were the treasurer when, now? LOESER: No, I was the treasurer -- well... LIEBESKIND: While Bert [Wolff] was still the president? LOESER: No, he was -- see, remember, they had this crazy thing that the election was illegal and Bert had to be president for two years. And Bill Willis was the treasurer. But Bert never sent him the books. LIEBESKIND: I see. LOESER: And I became the treasurer -- John, I think I was treasurer like 79 to 84 or 80 to 84, 85 -- I dont remember exactly. Diane Chen was acting as secretary because Hoffman LaRoche let us use their office because we didnt have any money to pay for anything. LIEBESKIND: Ben Crue succeeded Bert. LOESER: Was it Ben, or was it Bill Sweet? See, Sweet got the APS its tax-exempt status -- that was a major contribution. But there isnt any question in my mind, the organization was floundering. LIEBESKIND: Is the APS a 501(c)3? LOESER: Yeah, I believe -- if thats the right nomenclature. Whatever it is, if thats the right number -- Bill Sweet was the one who spearheaded that. But that, in terms of the well-being of the pain movement ... LIEBESKIND: I fully understand what youre saying. When you look at all...the American Pain Society in the last few years has been doing a lot and ... LOESER: But its based on its financial status. LIEBESKIND: All that couldnt have happened if t wasnt financially solvent. LOESER: It was during my tenure that we got an external management firm. We had some troubles -- you know, weve had three or four of them -- but the idea of getting enough money to get a management firm and get things going -- that was one. END OF TAPE JOHN D. LOESER INTERVIEW TAPE TWO, SIDE TWO JOHN LOESER: The other issue, I think, in terms of measuring the contributions, is working with Bill Fordyce to make the University of Washington Pain Center a really model institution, using it as a model -- I mean, Ive written the guidelines for education and fellowship training and so forth, and desirable characteristics, the IASP task force, educating anesthesia residents, two to five fellows a year, foreign visitors -- I mean, to me, one of the biggest pride I get is Cenon Cruz, an anesthesiologist from Manila, spent three months with us back in the mid-80s. He went back to Manila -- he changed their medical school curriculum so they have a big course on pain. He established the Philippine Chapter of IASP and he opened a pain clinic and started with cancer pain, modeled on ours. He sent a clipping today -- last Friday I got it from him -- a new pain center, multidisciplinary -- it looks just like ours. JOHN LIEBESKIND: You sent him on his -- on the way. LOESER: And, man, thats gone on all over the world -- there are people who have done it. I think organizing and keeping our institution going has been a major issue. LIEBESKIND: Whats been the cost to you, now, looking at home and elsewhere, whats been the cost to you for all this? Its been -- youve worked very hard, havent you? Youve put in, and still do, an enormous number of hours. LOESER: The institution -- the pain world at the University of Washington is subsidized a tremendous amount, not the least of which, John, is I took a sabbatical year in 89 to 90, went to Flinders with Mike Cousins. Mike was president and I was secretary of IASP and I made him take every Wednesday afternoon for a year and he and I would meet and work on IASP activities. For the first time, we had -- since it was the era when it was Bonica as president and Fink as secretary -- its the first time the IASP had had two of its executive committee members in the same town. [PAUSE] I spent that whole year there, on sabbatical. We spent every Wednesday afternoon working on IASP, plus all sorts of other times. The University of Washington paid two-thirds of my salary -- I had a Fulbright, so the Fulbright paid part of it -- I spent at least half my time working on IASP activities during that year. So the IASP got a huge subsidy because I took a sabbatical -- I worked in the pain clinic there, but I did no neurosurgery for a year. Prices Ive paid -- oh, Ive worked much too hard -- my children, none of them will go into medicine because they think that thats what happens when you go into medicine. My wife feels left alone sometimes too much. I probably am fat and flabby because I just dont have the time to do the exercise I know I should do. I did manage to stop smoking when I went on sabbatical, and I dont know what got you to stop, but I remember the two of us smoking away in Igls. LIEBESKIND: Her name was Julia. LOESER: I see. Well, my wife still smokes, but -- There is no question that within the discipline of neurosurgery, I have spent so much time on the pain world that I have lost neurosurgical skills -- I mean, I have a very narrow practice, a lot of things I dont do, I have not maintained currency in many aspects of neurosurgery, and I have not maintained any presence in academic or American organized neurosurgery, although in the beginning of my career I was obviously on that track and was doing the things like that. So within my own profession I have not achieved the status that someone with my ambition, skill, work habits, would normally get, but Ive put that into the pain world. But have I paid a price? I havent paid a price. I have made a profit -- I have friends all over the world, my big kids, when they were growing up, could go and spend a summer with Vittorio Ventafriddas family in Italy