The Education of Pain Physicians

Transcription

1 Pain Medicine 2014; 2015; *: 16: ** ** Wiley Periodicals, Inc. The Education of Pain Physicians Dr. Loeser is Professor Emeritus of Neurological Surgery, and Anesthesia and Pain Medicine at the University of Washington. The author reports no conflicts of interest. It has been my good fortune to have played a variety of roles both in medical education and in the evolution of the pain movement; I feel qualified to talk about how we should educate physicians who wish to focus their careers on chronic pain management. The plans for education and certification in chronic pain medicine that have been proposed and often implemented by various professional organizations do not adequately address the most pressing issues. I am acutely discomforted by the increasing prices chronic pain medicine and our patients have paid to be included in the domain of anesthesiology. Radical restructuring of the education and training of all physicians for the management of chronic pain patients is required if we are to effectively alleviate the burden of chronic pain and its accompanying excessive health care costs. I urge that chronic pain medicine should be considered an aspect of primary care, with specialist consultants available when needed, roughly analogous to subspecialties in internal medicine. The recent Institute of Medicine report on pain makes it abundantly clear that chronic pain is a prevalent and expensive problem in our country, to say nothing of the human suffering that it causes [1]. Addressing the education of pain medicine physicians is not only an academic debate; it is an issue for the practicing community and the public as well. Although we live in the era of evidencebased medicine, there are few controlled trials on how to educate pain providers, nor are there likely to be many in the future. Asking those who are involved in interdisciplinary struggles for turf is not the optimal source of information on these issues. All that one can do is look carefully at the past, assess what is happening now, and attempt to design systems that will improve things in the future. I do not profess to have a crystal ball, but I do have a retrospectroscope that looks back to the beginning of pain medicine. Overview The numbers of patients suffering from chronic pain mandates that basic chronic pain medicine be undertaken by primary care practitioners [2]. A small cadre of specialists cannot possibly shoulder this burden. As our population ages and modern health care allows many who would have died in earlier times of significant illness or injury to survive into older ages, there will be increasing needs for the management of chronic pain patients. It is vitally important that primary care practitioners be trained to take on the basic management of those who suffer from chronic pain. Pain must become an integral part of primary care education both in medical schools and residencies, for pain patients are a large fraction of those seeking care from primary health care providers, and they are known to be very time-consuming and emotionally draining for these practitioners [3,4]. Just as a patient with a fever is not automatically sent to an infectious disease specialist, a patient with chronic pain should receive initial diagnosis and basic care from his or her primary care physician prior to referral to a specialist. What is particularly lacking in most clinical residency programs is the recognition that chronic pain has not only a potential tissue-damage component but also a high likelihood that changes in the nervous system as well as affective and environmental factors are likely to be playing a significant role in the patient s complaints and pain behaviors. It is the failure to listen to the patient s narrative and assess such factors, coupled with ignorance of ways of ameliorating painrelated problems that deprives primary care practitioners of the ability to deal successfully with those who suffer from chronic pain. Not all chronic pain sufferers can be offered cure ; for most, symptom reduction, care, and empathy are reasonable goals. There is also abundant evidence that primary care practitioners are poorly educated about the benefits and risks of long-term, and often escalating, opioid usage. This is another topic that urgently needs to be a mandatory part of the education of every physician [5]. Although we do not yet possess evidence-based guidelines on how to use opioids, the wanton dissemination of opioid prescriptions in the past 20 years has clearly led to personal and community disasters that must be addressed without abrogating the moral obligation to provide care in the attempt to alleviate pain and suffering in all patients. Prescription opioid-related deaths now exceed the carnage caused by motor vehicle accidents [6,7]. The fact that John Bonica was an anesthesiologist and believed that anesthesiologic procedures were the cornerstone of pain diagnosis and management should not forever lock pain medicine into being a branch of anesthesiology [8]. He grew up in the pre-imaging era when much less was known about the anatomy, physiology, and psychology of pain. No other specialty had shown any interest in dealing with pain patients, and Bonica labored to fill a void. His personal interest in the subject matter, 2251

