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Chronic or persistent pelvic pain needs more than a simple band-aid medication or complicated surgical intervention, and Dr. Jorge Carrillo, MD has followed his passion to show the world how to more effectively treat these conditions. His work also fits right in line with what we teach through the principles of Integrative and Lifestyle Medicine and Medical Therapeutic Yoga.
One of the primary aspects of Dr. Jorge’s treatment style focuses on trauma-informed care. As you likely know, trauma can come in many forms. The more attuned your provider is to understanding how trauma affects a person’s health, their sense of safety, and their need for clear and compassionate communication, the better the outcomes will be.
What else does he teach and focus on within in his own practice? Patient-focused care. When your healthcare provider really hears what you want, they focus on helping you achieve your goal, not what they think you need. Being heard and being listened to, is one of the best feelings in the world and we live in a world where most physicians have only 13-18 minutes with their patients. This is not enough time to listen and hear everything that a person needs to say, especially when trauma and chronic pain are involved.
One final gem, that is critical and invaluable to Dr. Jorge’s work is the work of education. Too many of us are not adequately informed about how our bodies work, what’s normal for periods and even what isn’t normal. When we know more, we can seek out and ask for help from qualified, compassionate, and supportive healthcare providers so we can find health even when dealing with persistent pelvic pain.
We don’t say this lightly….we need more Dr. Jorge Carrillo’s in the world!!
This episode is not to be missed! Watch below or listen to the podcast.
Dr. Carrillo obtained his M.D. from the Pontificia Universidad Javeriana, in Bogotá-Colombia. Completed his OBGYN residency at Rochester General Hospital (Rochester, NY). After this completed a Fellowship in Minimally Invasive Gynecologic Surgery (MIGS) through the American Association of Gynecologic Laparoscopists (AAGL) at the University of Rochester School of Medicine and Dentistry. This Fellowship had an emphasis in chronic pelvic pain (CPP). After this he joined the University of Rochester as Assistant Professor and provided care to patients suffering from CPP conditions at their Center of Chronic Pelvic Pain and Vulvar Disorders. He subsequently completed a Dean’s Teaching Fellowship, a 2-year training program on adult learning and medical education.
Since 2017 he has been part of the Orlando VA Healthcare System (as a CPP specialist and MIGS), is an Associate Professor of OBGYN for the University of Central Florida, serves as faculty for the Orlando VA FMIGS and is the Site Director for the UCF/HCA OBGYN Residency Program. He is completing his Master’s for the Health Professions Education with the University of Maastricht (The Netherlands).
Dr. Carrillo is the 2023-2024 Vice-president for the International Pelvic Pain Society and serves as one of the Executive Board members, also has been the Scientific Program Director for their Annual Scientific Meeting for the past 3 years and the Co-Director for the IPPS Clinical Foundations Course for the past 4 years.
His expertise and research are in chronic pelvic pain and associated conditions, minimally invasive gynecologic procedures, patient education and health professions education.
0:00 Dr. Ginger Garner: Hello, everyone, and welcome back. I am here with an amazing guest today that I cannot wait to introduce to you. First, I want to say welcome to Dr. Jorge Carrillo.
0:13 Dr. Jorge Carrillo: Welcome. Hi, how are you?
0:16 Dr. Ginger Garner: Yeah, I’m so, so, so very glad that you’re here. You have an amazing wealth of knowledge to share with our listeners. I always like to brag on guests before we get started. So, I want to give the listener a little earful about your background and bio. And then we’re going to just jump right in with some like some real life examples and stories. But if that sounds good with everyone, we’re going to kick it off.
All right. So, Dr. Carrillo obtained his medical doctorate from, and I hope you guys that I pronounce everything right. I took, no, I didn’t take Italian. That was later. I took French in high school, which was really, it’s not that helpful currently. Pontificia Universidad Javeriana in Bogota, Colombia.
1:15 Dr. Jorge Carrillo: Perfect.
1:17 Dr. Ginger Garner: Good? Yes. And I’m going to commit myself, all three of my boys study Spanish, so you know, they’ve taught me, they’re teaching me. Commit myself to learn more of that. But you completed your OBGYN residency at Rochester General Hospital and completed a fellowship in minimally invasive gynecologic surgery. at Rochester also, and then we just go forward with everything that you have done, putting your emphasis into chronic pelvic pain.
You joined University of Rochester as an assistant professor, serving that CPP chronic pelvic pain community. Then completed a Dean’s Teaching Fellowship, which is a two-year program on adult learning and medical education. Which is pretty incredible and makes anyone who does that such an engaged, better teacher, I think. Since 2017, you’ve been a part of the Orlando VA health care system as a CPP specialist. And you’re also associate professor of OB-GYN for the University of Central Florida, serving on faculty there in Orlando, the VA, and also as the site director for UCF HCA OB-GYN residency program.
You are busy. You’re busy. So thank you for taking time today to talk to me. You’re also, because you apparently have spare time, completing your master’s for health professions education, which I had to look that up. I was intrigued by that at the University of Maastricht in the Netherlands. Maybe we’ll get a chance to talk about that because that is a big interest of mine too.
Jorge is the 2023-24 vice president for International Pelvic Pain Society (IPPS). And you have served as a scientific program director, you still are right for the past three years.
3:18 Dr. Jorge Carrillo: Yes.
3:19 Dr. Ginger Garner: And co director for clinical foundations course for IPPS for the past four years. You’re an executive board member and just like CPP extraordinaire in addition to the other things that you’re doing too. So welcome.