and his son came and spent a summer with us -- you cant buy that -- I mean, you could if you were a multibillionaire, I guess, but you and I cant buy that kind of thing. I spent two weeks vacation last summer with Alf Nachemson in their little farmhouse south of Gothenburg on the ocean, and my son and his daughter got to play together -- what terrific experiences -- you cant buy that kind of thing. Bill Noordenbos and his wife, Cox, who are much older than we were, and theyre both dead now, but Karen and I got to spend time with them and learn the proper way of drinking Scotch neat, no rocks or water. I mean, I cant begin to tell you. Its the people, I mean, the whole thing is the people, that matter and its the people that Ive come to know and work with, and the feeling that it has some redeeming social value that I have put my time and energy into. And most physicians end up spending their time and energy in this country making money. And so the pain world -- and there is a certain variety of other things. The scholarly end of things. I like reading and writing and playing a role in the journal Pain. The hardest thing I had to do about becoming president of IASP was recognizing that I just dont have the time to continue to be one of the editors of the journal Pain, and giving that up, because it has been a really wonderful process. Prices Ive paid, thats a hard one. Ive spent a lot of time in airports. Had to buy a good portable computer to make good use of the time. LIEBESKIND: Well, I must say, Ive always found you to be a cheerful fellow, I mean you seem very content with what youre doing, and someone who has enjoyed, as you said, the people and doing this thing. Some people seem more burdened by the whole thing. LOESER: Well, there are other things. I have always been fascinated by other places, okay, and perhaps because its IASP and not APS -- I mean, Ill tell you, the thought of going to another meeting in San Diego or Chicago or Boston, thats not -- but to go to Kuala Lumpur or Im off to Seoul, Korea, in September for the Korean Pain Society -- Ive never been to that country. So there is a certain amount of the pleasure of getting to travel and see places. But its really the people. I guess what Im trying to run through in my mind is, if I hadnt gotten into the pain world, would I have been as hectic and frantic as I am, and it may be, I mean it may be Id have found something else that was so grabbing. I think that -- LIEBESKIND: You seem the sort of person who is going to have a passion in relation to your work. LOESER: Well, I like doing things that Im committed to. You know, the price Ive paid is, at this age at least, I wish I had more time for my family. Karen and I had this great weekend together and we sort of looked at the week and I said, Well, Ill be home for dinner, I hope, most of the nights this week and Davids in bed when I leave because he goes to a daycamp this week that doesnt start till nine, so he doesnt get up till eight, but Im out of the house by seven. So its put a stress on my marriage, there is no question about it, but Im like -- Well, yeah, its put a stress on my marriage, but more its put a stress on me in terms of time to spend with them. As you are well aware, this is my second marriage, but the divorce occurred long before the pain world could be blamed for it. It was more likely the Vietnam War that was the main precipitant for that. LIEBESKIND: Did the Vietnam war shape your career in any ways, would you say? In any clear way? LOESER: It shaped me as a human being in a way. It didnt influence my career at all. I wanted to go into academic medicine, I left here, had a job, which was sort of an interim job -- I knew I was going to get drafted, spent my two years in the Army and came back to here. I didnt -- it delayed my academic career by a couple of years. LIEBESKIND: But it wasnt the same John Loeser who came back, huh? LOESER: No, because in spite of the fact that I had had a wonderful education, nobody can educate you about what war is through books or lectures. You just got to go see one, and those of you who havent seen a war dont know that its worse than anything you could read about, because the fact is, war shows you the way man evolved, back to the dogs and the apes and the God knows what else. All wars, every war, always has the same effect on the land of those in whom the war is fought. Women and children are raped and plundered. Men are murdered. The prostitutes and the taxi drivers become the most economically privileged people. Social organization is destroyed and the human beings whose land the war is being fought in are turned into clods of dirt. From what I can read, thats really the way its always been, although we tend to glorify certain things about it. From that I came home much more opposed to war as a solution for anything. I came home much more concerned about what was going to happen in the United States since six million Americans have been told it was possible to shoot somebody and not go to jail for it. I came home much more aware of the racism in the United States. My hospital was a beautiful physical plant -- I mean by that, it wasnt beautiful in the sense of architecturally beautiful -- but it was a superb clinical resource. We had, I dont know, about fifty docs and an equal number of nurses, and a couple of hundred corpsmen, and a little bit north of us was the 101st Airborne, thirty