2 Loeser coupled with his being the chairperson of a major department and his leadership in both national and international anesthesiology, made it possible for anesthesiology to become a dominant player in this aspect of health care. He was the person who first put pain medicine on the health care map, and I do not wish to detract in any way from his great accomplishments in launching our specialty. There were no guideposts created by medical specialties about pain management and no concepts of multidisciplinary pain management when he started his campaign to create a new discipline of pain medicine. He did forcefully teach all of his trainees that a thorough patient evaluation by chart review, study of X-ray images, and complete history and physical examination must precede any nerve block. This message has often been lost in the headlong rush to perform a billable intervention. We have moved forward since the post-world War II era. There is nothing unique in an anesthesia residency or in the characteristics of applicants for anesthesia training programs that selects favorably for the ability to manage chronic pain patients. Indeed, the great majority of anesthesiologists do not wish to practice chronic pain management. There has always been a small number of anesthesiologists who do desire contact with chronic pain patients; nothing should prevent them from entering into the diagnosis and treatment of chronic pain patients, but not solely on the basis of having completed an anesthesia residency. It is now generally recognized that acute pain and chronic pain have different substrates and treatment needs; anesthesiologists have special talents and skills for acute, but not chronic, pain management. The management of acute procedural pain is a core expertise of anesthesiology and belongs within that specialty. Acute pain management within the context of ambulatory medicine however remains in the responsibility of primary care medicine and the preparation of primary care providers to provide competent and comprehensive care needs enhancement. Primary care practitioners will have to deal with much acute pain, but outside of the hospital, utilizing strategies that are different from those used in the recovery room and emergency room. Acute pain usually does not require the multidisciplinary approach that is essential for successful chronic pain management. It is appropriate, therefore, that acute perioperative pain management specialists be drawn exclusively from anesthesiologists who have completed an appropriate fellowship in acute pain management. In contrast, anesthesiologists should no longer be the cornerstone for chronic pain management; their reliance upon invasive procedures has often been counterproductive and very costly. Although it is possible to include training in the management of chronic pain patients within the confines of an anesthesiology residency, this has rarely been accomplished in the past, and I see little chance of this becoming an integral part of such a training program. In addition, important aspects of chronic pain management such as psychology and rehabilitation are not to be found in most anesthesiology programs. Finally, there are other reasons to remove chronic pain management from the anesthesiology realm, and these are both financial and political. In most Departments of Anesthesiology, pain management is a secondary activity, not considered as essential to the discipline as providing operating room activities. The remuneration of professional services is much better in the operating room than in the chronic pain management clinic. Hospitals now fund a major portion of anesthesiologists salaries; the remuneration for operating room activities and procedures far exceeds that for the management of chronic pain patients. When money is tight in the Anesthesiology Department or the hospital, the first thing that goes is chronic pain management; chairpersons often feel that this is not the primary mission of the department. Chronic pain management is seen as a burden, and to my knowledge, there are no chairpersons of a major anesthesiology department who have made their careers via pain management. There are some indications for specialist care in acute, chronic, and cancer pain management, such as neurosurgery for pain, anesthetic procedures for pain diagnosis or treatment, psychological/psychiatric therapies for pain patients, physical medicine for musculoskeletal pains and pain rehabilitation, and neurology for neuropathic pains. The knowledge and skills required in these areas are beyond the competencies of most primary care practitioners. We will, therefore, need to have some physicians who have advanced training as chronic pain management specialists. The specialist s entry for this aspect of pain medicine should come via the completion of a relevant clinical specialty residency and then, a fellowship to learn more about pain patients than was conveyed in that specialty residency. However, none of these pain superspecialists should ever be the entry point for a patient into pain treatment. They should be available to the pain generalist when specialty care is appropriate. It is obvious that unless we change the way physicians are remunerated, there will be few generalists and far too many specialists, as procedures generate so much more money per unit time. We have seen this in recent years when pain fellowships have been offered to non-anesthesiologists. A significant number of physiatrists, neurologists, and other cognitively based specialists have obtained pain fellowships and devoted their careers to performing injection, stimulation, and percutaneous ablation procedures that generate greater revenue than usual practice in their parent specialty. This has occurred in spite of sparse evidence for long-term benefits of such interventions for most patients. Such practitioners often turn their backs on the wisdom of their primary specialty and become devotees of procedural medicine. As a surgeon, I can assure the reader that most surgical procedures are easier to perform than managing a chronic pain patient for weeks, months, or years. The disproportionate reimbursement for procedures vs cognitive activities has had a pernicious effect on chronic pain medicine. We have seen the flourishing of block shops that offer everyone who enters the clinic some type of needle-based procedure without any diagnostic assessment. Bonica would be appalled by this. Only short-term results are reported, and the placebo effect seems unknown to such practitioners. Additionally, there are now pill shops that wantonly prescribe opioids 226