3:33 Dr. Jorge Carrillo: Thank you so much for that wonderful introduction. Thank you.
3:37 Dr. Ginger Garner: I’m so glad that you’re here. I was looking at some of your publications that those started like a decade ago, right? Am I right?
3:45 Dr. Jorge Carrillo: Yeah, around about that time. Yes
3:48 Dr. Ginger Garner: 2014, something like that. So first of all, just just a random question, like what drove you into this arena in this space, this field?
4:01 Dr. Jorge Carrillo: So it was, I would say, luck, to be honest, a lot of luck. I, as you mentioned, I migrated from Colombia to the States to pursue my residency training. And, you know, the residency match is kind of random. Like you go interview several places and then the system picks whatever spot they have for you. So I was based in Florida at that time in Palm Beach with an uncle when I was waiting for the news. I was told, well, are you going to Rochester, New York? And I’m like, when did I interview? Like, what is a Rochester, New York?
So I packed my stuff, went up there and did my residency in the community program. And when I was a third year, one of my attendings, who was great with me, a great mentor too, he was helping me decide what to do with my career afterwards and I had elected him. He was from the University of Rochester, so he was like, why don’t you do a month at a MIGS program (Minimally Invasive Gynecological Surgery) that they have there with Dr. Fred Howard? And I was like, who’s Fred Howard? And he was like, oh, you’re going to love him, but let me make the introduction. And Dr. Howard took me as a month as a resident.
And that was a life-changing experience because it did not only expose me to what I was looking for, which was MIGS, minimally invasive surgery, But he happened to be one of the godfathers of chronic pelvic pain in the country and even outside without me knowing. And he is one of the founders of the IPPS. And that led me to see with a different set of eyes, because not that I had not seen it before during residency, but it was a totally different mindset. My very first encounter with a chronic pelvic pain patient with that different optic. And that was an eye opener. And after that, I was lucky enough to match with him.
And that was the introduction to that whole world of chronic pelvic, or I should say, persistent pelvic pain and the involvement with the IPPS. And then after I graduated, he retired and I stayed there, so I took over a big part of his practice with one of his prior partners who was one of my prior attendings, Dr. Amy Benjamin. We were in charge of this very big group of patients that will suffer from persistent pelvic pain conditions, not only Rochester but New York and even out of state. And that led me to meet wonderful people like you and, you know, my current partners.
And after, you know, completing 10 years in Rochester, I thought, you know, it’s a good idea to kind of start looking south to be closer to family. And so now I’m part of the VA with Dr. Georgine Lamvu, who is also very well known in the pelvic pain world. And she’s the current chairperson for the IPPS and Dr. Jessica Feranec, who was trained by her Dr. Mario Castellanos, who is another very well-known pelvic pain specialist and Dr. Chenxiu Yang. So we’re five of us here at the Orlando VA. So we do quite a fair, a lot of work with pain, but it was really to answer your, the short answer is it was luck. And I saw a potential and really making a big impact on patient’s life by pursuing this path.
And that came along with a lot of opportunities to not only study more these problems, but also learn more. Not only from the academic perspective, but from patients, which is a big source of learning material.
07:41 Dr. Ginger Garner: Yeah. Well, we are fortunate to have you in this field, first, I just want to say that. [Thank you.] And second, you know, you mentioned learning to study and learn. And, and that was the flashpoint for me, because as I’ve been in the field for over two decades, and most of us started out in orthopedics, because that’s where we stumbled upon the problem of pelvic pain. You know, it’s hip pain, knee pain, back pain, SI joint pain, and all of a sudden, it’s like, it’s not just that, you know. And so as much as I feel like I learn, I always feel like I don’t know anything. And there’s so much more to learn.
And I’d like to talk a little bit about that today, because so many people, everybody’s got a pelvis. So many people suffer from things that are related to pelvic pain, but they actually don’t know that’s what they may be suffering from. And then that leads them to, as you already know, but maybe you know this resonates with the listener is, you bounce around to so many practitioners. And because of the way our healthcare system is set up, no one ever really puts their finger quite on what is wrong, or you get dismissed or worse, you end up feeling like there’s a popular term out there now called medical gaslighting. And that’s simply the feeling that you know, you have been missed or not listened to. So there are so many people out there and we were talking before I hit record and you mentioned a stat on as many people suffering from persistent pelvic pain as do suffer from asthma and other really common issues.
09:29 Dr. Jorge Carrillo: Yes, correct. So we know from data, we know that for a fact that pelvic pain is as prevalent, if not more, than very common conditions that everyone knows about. And you actually see it on TV so frequently, right? The ads about medications to help treat asthma, for example, or medications to treat migraines and low back pain. And everyone basically knows what it is, you know, to have migraine, what it is to have asthma. But it’s interesting, when I meet with people who are not in health professions, you know, and they ask me, so what do you do? And I’m like, well, I’m a gynecologist, but I specialize in pelvic pain.
They’re like, what?
Yeah, pelvic pain.
So it’s like, you have to like, really dive in and explain what that is. And the very first thought, because I’m a gynecologist is, oh, so you treat endometriosis. Like, well, that’s just one, you know, like, which is, you know, I wish it was just only one, but it’s not only one. You know, so it’s very oversimplified.
You know, and unfortunately because of our system and there’s a lot of factors that contribute to that and, you know, we will, I think we’ll talk more about, you know, the timing that it takes for certain conditions to be diagnosed as well. But they have looked into that and what are the factors that affect that and really a cultural aspect is a very important one.