miles north of us. Youd go up there and visit them. Their soldiers are eighty percent black. They had, I dont know, some god-awful mortality rate of thirty percent, fifty percent -- come down and look at our hospital -- I think we had one black nurse, I think we had one black doctor, and one or two black corpsmen -- you know, we were a quarter percent black -- and we had a zero mortality rate, or virtually zero. You sort of looked around and you realized -- I mean, youd talk to the Army people, and they said, Well, were not discriminating against black people, everyone takes the same exam and if youre smart enough well let you go to medic, to corpsman school and if youre too stupid you end up cannon fodder. Thats not racist. So you see that. I dont think the Vietnam War had much effect in terms of professionally. It totally turned me around as a person, I think. Because you see, when you and I grew up, war was glorious. My father spent four years in England -- he was a physician, not a footsoldier, but man, it was heroism stuff. I had a lesson in heroism too -- that was an interesting experience in that it shows you how human beings work. I was the neurosurgeon on call one day when a helicopter pilot got on the radio and said, Hey, were flying in there with an elderly Vietnamese male with a large round hole in the front of his head and no hole in the back of the head and hes got an M79 grenade in his brain. I said, Give me the radio. Where are you? Were out over the South China Sea, twenty miles out. I said, Dump him off. They said, Dump him off? I said, Dump him off! What the hell, you have a guy with a live grenade in his head and youre flying him down here! The aircraft commander says, I cant, sir, thats against regulations. So at this point the commanding officer of the hospital said, We cant bring somebody with a live grenade into the operating room, it could destroy the operating room. Well set up a bunker in front of the hospital. Well get you some body armor, says he to me. Now, Army body armor protects your chest and your gonads, okay, they dont give a shit about your hands or your brain. So this helicopter lands and they bring this thousand-year-old Vietnamese man over, and the guy is basically brain-dead. I mean, he is obviously going to die. Sure enough, theres an x-ray picture of this huge -- an M79 grenade looks like a huge bullet, and its fired out of a rifle-like thing. Normally when it makes six rotations its armed and it explodes on impact, and this one was somehow defective or God knows what. But here it is in this guys head. So I said, Why didnt you just take the guy and bury him? Against Army regulations! You cant bury somebody with live ordnance on their body! LIEBESKIND: You needed a bomb squad, not neurosurgeons. LOESER: We had a Korean physician visiting us. He says, Well, Ill tell you how wed handle it in the Korean Army. Wed get the machete, wed lop the head off the guy, and wed take the head out into the middle of the field and shoot at it for riflery practice until somebody hit it and blew it up, and wed bury the body and wed be all happy. Thats against regulations too. So I put on the body armor and I took a great big uterine clamp and stuck in into this huge hole, and fished out this grenade, gave it to the bomb squad who had then arrived, and they took it out a hundred yards out onto the airfield and dug a hole and put it in and detonated it and made, you know, a six-foot hole in the ground. Of course, I felt like defecating, urinating and vomiting at the same time. LIEBESKIND: [laughs] Urinating in your body armor. LOESER: Sure enough, the elderly old Vietnamese man died and the commanding officer had volunteered -- he said, You know, youre not a regular Army type. These kind of things, the RAs sometimes have to do. If youd like me to do it, you dont have to do it. And I said, Hey, youre a chest surgeon. If this was in the chest, youd do it. But this is in the head, so its my turn. So I took it out. The Army gave me a Soldiers Medal and it got in the local paper and my wife wrote me a letter saying what the hell are you doing? You could have gotten killed doing that. So when I got to Fitzsimmons -- you asked me if the Army influenced my life -- Ill tell you this story. When I got to Fitzsimmons, you know, my second year, the first thing you do is you have to go see the adjutant general of the hospital. The guys looking at your dossier and he looks at me and sees I got a goddamn Soldiers Medal on. Because you have to wear the medal. If the Army gives you the medal, you have to wear it. He says, Whats that? -- because nobody ever sees a soldiers medal. I said, Thats a Soldiers Medal. He said, Soldiers Medal? Whatd you get that for? I said, Listen, you dont want to hear the story. Its done and over with, its been in the newspapers, been in the Army Digest, everything else -- leave me alone. He says to me, Major, you two-year docs are all alike. Youre not patriotic. You dont understand the Army. He harassed the hell out of me. He said, Im going to call the public information officer and have him come talk to you. I said, Look, Colonel, youre not going to want to use this story. Leave me alone. No! I said, Okay. So the PIO officer comes to see me. I told him the same thing. I said, Look, youre not interested in this story. Its been in the Stars and Stripes, its been in the Seattle newspaper, its been in all these papers -- Army