3 in high doses on the basis of patient request. Similarly, imaging studies showing nonspecific degenerative changes may be utilized to justify treatment without regard to the patient s symptoms. Only the patient has pain; imaging studies reveal structural changes but not symptoms. Successful chronic pain management requires attention to the patient s narrative and caring for the patient. Educating Medical Students Undergraduate medical teaching is woefully deficient in pain-related content on both the basic science and clinical levels. For example, neuroscience courses usually fail to discuss the plasticity that we know occurs in the nervous system and almost totally ignore the roles that anxiety, fear, and the social environment play in modulating the experience of pain. The distinction between pain and suffering is not emphasized, and pain behaviors go unmentioned, despite the fact that it is only the patient s pain behaviors that we observe and treat. Now, curricular change is often difficult to accomplish, as the medical school curriculum has been the last vestige of the feudal system in the post-modern world. Several reviews have recently been published that document the sorry state of pain education in both the United States and Canada [9,10]. Those of us interested in pain management need to play a leadership role in effecting changes in both basic science courses and in the introductory clinical clerkships [11,12]. Every specialty area has its share of chronic pain patients, and these should be addressed in all medical student clerkships. This will require faculty education to eliminate the many myths that are perpetuated by unknowing faculty members. Curricular change will not be easy to accomplish, but it is essential if we are to improve patient care. No one should graduate from medical school without a basic understanding of the principles of both acute and chronic pain management [13]. In today s environment in the United States, some knowledge about the long-term effects, benefits, and risks of opioids is also essential. Chronic pain is not a sign of either morphine or lidocaine deficiency. The current dependence of far-toomany patients and practitioners on a quick-fix approach is not appropriate in the treatment of chronic pain patients. In addition to improving education in our schools, the inclusion of questions about chronic pain diagnosis and management on the various standard examinations will spur health science faculties to include these areas in their curricula. Passing board examinations is one of the key goals of medical school and postgraduate educational processes. The Liaison Committee on Medical Education needs to take a strong stand on the inclusion of pain education throughout the medical school curriculum. How our graduates actually practice and utilize what they have been taught is generally not known; however, deficiencies in the care of chronic pain patients are painfully obvious. Training Primary Care Physicians Residencies in family medicine, primary internal medicine, obstetrics and gynecology, general surgery, pediatrics, Commentary and psychiatry (the required clinical clerkships in most American medical schools) must include relevant chronic pain medicine topics in their curricula and should provide supervised access to chronic pain patients in their specialty during residency training. In each of these disciplines, chronic pain patients abound and should have treatment initiated prior to being referred to chronic pain management specialists. This will require the assistance of the Liaison Committee on Graduate Medical Education and the various Residency Review Committees to insure that pain-relevant material is presented during training and tested in certifying examinations. Training Chronic Pain Management Specialists We do not need a residency program devoted to pain management; a 1- or 2-year post-residency fellowship should provide what is needed to manage chronic pain patients. Exactly what procedure would you have a pain specialist who had a 3-month rotation on neurosurgery, orthopedics, psychiatry, etc., perform on your spouse or yourself? What procedures would a specialty residency allow a very junior trainee to perform? Observation alone is not a good way to learn how to perform an intervention. I would want a fully trained, Board-certified neurosurgeon to perform my operation. This is why I believe that we should not have a pain medicine residency that rotates a trainee through all of the relevant specialties for a brief period of training before sending him/her out to treat patients. Instead, I would prefer to be treated by a person fully trained in a patient-care specialty who then has a1or 2-year fellowship in pain medicine to broaden his/her exposure to the issues presented by chronic pain patients. Such a doctor could then apply his/her specialty knowledge plus the fellowship training in pain medicine to appropriately treat chronic pain patients. Interventionalists who utilize needles to inject, stimulate, freeze, or burn to treat chronic pain patients should not be drawn from nonprocedural specialties. Interventionalists should never be the entry point into the management of chronic pain patients but should be a resource for the pain generalist when deemed appropriate. If the knowledge base of primary care practitioners is expanded so as to make it possible for them to deal successfully with most chronic pain patients, the need for chronic pain specialists will be reduced. The chronic pain specialist should be available to consult on problem cases, manage problem cases, and, when appropriate, advise referral to a super-specialist who can perform appropriate interventions in the small number of patients for whom they are indicated. Chronic pain management specialists can come from any clinical discipline and should not be restricted to graduates of anesthesiology residencies. Adequate numbers of chronic pain training programs will be needed to generate enough specialists to care for chronic pain patients who cannot be managed by their primary care physician. Chronic pain fellowships should be run by a consortium and not owned by any existing specialty. There should be 2273