You know, where always pain when it comes to those who have uterus and vulvas have always been dismissed. And it’s been more like, you know, just deal with it and try to go through it. And how many times I’ve seen patients that they have no idea that they have persistent pelvic pain and that they have a problem. They’re like, Oh, my periods have always been like that. And you’re like, well, they shouldn’t be like that.
11:15 Dr. Ginger Garner: So one important fact for, um, people to realize is they shouldn’t be like that. Because most people that walk through my door will sit down and go and say the exact same thing. Oh, how are your periods? Oh, they’re fine. And then you ask them about how they really are, and they are so far away from fine, but they have been taught to normalize it.
11:38 Dr. Jorge Carrillo: Right.
11:39 Dr. Ginger Garner: And that is where the problem begins. So let’s try to tackle a little bit of that today. I want to start with one of your papers from Journal of The American Medical Association, JAMA, in 2021. So pretty recent.
In it, you define chronic pelvic pain. And I know we’re moving towards a language of, you know, using the word persistent, you know, over chronic pelvic pain. And I think destigmatizing someone’s experience of having that persistent pain is kind of what’s influencing this shift. Which I think is important because just like with mental health issues, you know, and de-stigmatizing chronic pain and particularly pelvic pain is important too. So it is challenging. It is multi-layered. I’m going to take this right out of your abstract. And this is what you said.
“CPP is a challenging condition. It affects approximately 26% of the world’s female population. It accounts for 40% of laparoscopies and 12% of hysterectomies {I went on that} in the US annually, even though the origin of CPP is not gynecologic in 80% of patients.”
Y’all just rewind that and listen to it again, you know, because that is really important. Um, that origin of the pain is not gynecologic in nature in 80% of people. Both patients and clinicians are frustrated. The review, so now y’all are going to have to read the paper, I’ll put the link in the description in the show notes, summarizes the evaluation and management of CPP, including recommendations from consensus guidelines, which is what really facilitates the way in pelvic health, we would reach out and help you if you’re suffering from pelvic pain.
So now that we’ve defined it of CPP in women. I want to mention an article that you did in med central. I don’t remember the date on it, but it’s it’s recent.
13:55 Dr. Jorge Carillo: It’s like a year and a half, two years, something like that.
13:58 Dr. Ginger Garner: Yeah, I loved the case study format that you put it into. And it just describes so many people. The title of it was, “Somatic, Visceral and Neurologic Abdominal Pelvic Pain, the Triple Ripple Effect”. So I’m going to volunteer just a case and let’s talk about what, you know, it should look like because we kind of know what happens with medical gaslighting and with being dismissed and women being told to just normalize that pain.
So here’s a story. We have a who’s a middle-aged female now, so we won’t even be any more specific than that, because I feel like we’re telling a story of an entire population rather than just a single person. But this individual was 16 years old when her period started, which was dysfunctional from day one. You’ll probably already know the answer to what her OBGYN’s treatment was, was birth control. No other questions asked at all that that is most of what I get, you know, coming through the door. So this is pretty typical so far. Those birth control gave this individual chronic UTIs. So already, we have some red flags going up. She wasn’t able to continue with that mode of treatment.
Then there was an onset of infertility for 10 years. in which this person had GI pain, IBS-like symptoms, so irritable bowel syndrome, for those of you guys listening, hip and back pain, which can be kind of vague and moving, right? Lots of pain with breathing that would be transient and kind of random. And dyspareunia, for those of you listening, that is painful intercourse or attempted intercourse. And then some nerve pain that appeared to be somewhere in the area of around L5 to S2. And so that’s been kind of persistent. So let’s talk about what best care would look like if this woman walks into the office.
Dr. Jorge Carrillo: So first of all, so she’s already middle-aged, so it means that she’s had this pain for more than a decade, right, like at least two decades. [Yeah.] The very first thing, and I love the fact that we’re starting with this, the conversation, because as you mentioned, I usually do this when I, as I was telling you before, when I do lectures about the topic, I start with a brief case that is something very similar to what you exposed, right? But then I ask a question to the audience usually, and it is, if after five minutes of interacting this patient, how do you feel as a health professional? Like what kind of emotions you get from that interaction, the first five, 10 minutes that you have someone who comes with this challenging, complicated story of their health and all the obstacles that they’ve gone through and how they are where they are. And then I usually use an app that allows people to type their answers and you know we can see live the answers.
All the replies that I get are negative emotional feelings, right. Negative emotions like you know people say well overwhelmed or worried or sometimes they feel scared about how they can help the patient, right? So, but you see all this negative emotions that come up in those answers and I’ve done it not only in gynecologists but general practitioners, students, residents, nurse practitioners, like different kind of fields and health professions. And it’s always, you know, over, like, the answers are like, well, yes, this is an issue. But then I tell them, look, just imagine for a second, if you feel that way, how do you think the person that is right in front of you feels? Right?
And my intention of doing this is to hopefully kind of make people be aware of the kind of situation that you’re standing in front of, right? When you’re facing someone who has all these challenges, because there’s something very important that it should be the very first thing that we do is when we approach someone who has this problems in general, is to do a trauma-informed care approach, right? And to recognize that we all have some sort of trauma in our lives and to recognize the impact that that trauma has on us. And to acknowledge that there is an actual that has been described association between trauma and persistent pain. It will allow us to be able to set up a better environment when we start that first appointment with the person.