Doctor Takes Live Grenade Out of Head -- I said, Youre not going to want to write this thing up. He says, Tell me the story! I want to write it up! So I told him the story, just as I told it to you -- and I said, there was this old Vietnamese man who, as I predicted, shortly thereafter died. He looks at me and he says, Major, youre right. If it was a Vietnamese and he died, its not worth writing about. The Army and I didnt get along too well, to put it bluntly. So I have a Soldiers Medal and I survived that war. But the pain world has actually been, without any question in terms of my professional feelings about myself, yeah, sure, I got to be Professor of Neurosurgery at the University of Washington, and if you ask me, who are you, what are you, my reply is, well Im Professor of Neurosurgery at the University of Washington. I have told many, many people that I have the best job in the world. Nobody could have had a better job than me in terms of all the things Ive been able to do without changing jobs. But in terms of what gives you the feelings of who you are and what you are and what matters, its clearly IASP -- I mean, its just been an unbelievable experience, and it relates to both the people and the feeling that, gee, you are doing something that is of value above and beyond your own personal interests. And you know, I give my money to NARAL, and thats clearly of value, but its in my own interest. LIEBESKIND: Whats that? LOESER: The National Abortion Reform thing -- you know, you give your money to whatever charity you want, or Harvard Alumni, or something to the school you are working for. LIEBESKIND: But youve given your life to this cause. LOESER: But moreover, all the other things I think you have a certain self-interest -- why do you give money to Harvard? Not because you value Harvard in some way -- you went there. Its in your own self-interest, its your alma mater. But the time and effort in IASP has been a very different feeling because I really have the feeling it matters. I mean, someplace, somebody in the world is better off because of what this organization has done. LIEBESKIND: Some lot of people. Some large number of people. LOESER: And I have been part of it. I guess the other thing that tears at me is my role in IASP has also been like my role in APS was, in the sense that what I have actually done and spent time on is what the organization has needed, but its not really been what turns me on. I mean, what turns me on is the ideas, the research, the thinking, the conceptual things, and yet what the organization needs is somebody to make the damn thing run right and put the pieces together, and although Louisa does a huge amount of the running of the organization, Louisas forte is not thinking up new things and imaginative ideas, her forte is the nitty gritties. But the organization needs someone who is going to do that. I spent a lot of time at it, even though I wished I had the time to sit there and think about things, and thats why Im starting to envy you a hell of a lot when I hear about what youre planning to do with your life and what you want to do. But I cant afford to do what youre doing because Im addicted to the amount of money that I make as a neurosurgeon, and Im paying for too damn many kids educations and I still have one in business school and one in law school. LIEBESKIND: But the time will come. What does the future hold? Youve got three years in the barrel here, coming up, in IASP, then you are going to be past president. LOESER: Yeah, but the past president has -- plays a role also. I mean, Michael Cousins -- I mean, Im using the models of my predecessors, past presidents -- Mike Cousins has been a very important contributor as past president, and Ron Melzack was an important contributor as past president. And I hope Ulf will be, you know, because he represents a repository of knowledge and experience that the institution can ill afford to lose, and thats why I like the concept of keeping the past president around. Its going to be real tough in my tenure because both Dubner and Fields have decided not to run and therefore it will be the first time that there is going to be three new and only two old. Up until now its always been the reverse. So thats going to be a bit of a problem, I think. LIEBESKIND: The Executive Committee -- three new members on the Executive Committee. LOESER: Yeah. Oh, I dont know -- whats the future going to be? Well, what would I do if I had complete freedom to do things? Oh, Id like to continue to develop the educational and research activities of the Pain Center, which I think need more development. Id like to bring to fruition some of my research activities in the epidemiology-economics type arena, because I think that thats something that should be done. Id like to have the time to start asking again the clinical questions that can be answered in the lab, which is what I was really embarking on as a career, and that was what my department was so strong about in terms of clinical and research interactions. Im keeping my eye on Greg Terman. LIEBESKIND: Yeah, what do you think of him? Hes going to be a leader in the field, isnt he? The guys a prince. LOESER: Yeah. Absolutely the best damn guy weve ever gotten hold of, no question about it. As long as we can keep him in the right game, the right ballpark. I have protected him. Hes had no excessive administration responsibilities. Hes had really