4 Loeser a Board of Chronic Pain Medicine that oversees fellowship training and certifying examinations. The completion of a clinical residency should be a prerequisite for entry into fellowship training. It is not possible to manage the pain that may be due to an organ pathology (including the brain) without a full understanding of the diseases that afflict that organ, and this is why I argue for the completion of a clinical residency before embarking upon a pain fellowship. If and when chronic pain becomes an American Board of Medical Specialties-recognized specialty, then the specialty should administer and monitor the training fellowships and certifying examinations. There is good reason to offer both 1 and 2-year fellowships to provide both practitioners and academics for the future. The second year of fellowship can be utilized to perfect skills in a specific area of interest or to engage in research and teaching activities. However, for clinical purposes, only 1 year should be required. Chronic pain fellowships should not be under the aegis of anesthesiology, for this biases both who applies for a fellowship and the curricular content. For chronic pain management training, a familiarity with the indications for, and results of, and techniques of performing injection therapies will be useful, but these should not be the major components of a fellowship program. Whereas some simple blocks may be appropriate for the primary chronic pain specialist, many others require much more extensive training and should be restricted to interventional specialists. I believe that optimal management of chronic pain patients should be based upon a three-tier system. The first line of treatment must come from primary care practitioners whose education has made them competent to deal with routine acute pain as well as most chronic pain patients. For patients who are too complex or difficult for primary care management, we need chronic pain specialists who have entered this field after completing a clinical residency and a fellowship in chronic pain medicine. Finally, for that small group of patients who need a specialized procedure, we need interventionalists who have the appropriate training in an interventional specialty and have completed a pain fellowship. Such providers are at the end of the treatment hierarchy, not the beginning. The leaders of both pain medicine and primary care need to step back from the present situation, assess what the needs of American society really are for chronic pain medicine, and design a rational system to educate and train chronic pain-competent physicians to meet that need. We should not exist primarily because we can earn a good living doing what pleases us. There are higher callings upon physicians, and they are part of the heritage of our profession. It is time for changes in the education of physicians and the provision of care for chronic pain patients. Acknowledgments I thank Steven Butler, MD for his helpful comments on an earlier version of this manuscript. Funding/Support: None. JOHN D. LOESER, MD Professor, Emeritus Departments of Neurological Surgery and Anesthesia and Pain Medicine University of Washington Seattle, Washington, USA References 1 Institute of Medicine of the National Academies. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington (DC): National Academies Press; Breuer B, Cruciani R, Portenoy RK. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: A national survey. South Med J 2010;103(8): Dobscha SK, Corson K, Flores JA, Tansill EC, Gerrity MS. Veterans affairs primary care clinicians attitudes toward chronic pain and correlates of opioid prescribing rates. Pain Med 2008;9(5): Glajchen M. Chronic pain: Treatment barriers and strategies for clinical practice. J Am Board Fam Pract 2001;14(3): Bohnert AS, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13): Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med 2010;363(21): Paulozzi LJ, Weisler RH, Patkar AA. A national epidemic of unintentional prescription opioid overdose deaths: How physicians can help control it. J Clin Psychiatry 2011;72(5): Bonica JJ. The role of the anaesthetist in the management of intractable pain. Proc R Soc Med 1954;47(12): Mezei L, Murinson BB. Pain education in North American medical schools. J Pain 2011;12(12): Watt-Watson J, McGillion M, Hunter J, et al. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14(6): Murinson BB, Nenortas E, Mayer RS, et al. A new program in pain medicine for medical students: Integrating core curriculum knowledge with emotional and reflective development. Pain Med 2011;12(2): Watt-Watson J, Hunter J, Pennefather P, et al. An integrated undergraduate pain curriculum, based on IASP curricula, for six health science faculties. Pain 2004;110(1 2):

5 13 Upp J, Kent M, Tighe PJ. The evolution and practice of acute pain medicine. Pain Med 2013;14(1): Appendix I have been heavily involved in pain treatment, research, and education since 1969, when I joined the neurosurgery faculty of the University of Washington. I was one of John Bonica s foot soldiers in the early days and played a small role in organizing the famous 1973 Issaquah pain meeting Commentary that led to International Association for the Study of Pain (IASP) and then American Pain Society (APS). I was a founding member of IASP, APS, and American Academy of Pain Medicine (AAPM) and belong to many other painrelated organizations. I was the initial chairperson of the Education Committees of both APS and IASP. I have since 1969 been a member of the Pain Center at the University of Washington and was its Director from 1983 to I was the Assistant Dean for Curriculum at the University of Washington, School of Medicine from 1977 to