And in the trauma-informed care, there’s a lot of literature about it. Actually, the VA was one of the first places that started with that kind of approach. But it’s in a lot of literature, not in the GN world. As many other things that we see in persistent pain. It’s not in the GYN world, it’s in different worlds.
19:19 Dr. Ginger Garner: That’s so important to make a point of. So if you’re listening and you have brought similar symptoms to your GYN, it’s to acknowledge just straight away that they probably haven’t been trained to particularly not only recognize and assimilate that CPP is more of a, you know, it’s a systemic experience. It’s not just limited to reproductive organs, you know. And that they may have never even considered a trauma-informed approach.
19:55 Dr. Jorge Carrillo: Right. And what most of the people think when they hear the word trauma is sexual or physical trauma. But it’s not only that. I mean, trauma really comes in different forms and shapes. There’s, for example, immigration trauma. There’s such a thing as obstetric trauma. There’s things as the trauma that someone can experience after going to the emergency department several times throughout the year and being dismissed, being told, “oh, you have nothing. You know, we’ve done everything. You’ve got nothing.” That generates trauma.
So it’s more complex than just what we’re used to here, which is sexual and psychological or physical trauma. So it’s important to know that that actually exists. And I think it’s important for the health professional out there to be able to identify it by asking to the patient before anything, before doing an exam, for example, what is their prior response to a physical exam? How do they, you know, how much can they tolerate an exam, right?
And so simple questions is like, how do you do when you get your pap smears? Like, how does it go? Like, do you encounter that it’s difficult? Are there any issues? Is there pain when you go through an exam, right? Being aware that there are methods that you can provide to patients.
In that paper that you mentioned, we have a small table in which we go through specific actions that people can do to, applicable to pelvic pain, that they can do to better kind of create an environment as low as you can in terms of being able to reproduce that trauma that someone has, right? Like such providing a mirror when you’re doing the exam, telling the patient, hey, you’re totally in charge. If you feel that this is uncomfortable, if it hurts, I’ll stop. We don’t have to do it today. We can break it down in steps, explaining why you’re doing certain things.
It’s very important just to start with that, because again, it gives that empowerment back to the patient, which is usually what happens when you go through trauma, traumatic experience, you lose power, you feel like totally the loss of autonomy. And physiologically speaking, and you know this very well, trauma acts within the pain cycle as well, right? You know, being able to reduce that is really also going to help in the sense when it comes to treatment, right, trying to identify those traumatic experiences.
So that’ll be the very first thing, you know, that I would do on someone who walks in with that story is try to inquire a little bit more about their traumatic experiences and try to see strategies that might help that initial encounter, you know, facilitate that initial encounter.
After that, usually what we do and the way I was trained is that when you start asking about symptoms, and this is stepping a little bit away from the gynecological training that we have, because for GYNs it’s very easy to say, oh, you have painful periods, you have heavy periods, okay, let’s stop them, right? That’s a treatment. And, you know, we usually stop there. Right?
And we need to, when we’re facing someone who has persistent pain, we really need to dive in and to back what they teach us in medical school, which is to ask more about the pain, you know, because patients are going to walk in, they’re going to say, it hurts down here. That’s it. So it’s our jobs to ask, well, can you describe a little bit more how you feel their pain? Like what is the quality of the pain? What is the intensity that radiates? if there’s any patterns on your pain, what make things, what might make that pain worse? What might make that pain better? What has worked? What hasn’t worked?
You know, those simple things that we were taught in medical school, but for some reason, when we’re practicing, we’re like, oh, painful periods, okay, stop it. You know, and that’s it.
So we use a form. a questionnaire that, you know, there’s one of the versions, the International Pelvic Pain Society has one, in which we have compiled and put together this document that is a 14-page document that goes through different validated questionnaires that are out there exploring different aspects of the pain. Because one of the biggest things that our job should be as health professionals, when someone with all those symptoms walk in to our office, is to be able to educate them about what is going on with their pain.
And that’s one of the most important things that usually patients look for. You know, it’s like, is this pain something that is going to kill me? You know, is this something that is really bad? You know, what is causing this pain? You know, and there’s research about that, looking at what patients actually are looking for. They look to be heard. They look to be treated as a whole human being. You know, they look to get some answers about their pain, but especially to make sure that the pain is not nothing that is going to kill them, you know. And as you mentioned, what they get, is totally the opposite.
Often they get dismissive reactions, they get downplayed, they get gaslit. So there’s a huge disproportion in terms of what patients are expecting to receive in that visit and what they’re actually getting based on research. So the questionnaire, it’s a good opportunity a lot of times for patients to, as they fill up the questions, to kind of think and be like, realize things. It’s very interesting.
You know, like sometimes I’ve seen patients that come back with a question. I’m like, you know, I’ve always thought that my pain was only with periods, but I’m realizing that there’s more to it that is not just that. And that’s like the aha moment for us to say, you know what? Yes, because very rarely when patients come with persistent pelvic pain, they come in with only one cause of their pain. And there are studies looking at that, like in big pain centers, there are studies that have looked, for example, in Rochester, there was this paper that Dr. Howard published years ago, 500, a cohort of 500 patients. They looked at individual causes of pain and how often they presented alone.
Just to give an example, endometriosis of all that cohort of patients was present alone only in 18% of the patients. Most of the times it was endometriosis and bladder pain syndrome, endometriosis and IBS, endometriosis and myofascial pain syndrome. So it’s usually a whole combination of things. That’s unfortunately the nature of this condition. So we should proactively be looking at that.