true emphasis on his research. Hes got a wonderful clinical-slash-research job with a big research commitment, and if he doesnt make it, it aint because the institution didnt really give him the potential. LIEBESKIND: He has an article coming out now in Nature, or its out now or something. LOESER: Fantastic. LIEBESKIND: Hes making it. LOESER: Well, he was well trained. He came to us better than most by a longshot. So if I could, Ill tell you -- another way of answering it -- theres only one man Ive ever met whose job I coveted. And that was Peter Nathan. Peter Nathan, who said to me, I am a research neurologist. I said, Peter, what does that mean? He says, Well, I have an appointment at Queens Square and I can look at and test and study and think about any patient who comes near the institution and I dont have to take care of any of them. [Liebeskind laughs] And that I have envied. Because to me what has really been a big problem is, I have a very definite patient-centered approach to things. I spend a lot of time talking to my patients. LIEBESKIND: Youve got Mrs. Smith hanging around your neck. LOESER: And when I take care of a patient, theres a tremendous time commitment and the clinical commitment that eats into the intellectual, conceptual time. And thats what kills me. This afternoon Ill be here all afternoon in clinic. Wednesday Ill be here all day in clinic, and its not that I dont enjoy the clinic, its that -- so if I could earn the money I make as a neurosurgeon being a research psychologist, Id like to, but its tough to cut back, and especially as I say -- you and I are in the same boat -- I have a kid whos going to go to college the year I retire, if I retire at age 65, and theyre telling me that for me to fund him going to college, if hes going to go where I went to school, its going to cost fifty thousand bucks a year. [Both laugh] I mean, and Id like him to have the liberty -- I dont give a damn where he goes to college, but Id like his decision to be made on something other than whether his father could afford it, thats for sure. LIEBESKIND: Independently. John, I dont know how much more time we have here this morning... LOESER: Not much. LIEBESKIND: ...I have lots of time, you may not have much more. I have a couple of selfish questions that maybe you could briefly... LOESER: Ill tell you what I want to do. I want to leave here by ten to twelve, take you over to the U, where, A, your coat will be, B, I need to look at something briefly, and C, there is a taxi stand right there. Thats what our plan will be. LIEBESKIND: OK, so we can do what I need in the next few minutes. Just for my own benefit, as Im getting into this, as you know, youre only the -- Ive interviewed John Bonica and Bill Fordyce, Louisa Jones... LOESER: So all the UW people, huh? Okay. LIEBESKIND: John Reeves, I sort of had a practice, first session on him before to try out my new machine. Anyway, Im very new to this and Im interested very much in especially your view both on who else I should interview and why you would choose them, and the interview process. What do you think? I mean, I could give you a list of the questions I never got to ask you. But in a sense youve addressed virtually all of them. I mean, I sort of let you... LOESER: Well, its a little stream of thought. LIEBESKIND: And youve really -- you might be interested, Ill leave this with you and you can see -- weve kind of covered most of what I wanted to get into. So Im interested in what you think of the process and how that can be improved. LOESER: Well, I wouldnt presume -- oh, who else you should see. Well, first of all, youre on an IASP project or an APS project or a John Liebeskind project? Are you going to try and get out of the English language, I mean, into other places and other people? LIEBESKIND: Im on a John Liebeskind project, thats what it is. Certainly if we set up a task force as you and I had talked about, it will involve other people doing this, then of course we would want Japanese language people, or Italian or German or whatever. Let me -- Maybe I should preface this by saying that I am trying to take a historical point of view, but its kind of an intellectual historical point of view. Im interested in the ideas, and, if youve noticed, thats whats weve majorly... LOESER: Yeah, I understand that. I know a little bit about the ideas in the pain world, and there isnt any question that some of the great people are gone. Youve missed Bill Noordenbos, youve missed the Leriche, Foerster, you know, that thing, so you are going to have to get that from the books, so to speak. Bill Livingston, no question a seminal thinker, but Bonica can tell you about that, and Melzack, I would not fail to get Melzack to talk about Livingston. LIEBESKIND: Oh, no, Im sure he will. LOESER: Now clearly -- these are so obvious -- you need Melzack and Wall, no question about it. If you go back a little before that, believe it or not... LIEBESKIND: By the way, I dont know if you know this, I have Pat and Dame Cicely Saunders back to back in early August, and Ive written letters to Bill Sweet and Janet Travell and Im going to call... LOESER: Travell is outside the pain world. I mean, you can get her, but shes clearly outside the pain world. LIEBESKIND: Well, so is Dame Cicely Saunders, but I just wanted to get that... LOESER: No, well, shes in it in the cancer pain, well, yeah, okay. I think you need to go back at the sensory