And it’s a good way to kind of also explain to patients that, you know, probably a birth control pill is not going to fix the problem. It might fix one of the symptoms. You know, it might help you with the dysmenorrhea, right? But it’s not going to take care of everything, right?
So the same thing goes for: often they will look for surgery, right a hysterectomy. Well, yes, there’s a role for that. There’s a role for surgeries to operate for endometriosis. However, doing that alone, a lot of times doesn’t do the trick. You have to look at as any other kind of persistent pelvic pain looks like, which is in a multimodal, multidisciplinary approach under a whole, the umbrella of a biopsychosocial model. Which I know a lot of terms that people might not grasp very well, but basically that whole biopsychosocial concept that says that persistent pain, it should not be looked only as a focus area of pain generators, because it has different layers.
Pain in the end is an individual experience that is basically learned. And we cannot ignore the psychosocial aspect of it, because it has a big impact on things.
27:40 Dr. Ginger Garner: And so to break that down for those of you listening, Biopsychosocial has been a term that we have like a kickball on the playground, you know, in healthcare. We’ve used it on the playground for such a long time. There are so many studies that validate and support that the biopsychosocial model is, you know, is the best method for treating pain across the lifespan and, you know, for many, many different conditions, not just for what we’re talking about today.
However, when we look at and in the things that I have contributed to in terms of my past books being on integrative medicine, essentially yoga and lifestyle medicine, things like that. When you look at the number of clinicians who are actually practicing this model, it’s not getting translated, you know, into real everyday practice. And that’s, there’s a lot of reasons for that, that we could, you know, spend a whole nother hour talking about. It’s limited time with patients, it’s being rushed, it’s productivity and being pushed to, you know, accomplish a certain, you know, number instead of really being patient-focused and person-focused.
But ultimately, what we mean by biopsychosocial is if someone comes in to see either, you know, one of us, you know, in practice, we’re going to ask them about, you know, their access to even something like green space. Do they feel safe taking a walk in their neighborhood to help manage their, you know, chronic pain, their pelvic persistent pain?
Otherwise, how am I going to, you know, as a PT, how am I actually going to look at prescribing something that might be integrative in nature if they don’t even have the space to get out and do it, or if they’re not sleeping well? If they’re struggling in relationships and maybe they frankly actually don’t feel safe in their relationship at home. Maybe their partner is dismissing their pain. I’m going to ask them about that.
Nutrition contributes to inflammatory conditions, what we eat, not just how we process stress or sleep. So those are some of the, you know, the bio-psychosocial factors that we’re talking about here. We’re also talking about using and appreciating best evidence, which means what the science supports, modalities which are going to help manage pain for the long term. Things like yoga, which have really a lot of evidence backing it now, and all of the pillars of lifestyle medicine have an incredible, really powerful evidence base to support it. So for those of you who are going biopsychosocial, what the heck is that? That’s what we’re talking about in terms of things being multimodal.
And then asking you questions that really not just convey that we care as practitioners, but also convey that we’ve looked outside what would have just traditionally been looked at, which is you have pain in one place, well, where is the problem in that place? When it could be more of a global issue.
30:47 Dr. Jorge Carrillo: Right, right. Totally 100% agree with that. And you know, it also, I think that it opens up the opportunity to talk about goals, right? And of the treatment, right? Because as I said, again, as a gynecologist, someone comes in with dysmenorrhea with painful periods, and then in my head, my goal probably is, well, I need to help her stop her periods, right? Now, is that really what she’s looking for? Is that really what the patient right now is looking for? Right? I’ve seen cases in which yes, patients have a history of painful periods.
But the biggest issue after really digging in and asking, right, they might have nerve pain, you know, they might have muscle pain, they might have…And then suddenly it opens up the door of discussion of look, I’m the one who is supporting the family. My job is this job, I have to sit down six hours, They’re going to fire me if I cannot achieve this goal. Like right now, I don’t care about my pain with intercourse. I’m not even sexually active, I don’t care about it. I don’t care about my periods right now. That’s not the biggest issue right now. I need just a simple acknowledging that there are other things.
But again, the thing is that when you train to treat everything with a hammer, you see every single thing as a nail. And that’s one of the biggest things that we see in every cluster of specialty, right? Someone goes to the urologist, well, they get the whole battery for urology. They don’t find anything, I have no idea what you have. Go and see the GI doctor. They get the whole battery for GI doctors, you know. And the problem is that we’re missing that person who’s going to lead to different specialties, who’s going to lead. But there has to be a communication with the patient who’s suffering from this.
And there has to be an identification of what is called a shared decision model, right? What are the goals? What are the objectives? You know, help the patient to find those goals and objectives, right? Under an approach in which, you know, something that is feasible for that individual, because we all have different contexts. So It’s a very unique thing. Pain is a very unique thing. And that, what I think, is what makes it challenging, right? It’s not appendicitis. You walk in with appendicitis, well, just take out your appendix. You’re fixed, right? No, it’s much more complicated than that, right?
32:12 Dr. Ginger Garner: Yeah. Yeah, it really is. And the last few things you said, I just want to go back and emphasize it a little bit, because I think that’s a common frustration point, where particularly women, too, because they are more likely to be dismissed, in healthcare. As well as I think the LGBTQIA community is more likely to be dismissed as well.
And so what happens is they did go to the urologist, they did go to the gastroenterologist, they did do all that, they went to their PCP, and all of them said exactly what you just said. And that if you have gotten that experience That’s what we’re talking about today to let you know that there’s care that exists that isn’t so siloed. And we just want to be able to point you in the right direction to help you get that care, that it doesn’t have to continue to be that way.
And of course, Jorge, you’ve been doing incredible work, which is a good segue to talk about an upcoming paper that you have that talks about how we can change that, how we can fill some of those gaps, how the training that we received. I mean, when I went to PT school, I got zero in trauma-informed care. Everything I learned about it happened afterwards, over two decades to get that. Let’s talk a little bit about that new paper coming up.
What sneak peeks can you give us about that so that people can feel encouraged that you are one of so many people, thank goodness, that are really working hard to change this so that we can basically stop medical gaslighting from happening with people with pelvic pain.
34:34 Dr. Jorge Carrillo: Thank you so much for that. And I really believe that one of the ways in which we can start changing things is definitely with education. And I’m biased because I love education. I love learning more about how to be effective educating. But to be honest, the way how this last project that we’re working that hopefully will be published, I mean, we submitted for publication, it’s under review after a few edits, so we have good hopes, but we presented our work at this year’s IPPS meeting. And what we found is that I’ve always seen through the course of these years that I’ve been focusing my practice in pelvic pain, that a lot of times people say, oh, it’s lack of education, there’s lack of education. But we don’t go beyond that, right? So after seeing this, I was like, you know, I’m gonna say, we assembled a team that are IPPS members, you know, four of us, five of us, I mean, and we did a literature review of current clinical recommendations, guidelines.
So something similar to what we did with the JAMA paper, right? But we compiled a whole different papers that were kind of similar to the JAMA paper in the past 10 years, five years. And from there, we did what is called a thematic analysis. So we sit down, we read the papers, and we designed different clinical themes that will help and guide, or that are recommended, right, that a health professional should do when they see a patient that suffers from pelvic pain, from the evaluation to the management.
After we built those clinical themes, we went further and we’re like, okay, so we’re going to use these themes as an actual template and analyze and do what is called a SWOT analysis, where you look at strengths, opportunities, weaknesses, and threats of different things. So we looked at the current milestones, which are educational documents that are like the standard for OBGYN residencies and fellowships. So we grabbed those documents.
The milestone is something that you look and you use to assess someone, the progression of someone in their career, right? It’s used to say, you know what, you hit this milestone, you’re good to move on to the second milestone and so forth. So we grabbed those documents and we saw and we analyzed those documents and we’re like, okay, so how much of pelvic pain is being addressed currently at OBGYN residency programs and fellowships? Without significant gaps.
Like we actually are showing that there are huge gaps in terms of what it should be, it should have been educated, right, for the residents and the fellowship levels and what the clinical guidelines are asking people to do. And one big thing that we noticed is that there’s a lack of trauma-informed care, like there’s a lack of a milestone looking at trauma-informed care, which is like for gynecologists, it should be something big, right?
But then we noticed certain things, you know, and then when the paper comes to the level, you’ll be able to read in depth, what is it, but there were things like, you know, for example, the Urogyn, the pelvic floor reconstructive medicine, you know, the Urogyn fellowship, They have very set milestones for bladder pain syndrome and some set milestones for pelvic floor dysfunction, right, but they don’t mention anything about, for example, pudendal neuralgia, you know.
You know, there’s things that could be applicable to other subspecialties, right. You could think of, you know, REIs [Reproductive Endocrinology and Infertility Specialists], for example, they see so many patients with endometriosis, you know, pelvic pain should be something, and we’re not expecting them to manage them, but at least to be able to identify those that have, right?
So things that will make sense, but are not very well plotted in those documents. We analyzed the AGL documents, the FMIGS, like the subspecialty that I did. They have a very robust set of milestones that really tackle pelvic pain. So it really kind of shows you that that field, might be positioning as the field that should be leading the care of those patients, which would make sense, right?
You have people who are trained to do endometriosis surgeries, right? Very complex endometriosis surgeries. So the least thing that you should do as, you know, as a surgeon, because most of the surgeries are done because of pain, is to know how to treat pain. I mean, that will be like the logical thing, right? And still, they’re missing a few things, but at least from every single field, that is the one that is most comprehensive.
But again, it’s alarming that OBGYN residencies, you know, they don’t have that. And hopefully with this paper, we can better shape how people are being educated in this field. I envision utilizing this, which is my next project, hopefully by the end of next year when I’m done with my presidency at the IPPS, I can deliver a curriculum. An educational curriculum for health professionals. That is my ambition, that is my goal, hopefully, that I can develop something like that, that can be applicable to different kinds of health professions. Because again, pelvic pain is something that you don’t need to be a GYN, you know, to help someone that has pelvic pain, right. And we know it like physical therapists, urologists, you know, call anyone, anyone can can can do that job.
40:29 Dr. Ginger Garner: There’s so many professions where there’s that intersectionality. And that I could keep talking, because I wanted to mention your another paper that you did, that was just published, actually, wasn’t it? On moving beyond surgical classification systems for endo? [Yes]. Oh, goodness, we might have to come back and talk about that later time. But endometriosis is one of those things that, and actually, today is the first, my first podcast back after my endosurgery. And I’ve been pretty public about that and vocal on YouTube and Instagram and whatnot, just to share my journey to let other women know that, well, here’s how I got through it and I’m getting through it actually. But also to raise awareness, you know, about the history and the struggle of actually getting diagnosed and, you know, getting the correct treatment and that kind of thing.