physiology side and Ainsley Iggo played a bit role, and Ed Perl, and oh the guy that trained Dick Black who was in Toronto, who did all the trigeminal work, whose name Im blocking. There was a physiologist, but you need to look at that. You need to look at, then, the psychology end of it. You need to get Merskey. LIEBESKIND: Yeah. How is Ainsley? Not so good; I understand, hes battling prostate cancer. LOESER: Youre telling me something I dont know. He dropped out of the world, as far as Im concerned. His -- I dont know, Im not going to say anything about Ainsley. Im sorry to hear that; I was not aware of that. Lets think, who else would I ... LIEBESKIND: Thinkers, movers and shakers, people who have changed the way we think about pain. Or who have views about who else has. LOESER: Well, the Ben Crue side of this equation -- I think hes -- you may or may not want to go that way. LIEBESKIND: Why would you mention, why would you even think of Ben Crue? He was there early. LOESER: Because the fact of the matter he, he is a neurosurgeon, one; two, if you go back and look at publications on pain on human clinical research, he was there early. Dont know. You see, theres two different sets of the world. There are the people who played a role in APS or IASP, not all of whom made significant research or clinical contributions. I mean, you go back and look at my CV, I published both research and clinical articles in the early days related to pain, and then conceptual articles and so forth. But you take Bert Wolff -- I mean, Im sure he has written articles on something -- I dont know what theyre on, but I dont think Bert played any role in the intellectual history, but after all, he did order the best wine Ive ever had at a banquet, which was the year that the American Pain Society damn near lost its shirt, having a meeting it couldnt afford in San Diego [both laugh] and Bert made sure the wine was first-class. I give him credit for that. That took chutzpah that anybody Ive ever known. But, you know, there are people like Diane Chen who got the APS basically funded through Hoffman-LaRoche for several years in the beginning. She made a great contribution. LIEBESKIND: Well, its in that sense that I interviewed Louisa and, very sincerely, this was not gratuitous. LOESER: I think Bill Sweet is an important person in the system in a variety of ways. I think you could get into looking at some of the sensory detection theory people, Crawford Clark, people like that. I think Dick Chapman has played an important role. You probably want to get after him. LIEBESKIND: I was talking to Greg Terman at a meeting not long ago, and all of a sudden I found he had all these opinions about very important issues, and it made me realize, yeah, its important to get the old farts while theyre still around, but if Im going to really be focusing on what people are thinking here in the 1990s, I got to get some young opinions. There are some strong opinions here. LOESER: Yeah, but thats a different book. As I understand, what youre trying to do is capture the 60s to 90s. I mean, youre talking about what happened between -- well, youre not going to have living people to go back before the 60s. And if you try and put up past the 90s, youre going to be too big and too close to it. You are going to lose the advantage of having perspective on it, and, you know ...What is the denouement of the NMDA receptor issue? Nobody knows right now. I think you are going to have to talk about -- one chapter I could see would be the development of experimental models for pain states, inflammatory models, neuropathic models, and it goes back to LIEBESKIND: To Pat. LOESER: Well, it goes back to deafferenting spinal cord. LIEBESKIND: Right, thats right. LOESER: And the dorsal root reflex and other things. But I could see that. But my suggestion to you is, if you try and run it up to the present, youre never going to know, youre never going to be able to finish -- its a contradiction in terms. LIEBESKIND: Let me say, by the way, that I have two purposes. One is the one that youre thinking about, just the prospect of a book or something that would have a page one and a last page. The other is, I just want to provide tapes and transcripts of those tapes for subsequent historians. LOESER: Yeah, come on, John, thats fine. But theres no fun in that. I mean, you go around and interview people and store the tapes someplace? Thats not an intellectual job. You could hire, you could send Joe Schmo with a list of questions. Youre into more than that. LIEBESKIND: Well, Im not saying Im not. Im saying that I think thats a worthy end in its own right, because its providing a basis for history, for other historians... LOESER: I accept that. LIEBESKIND: ...some of whom who may be more ambitious or talented than I, possibly ... LOESER: If I were writing your book and your source, because I think youre going to have to do more than tapes -- I think youre going to have to start having a data base system available that others may be able to use, and youre going to be in the twenty-first century, not the twentieth century, which means if your legacy is going to be of value, youre going to put these tapes into a database, the software is now available so that you can actually put audio in, so that somebody could use a database and say, I want to learn about animal models of inflammatory pain, and they could now have 12 different people