But one of the things I wanted to mention about that was in kind of getting back, if I turn my I’m just going to do this. I’ve got a heating pad for everyone who wants to know how I’m doing. I’m doing great, actually. But I’ve got a little heat here and it makes me feel good. Is that that experience when you mentioned so many providers being able to recognize and then properly refer Endometriosis is one of those things that’s very kind of systemic in nature that can be aggravated by an inflammatory response because you’re allergic to a particular, you know, food or you didn’t sleep well or whatever that may be.
And so if you’re listening, you know, I just want you to know that if you’re having symptoms that seem to be widespread and that no particular practitioner has said, maybe you should go, you know, and be referred to this practitioner, maybe it’s to pelvic health or otherwise, then just know that you’re not crazy, you know, it’s not all in your head. Symptoms with pelvic pain conditions can feel very widespread, even things like migraines, and orofacial tension due to its fascial connection to the respiratory diaphragm, which is connected to the pelvic floor.
So just be encouraged by that, that we’re, you know, we’re kind of acknowledging that, you know, this, the problems and the gaps in education exist, but there’s so much that can be done. And so much, and a lot of, you know, compassionate people out there ready to help you.
43:02 Dr. Jorge Carrillo: Yeah, one thing that you mentioned that is, I think is very important is to really acknowledge that what you as a patient and you know those who suffer from persistent pelvic pain, and us as health professionals who are trying to help you, right. We’re facing visceral pain. Now getting into the physiological aspect, it’s a totally different monster than nociceptive pain, right?
Everyone is used to the concept of pain as being the typical example that they give us of, you know, stepping on the nail, right? And that gives you pain, so then you just remove the nail, or you won’t step on the nail again, and that’s it, that you get rid of the pain. Visceral pain has a different way in which it behaves. And by those, you know, for those who are not very familiar with this topic. Visceral, a viscera is the uterus, or the fallopian tubes, the bladder, bowel, those are viscera.
And there are two particular phenomenon that occur at the level of visceral pain that really makes it a challenging problem. And one is called visceral somatic convergence, which basically explains the pattern of referred pain, where the pain could be starting at the uterus, and this referred to a somatic area like the abdominal wall, at the skin area, or at the muscle. So patients might have, even though their primary origin of the pain is coming from the uterus, or the fallopian tubes, or the ovaries, they might experience pain not only there, but also in the abdominal wall, or the low back, or the gluteal area, or, you know, the muscles that are in the perineum. And that’s called visceral somatic.
But on top of that, there’s another problem that is visceral-visceral. Visceral-visceral convergence, where an organ that is a visceral organ that is emitting pain goes to the spine, and that stimulates a nerve that goes to a different visceral organ that has nothing to do with the problem, but just gets involved, which is often why we see patients that suffer from, for example, from endometriosis, that once you start treating their periods, their bowel symptoms get better, or vice versa.
You know, someone has IBS, you start, and also painful periods, you start treating the bowel symptoms, and then suddenly their periods get better. So that makes it very challenging at every level in order to try to understand. And if on top of that, you add this new concept that you’re talking about, which is the concept of chronic overlapping pain conditions. A concept that was raised in 2016. 2017 was I think the first time that was raised, where you have a multiple set of conditions that often share mechanisms that are very similar, are seen more frequently in women than in male, and it affects anyone.
And the more conditions that are related to this big problem a person has, the higher the risk they have to develop more. What are those conditions? Endometriosis, bladder pain syndrome, IBS, chronic migraines, TMJ problems, low back pain, vulvodynia. And how many times we, fibromyalgia, how many times we see patients that walk in with endometriosis and many other things as well. So that’s why we can’t stop and just, oh, you have painful periods.
One issue, for example, if you have painful periods and you have fibroids, often that will be the end of it. Everyone will be like, okay, it’s your fibroids. That’s it. You have nothing else. People won’t even think, oh, it might be endometriosis as well, because that also can happen. So again, I do think that it’s a matter of educating both sides, health professionals and patients.
You know, one thing that I sent you the link of that, you know, feel free to share it is that we designed a website, with my partners here, that are free for patients. That is called pelvicpaineducation.com. We have, we have designed short clips, five minute educational clips for free, about different aspects of pelvic pain. From the very basics of what is the difference between acute and persistent pain, all the way down to more specific things related to different conditions, such as pudendal neuralgia, myofascial pain, bladder pain, all those. We have like 14, 15 videos there with material, educational material. We compile links from different websites. When we launched this website, we were so excited because after the first month, we already had thousands of viewers from different parts of the world. So it’s been a great resource, I think, for patients. And, you know, we’re constantly kind of working on updating it. But I think it’s a good way to educate, you know, people who have these kind of problems.
47:43 Dr. Ginger Garner: And that is the wonderful thing. Although there can be so many negatives to social media and the internet, but that is one of the amazing things that the age of the internet and digital media has brought us is the ability to do that. So we’re absolutely going to be sharing that website and your other resources in our show notes. And I have one more question for you.
48:06 Dr. Jorge Carillo: Yes.
48:07 Dr. Ginger Garner: It’s about music.
48:08 Dr. Jorge Carrillo: Oh, OK. Yep.
48:11 Dr. Ginger Garner: Um, it’s like a rapid fire question. Cause I know both of us are musicians. I spent around 15 years, you know, kind of moonlighting and doing jazz gigs and, and, uh, and other things like that. But I also know that you play, I don’t know if you sing too.
48:25 Dr. Jorge Carrillo: I don’t sing. That’s why I don’t sing. I do not sing.