speaking on that and youve chopped the little pieces up and moved them around. But anyway, I would think that you need to, in a sense, separate the administrative or organizational from the specific issues, developments in clinical care, like intrathecal opiates or aggressive use of oral opiates or electrical stimulators or stuff like that, and then conceptual development. You know, the concepts of pain are what determine everything, and most people dont have any concepts of pain. I give the same damn lecture over and over again. I use the quote from Sir Thomas Lewis, who said after forty years of studying pain, I dont know what the hell it is. It seemed to me, what a tragedy of a mans life. So my problem is, I know what it is, but I havent had forty years to study it. [Both laugh] But I think that you need to go back to Issaquah, look at the people who spoke then. That will tell you whom Bonica and the cohort were able to identify as people who at that time had done something to make them look like they were prominent in the pain world. And then sort of track through and see whats happened and which ones came and went. See, by the time you get to 75 and Florence, then political issues were coming in. You know, Madame Albe-Fessard, and problems of the French wanting adequate representation and the Germans and the this-es and the thats -- that changed things to some degree, but I think that history is still fascinating. I mean, you could write a history of IASP. LIEBESKIND: Well, I was just going to say, theres the history, an intellectual history of pain, theres the history of IASP; then you know, history is people and there are fascinating people, of which, Im sorry, youre one, John Bonica is certainly one, and there are many others, you know, you get down into the question of -- thats why Im trying to ask some questions of how to get into this, and some other things. LOESER: Well, I can tell you, I spent a few years in psychoanalysis during the years when my first marriage was ending, and he kept saying to me, You think of yourself as a machine. And I kept saying, Yep. [Both laugh] And there are a lot of damn things in the world that need to be done, and there is no question that my experience has been, most people dont give a shit. And theres a limited number of people who you can count on who say, This matters. Im going to get this done, or Im going to try and get it done, or Im going to find people to get it done. It was just like you heard Louisa, when I yelled at Louisa, I talked to Ron Paul -- hes going to run the local arrangements. Im thrilled, why, because -- I call him up, and I say, Ron, I need somebody to be the local arrangements person for the IASP meeting in Chicago -- its your hometown, you lived there 30 years, and before I could give him a pitch, he says, Wow, that would be fabulous, Im flattered that youd give me the chance to do that, Im looking forward to doing it, boy, I never thought Id have the chance to do something like this. And you say to yourself, Wow, I found a guy who functions the way I do, that is, someone says, heres a job and the guy says Ill do it. It isnt always perfect, he isnt smarter, but its somebody who says this is something Ill do, and my experience has been the number of people you can find in the world who do that is really small. Thats the problem you have in running a big organization. Yeah, Ill do this, Ill do that. Weve got to go. LIEBESKIND: Youve got to think about it, see how it fits in. All right. LOESER: You got a couple more questions? LIEBESKIND: No, Ill end it right there. Its quarter of twelve and this has been a wonderful interview. Thank you very much. LOESER: Youre welcome, John. END OF INTERVIEW      PAGE ii  PAGE 1 .1M[\_qst * A J P ^ b x y ~ wwwlhQ%hCJaJhQ%CJaJhQ%hQ%CJaJ hCJ hQ%CJ hCJ h"QCJ hdVCJ hCJ hV=CJ$ hAoCJ$ h"QCJ$ h!CJ$ hQ%CJ$hQ%CJ$OJQJhCJ$OJQJ hQ%5CJ0 h5CJ0 hCJ$h6B*CJ$ph)./01HM\]^_tuvw * $a$gd! $@&a$gddV$a$gddV$a$$@&a$* N O P c x y 789RShij@&gdAogdAogd"Q$a$$@&a$$a$ IJhk@Alm5789:R0?^-j'CQRS_su  hQ%6CJ h6CJ h2)CJ hdVCJ hV=CJ hQ%h"QCJaJhV=CJaJ hQ%CJhQ%CJaJhQ%hQ%CJaJ hCJ hCJ h"QCJ@  {|}GJKLd $@&a$gdQ%gd"QgdQ%@&gdQ%@&gdAogdAo  ST (5Uy{|} DGJLcfqstuvwxyľıhB*CJphh5B*CJphhQ%5B*CJph hQ%6CJh hdVCJ h6CJ h2)CJ h"QCJ hCJ hQ%hCJaJhQ%hQ%CJaJhQ%CJaJ hQ%CJ hQ%CJ hCJ2defvxy""""""%#dgdQ% $d@&a$gdQ% $da$gdQ% $@&a$gdQ% $@&a$gdQ%& & <$@$**a+~+ .!.'.=.P.Q.005566H7P7A9B9[<\<<<}BB=FLFFFFF/I0IMJNJ9K:KPPPPcRdRgRhRRRRR$T&TUU`]a]d]e]__yaaQdRdddddGgQghhZu`B*CJphhB.hQ%6B*CJphhV=B*CJphhB.B*CJphhQ%B*CJphO%#&#H'I'''J(K(((**R-S-----..?.@...//002dgdQ%22222222%4&4;4<4444455g5h556:6;666A9B9W9dgdQ%W9X9i9j999Z:[:::<<@@6A7ABB(F)FFFHHgHhH9K:KMdgdQ%MMMMNNOOdOeOPPQQQQ3R4RLRMR%T&TWWyWzWYYYdgdQ%YYs[t[[[@_A_z_{_____6a7aXaYabbCbDbbbbb@dAdddgdQ%dd"f#fFgGgiiiiii"j#j@kAkooppWtXtqtrtvvwwzdgdQ%hhhh?kAkkkkkkkkknnnnRtSt~ttttavvwwJxKxNxOxxxxx}~~~~~'݈ވ.0<=-^_cdde]^stGHBD hB*CJphhZu`hQ%6B*CJphhQ%B*CJphhZu`B*CJphSzzz{b|c|||~~=>DEbcgḧdgdQ%͈̈ /089 <=WX<=?@XYKdgdQ%KLݘޘ!"GH`aޚߚ<=ijݝޝbdgdQ%bcɟʟghϥХ^_|}GHdgdQ%߫XYCDno :;TU $da$gddgdQ%-05zٴ6:dehi޶:ZZvWXGcEGhprοh#kB*CJphh,hQ%6B*CJphh,B*CJphh,hB*CJphh,hQ%B*CJphh,hQ%5B*CJphh,h5B*CJphhQ%5B*CJphh5B*CJphhQ%B*CJph3./0yz-.FG }~ùĹCD'(׻dgdQ% $da$gd׻ػ WX*+FGqrEFdgdQ%78%&)*EFcdgdQ%hi.~   }~Q!V!##&&P)Q)+-,-33????y@z@BBCCKDkDIh]FB*CJphh>%6B*䴳=*䴳>*䴳#%6B*䴳#*䴳%*䴳<= <dgdQ%<=`a34UVTUYZHI  dgdQ%&'cd##%%&&P)Q)++9,:,-dgdQ%--+-,---//8090113 333U4V444666666888dgdQ%88::::;;==>>:@;@@@CCEEIIIIIIII $da$gd]FdgdQ%IIIIIIIJ*J0J3JLLMMOO^PhP;RhQ%6B*CJphhZu>B*CJphhOhQ%6B*CJphh]FB*CJphhOB*CJphhQ%B*CJphhO5B*CJphhQ%5B*CJph@ef3467{|WXdgdQ%j k   :;UV4!5!4$5$''dgdQ%'''((((****--//,0-0I3J333q6r6668899dgdQ%2,2 8'8,8-888@@J"JJJPPSSUUfYYZ:ZZZZZn[o[\\QaRabb0cOcddIhJhiimmpprrrrrrrrrrrrr뼵 hg@0Jjhg@0JUh%jh%U h 9fh 9fhQ%5B*CJphhZu>*䴳ʰՋ%6B*䴳ʰՋ*䴳%*䴳չ*䴳<9+9,9I9J9.</<l<m<L@M@@@@@LAMAEBFBCCHCICEEJEKE=F>FdgdQ%>FFGGGEIFI K!KHKIKKKLL%M&MvMwM)O*OOOPPQQQQQQdgdQ%QSSVVWW;XdgdQ%rrrrrrrrrrrr $da$gdZu>$a$ rrrrrrrrrrrrr h 9fh 9fh%hg@0JmHnHu hg@0Jhg@h:0JmHnHujhg@0JU B 0000PBP/ =!"#$% DpB 0000 PBP/ =!"#$% Dp+s666666666vvvvvvvvv666666>6666666666666666666666666666666666666666666666666hH66666666666666666666666666666666666666666666666666666666666666666p62&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH 8`8 Normal_HmH sH tH DA`D Default Paragraph FontViV  Table Normal :V 44 la (k (No List / WP DefaultsX$ Gp@ P !$`'0*-/2p5@8;=@da$%B*CJOJQJ_HmH phsH tH j/j Bibliogrphy0d^`0!B*OJQJ_HmH phsH tH F/F Doc InitB*CJOJQJkHmH sH uH/!H Tech InitB*CJOJQJkHmH sH uF/1F PleadingB*CJOJQJkHmH sH u4B4 Header  !4 @R4 Footer  !.)@a. Page Number@Yr@  Document Map-D OJQJ0/0 Default Para/ _level1D$ & p@ P !01$^`0a$CJ_HhmH sH tH / _level2A$ # p@ P !01$^`0a$CJ_HhmH sH tH ~/~ _level3>$ p@ P !p01$^p`0a$CJ_HhmH sH tH |/| _level4;$  @ P !@ 01$^@ `0a$CJ_HhmH sH tH x/x _level58$ P !01$^`0a$CJ_HhmH sH tH v/v _level65$ P !01$^`0a$CJ_HhmH sH tH r/r _level72$ P !01$^`0a$CJ_HhmH sH tH p/p _level8/ $ P !01$^`0a$CJ_HhmH sH tH l/l _level9,!$ P !P01$^P`0a$CJ_HhmH sH tH /" _levnl1D"$ & p@ P !01$^`0a$CJ_HhmH sH tH /2 _levnl2A#$ # p@ P !01$^`0a$CJ_HhmH sH tH ~/B~ _levnl3>$$ p@ P !p01$^p`0a$CJ_HhmH sH tH |/R| _levnl4;%$  @ P !@ 01$^@ `0a$CJ_HhmH sH tH x/bx _levnl58&$ P !01$^`0a$CJ_HhmH sH tH v/rv _levnl65'$ P !01$^`0a$CJ_HhmH sH tH r/r _levnl72($ P !01$^`0a$CJ_HhmH sH tH p/p _levnl8/)$ P !01$^`0a$CJ_HhmH sH tH l/l _levnl9,*$ P !P01$^P`0a$CJ_HhmH sH tH PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭Vc:E3v@P~Ds |w< jD %( hIdP2rr:=?AHNRX[`eio* d%#2W9MYdz̈Kb׻c<-8IQa|Ҧz'9>ǯ`rr;<>@BCDEFGIJKLMOPQSTUVWYZ\]^_abcdfghjklmn  "(!!8@0(  B S  ?,)-).)/)0)1)*7--:Ej5A8DOOj8*urn:schemas-microsoft-com:office:smarttagsCity9*urn:schemas-microsoft-com:office:smarttagsState>*urn:schemas-microsoft-com:office:smarttags PostalCode9*urn:schemas-microsoft-com:office:smarttagsplace U[HNx~ku: B L R f n  KQ &kq8>!$%(!!! """"#$$////91?1112204?46677+:5:A:M:;;f<r<==E>I>L>S>>>jCyCUE_E'I1IJJJJ7KAKKKLLO(OOO,]0]__LcRcccHgNghhiimmnnoo`ofooovq}qqqssss*v0vbvhvwwY}`}~~Y_yOU{w}U_VZ28ak"      **T+[+c+m+//0000N1T111r2x244S5Y57 799 ::==k>q>?@5A;AAACCEESFYFLJRJmJsJJJUUUUWW.X4XZ Z\\]],^2^__D_J_OaWaaabbccAcGc eeeenlxlll:r@risosu uuv]vcv{ww+|.|/|2|C}N}~~.Y_3:~5@Lj rzjp39$jo$)/%+PV%2  ) 3:\%d%)")i.o.x0}0_3i3::>>b?l?ABBB B(BBBBBBCCCDDDDFFG%G,I0IIIYN`N_PePTTWWX_^_``aa!a&abbjjjjjjjjjjjjjjHL7H& &J&P&~))T9\9 EEWWK\Q\R\jjjjjjj333333333333 9 : GG!"%&}~TTQYRYZZO[O[aajjjjjjjjjjjjjj 9 : GG!"%&}~TTQYRYZZO[O[aajjjjjjjjjjjjjjjjjjIH~ )0"m=O>!%o%2)*k,/(/V=Zu>d>I\LxIQtRTMY^U`Zu`6dH|d 9fWlAoZq]s$x}4E~TP ,^_dVQ%>"Q :$AxsN.g@]!pm^h#k]F{"@B.Nbjj@j@UnknownG.[x Times New Roman5Symbol3. .[x Arial75 Courier5. .[`)TahomaA$BCambria Math"҈g҈gxTFX\`<bX\`<b!4|i|i2QHP?xIQ2!xx HOWARD FIELDS INTERVIEWBiomedical Library Network UserMMeldrum Oh+'0$ 8D d p | HOWARD FIELDS INTERVIEW Biomedical Library Network UserNormal MMeldrum2Microsoft Office Word@@^@:{@:{X\`GLVT$m$ O  !-. "Systemy`My--@Times New Roman--- O2 v-0 John C. Liebeskind History of Pain Collection              2 vy0   @Times New Roman---  2 0     2 0     2 0   @Times New Roman--- ,2 0 Oral History Interview       2 40    2 y0 with   2 0     2 810 John D. Loeser   2 80   ---  2 U0     2 q`0     2 `0   @ Arial--- &2 -0 Ms. Coll. no. 127.     2 0 24   2 0   ---  2 `0     2 `0     2 `0    2   0 Conducted:    2  0 12 July 1993      2 0    2 5 0 Interviewer:       &2 5y0 John C. Liebeskind     2 520     2 Q*0 Duration: ca.      2 Q0 4.0    2 Q0   2 Q0 hours    2 Q0    2 m[0 Pages:    2 m0 i  2 m0 v  2 m0 ,  2 m0 54   2 m0     2 `0     2 `0     2 `0     2 `0   @Times New Roman---  2 0    82 0 History & Special Collections         2 0 for the    2 0 Sciences    2 X0    ;2 &  0 UCLA Library Special Collections            2 &'0    .2 >0 Los Angeles, California        2 >0   2 >0 90095   2 >0 -  2 >0 1  2 >0 798   2 >40     2 V0     2 n0     2 G0 2000, revised    2 0 2016   2 0   @Times New Roman--- --  00//.. ՜.+,0 hp  UCLAb<|i %HOWARD FIELDS INTERVIEW.John C. Liebeskind History of Pain CollectionOral History InterviewwithJohn D. LoeserConducted: 12 July 1993/History & Special Collections for the Sciences!UCLA Library Special CollectionsBiographical SketchInterview History)Topical Outline (Scope and Content Note)Access to the InterviewTerms and Conditions of UseCitation InformationEditorial NoteQThe interview transcript has been annotated -- with notes offset in [square brac?Related Materials in the Liebeskind History of Pain CollectionQResearchers are referred to the following related materials: oral history intervAcknowledgmentsQSupport for the John C. Liebeskind History of Pain Collection and its Oral Histo[PHOTO PORTRAIT NEEDED]John Loeser, MD NeurosurgeonJOHN D. LOESER INTERVIEWTAPE ONE, SIDE ONE Title Headings$  !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-./0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnoprstuvwxyz{|}~Root Entry Fې{1Tableqf:WordDocumentSummaryInformation(8DocumentSummaryInformation8CompObjr  F Microsoft Word 97-2003 Document MSWordDocWord.Document.89q