48:28 Dr. Ginger Garner: When I see you in person, you can play, I’ll sing.
48:30 Dr. Jorge Carrillo: That would be awesome. Yes. You have a beautiful voice. Yes.
48:35 Dr. Ginger Garner: Thank you. All right. So what is the latest thing you’re working on playing, um, you know, these days?
48:40 Dr. Jorge Carrillo: Yeah, so that has become, like, I stopped playing. I learned how to play when I was 12, 13, and there was a gap, like a 10-year almost gap, when I was in residency fellowship where I stopped playing. Honestly, I don’t know why. I have no idea why.
48:58 Dr. Ginger Garner: I don’t either. Music is medicine, right?
49:01 Dr. Jorge Carrillo: I know, I know, I know. And, you know, it kind of hit me like three, four years ago. And I went through a moment of my life where I was like, Why am I doing this to myself if I like it? I was doing other things that I like, but, you know, I, I was like, you know, I always played acoustic, but since I was a kid, I wanted an electric and, you know, it wasn’t until like three years ago that I’m like, I’m going to do this and it evolved.
And, you know, now every weekend is my time. And, you know, I have a set list of songs that I kind of like, Oh, I’m going to learn this one. And now everything is in YouTube. So, just go in and you have this awesome musicians who have already broken down the songs and just takes like 20, 30 minutes to learn them.
49:43 Dr. Ginger Garner: Yeah.
49:44 Dr. Jorge Carrillo: Because before, when I was in Colombia playing with acoustic, I was hitting stop, play, rewind, stop, play, rewind, and that’s everything by ear. Now it’s so easy. So right now I’m working on My Sharona.
49:57 Dr. Ginger Garner: Okay. Yeah.
49:59 Dr. Jorge Carrillo: So every week I pick, like, one or two songs and I start, like, you know, it’s my therapy, as you say. I start first, like, listening to the song several times. Kind of paying attention to the guitar, getting an idea of the details, the riffs, the rhythm, and all that. And then I start looking at the classes that are there on YouTube and kind of start learning. And then when the weekend comes, I sit down and I already have in my mind a method to go through, which are like my two, three hours of getaway, my me time.
50:31 Dr. Ginger Garner: Totally. And what it does for your brain, not to mention your soul, it’s just absolutely amazing.
50:37 Dr. Jorge Carrillo: Oh, it’s like, you know, when I sometimes it happened to me that I start like, you know, after my kids are asleep, like at 9/10. And then when I realized it’s 3am, and I’m like, Whoa, I have to take my son to a soccer game in four hours. Yeah, you get into the zone. And it’s really, really fun and really nice and good therapy, for sure.
52:01 Dr. Ginger Garner: It absolutely is. So, one of the things I just have to tell listeners too is that, you know, when I’m doing my work, because we’re obviously both so passionate about pelvic health, is I’m fixing to, that’s my southern term, I’m fixing to, getting ready to start my pelvic PT for obviously the surgery. And one of the things I’ll do is to sing. Is to get back into because my voice is, if you look at my earlier video in the hospital from this surgery, and my voice is terrible. I can barely speak, not to mention your, you know, throat is sore and all that stuff. But through imaging, you can see a clear connection between the voice and the pelvic floor when I’m, you know, working in the clinic. So there’s all these intersections in the ways that music is so incredible, but it also is a pretty powerful thing for pelvic rehab too. Plug on music.
52:03 Dr. Jorge Carrillo: It is, it is. And I often use, you know, I am a true believer of the explain pain theory, you know, for patients. And I use often the analogy of, you know, for sensitization, the analogy of the amplifier and the guitar and all. And actually, I’m working on the video that is going to come up explaining in like one and a half, two minutes about that, but actually showing, showing how it is with a guitar and stuff. So I mean, anytime I can combine like those right now, those are like the like, cognitively speaking, because, of course, you know, I have my family, my kids and my wife and all that. But cognitively speaking, I have like right now quite a few things that I’m passionate about. One is education. One is pelvic pain and now music. Well, my guitar. Right. So if i can combine those three oh, I’m in heaven.
52:55 Dr. Ginger Garner: Yeah, exactly nirvana. Yeah right exactly. I feel the same way. Thank you so much, Jorge, for being here. For taking this time out of your really crazy schedule. Keep doing amazing things in the world, and I hope to see you. I wasn’t able to be at an IPPS meeting. I was actually in surgery at that time, so I hope to see you in the future at a next meeting, and just keep being awesome. Thank you.
53:23 Dr. Jorge Carrillo: Well, no, thank you so much for the invitation. This particular episode, well, I’m going to say I’m a huge fan of your work. You are amazing. And, you know, I’m really glad that we have people like you out there that we can collaborate, you know, and thank you so much for all the work you do. Thank you for having me today, especially this episode. Congratulations. That is your comeback. I’m so happy to see you that you’re doing this great.
53:46 Dr. Ginger Garner: It’s very serendipitous that you were here for this one. Yeah. Yeah.
53:59 Dr. Jorge Carrillo: So thank you again. And next year, Cartagena. IPPS is going to be in Cartagena. So. It’s going to be very special because this is the World Congress of Pain, so it’s IPPS, Convergence, and ISP. So it’s going to be a big one, an important one. Needless to say, it’s my presidential year, so I’m very excited about it.
54:10 Dr. Ginger Garner: Yes, it will be. All right. All right. That’s one for the books. Thank you again.
54:17 Dr. Jorge Carrillo: No, thank you.
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