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American Pain Society
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Glenview, IL 60025
Robert P. Yezierski, PhD, Department Editor
Jane Martinsons, Staff Writer
Now in its eighth year, this course started in 2002 initially through my efforts and those of two other neurologists and pain specialists, Brad Galer, MD, who at that time had left the University of Washington and was working for Endo Pharmaceuticals, and Miroslav Backonja, MD, of the University of Wisconsin, who is now an APS director-at-large.
APS Fundamentals of Pain Management: A Primer for Residents and FellowsAPS is pleased to again sponsor its resident’s course, “Fundamentals of Pain Management: A Primer for Residents and Fellows.” This intensive 2-day course for third- and fourth-year residents and fellows in anesthesiology, neurology, family practice, emergency medicine, and physical and rehabilitation medicine is planned by a program steering committee comprising pain management experts from across the United States. As in past years, a limited number of scholarships for nonmedicine trainees will be offered. Application InformationThe 2009 program will be held Tuesday, May 5, and Wednesday, May 6, 2009, prior to the APS Annual Scientific Meeting. Residents and fellows wishing to apply for a scholarship to attend the course should complete and submit the application no later than January 12, 2009. Visit www.ampainsoc.org/meeting/ annual_09/residents.htm for application information. |
Each of us, as well as another very close colleague and friend Marco Pappaggallo, MD, were very concerned with the fact that nearly all neurologists appeared to be so underprepared and undertrained to assess and treat the various painful conditions that they routinely encounter. We four were among a small group of neurologists in the country who were interested in seeing patients who had chronic noncancer pain. We regularly spoke with each other about how we could improve pain management education for residents. Endo Pharmaceuticals, which at that time was developing Lidoderm for postherpetic neuralgia, was interested in helping us to provide true solid noncommercially unbiased pain education for neurology as well as other residents, so we started thinking about developing a course for these trainees.
We were wondering why neurology attending physicians in the real world didn’t have an interest in taking care of people in pain when it’s the most common reason why patients visit physicians. When Dr. Backonja and I were residents, we received “scholarships” to go to a pharmaceutical company-sponsored program that targeted such areas as teaching neurology residents about epilepsy. It was an unbiased, solid education. Although I am not an epileptologist, I feel confident about the initial evaluation of a patient with epilepsy if faced with such a clinical situation and am able to comfortably refer patients for further specialty care as needed. The four of us reasoned that we could develop a similar pain management course that, even if the participating resident did not pursue a career in pain medicine, nevertheless that resident would feel comfortable in the assessment and initial treatment of a person with acute or chronic pain and be able to make appropriate and timely referrals as needed. Given how prevalent acute and chronic pain are and how prevalent the underassessment and undertreatment of acute and chronic pain are, we felt this was an extremely needed education priority for residents.
We wanted to provide neurology residents the tools to feel comfortable caring for people in pain when they encountered them in clinical practice. After further discussions, it became clear that this type of course should also be offered to anesthesia and physical medicine and rehabilitation residents. Ultimately, we elected to ask APS, the largest and most experienced pain organization in the country and the national branch of the International Association for the Study of Pain (IASP), to allow us to offer this course in association with its annual scientific meeting. Endo Pharmaceuticals graciously agreed to support this program, which initially included approximately 30 residents chosen from anesthesia, physical medicine, and neurology—subspecialties that fit well with the American Board of Medical Societies (ABMS) subspecialty certification in pain management. The point was to foster multidisciplinary education of residents of different backgrounds by some of the world’s most respected pain specialists—from basic scientists and cancer pain specialists to interventionalists—and to encourage multidisciplinary discussion among the residents.
Early participants included Ajay Wasan, MD MSc, now a Harvard Medical School associate professor and leading pain researcher, and Leanne Yanni, MD, who was one of the first primary care pain specialists to attend and who is an assistant professor of medicine at the Medical College of Virginia. I recently spoke to Dr. Charles Wang, an assistant professor of anesthesiology at Mount Sinai University Medical School who thanked me for this course and said that when he attended it as a resident, he had no idea that he was going to go into pain management, but afterwards he knew that was what he wanted to do. Both Drs. Yanni and Wang have participated as faculty members of this course, and this year Dr. Yanni is a member of its organizing committee. There truly are many stories like that. It has been very rewarding!
We have a course committee with longtime members as well as new members; I’m just thrilled and privileged to still be the chairperson of this whole process—it really has been a fantastic experience. The committee reviews what’s new in pain management and, more specifically, we review course evaluations from the prior year. We always have a very, very, very balanced approach to pain management—from basic science to basic pharmacological treatments, interventional treatments, complementary treatments, and rehabilitative treatments to cancer-related pain and pain related to substance abuse and so on. Increasingly, we leave time for patient presentation and smaller, participatory group discussions to help participants learn in an interactive manner.
Several basic researchers have been involved in the course over the years, and we receive great feedback from participants asking to learn more about basic mechanisms of acute and chronic pain.
Gary Bennett, PhD, of McGill University, and Frank Rice, PhD, of Albany Medical College and other nationally and internationally known physicians and academicians have participated at various levels during this 2-day course. We hold an informal dinner that includes a keynote address by the current APS president and where faculty members sit at tables to foster discussion with program participants. After the course, communication is fostered by circulating an e-mail list of participants and faculty. Both the faculty and course participants consistently report how much they value the ability to interact and speak with each other during this course.
In 2009 we’re going to have much smaller (10- to 15-participant) breakout sessions to pair basic scientists and clinical scientists with participants to focus on smaller group learning approaches. This way, we’ll be able to discuss case presentations with particular emphasis on translating the known basic mechanisms of the particular pain disorder into a mechanism and evidence-based treatment approach. Because each group will be comprised not only of basic and clinical scientists but also participants from various backgrounds, we will truly be teaching an integrative and multidisciplinary approach to pain assessment and treatment. Our hope, of course, is that program participants would then use this approach when they return to their institutions and throughout their career.
We’ve created an environment where people with limited prior understanding or training can interact and learn from internationally renowned scientists. That’s key. I’m sure that some of the greatest discoveries in the world have been made by people outside the field who ask, “What if?” Often fresh insight paves the way to major positive changes in the way a scientific challenge is viewed and solution approached.
Existing without a comprehensive multidisciplinary approach is the biggest threat to pain management. Overemphasis on the use of injections, other procedures, or medications as sole treatments for acute and especially chronic pain has repeatedly been demonstrated not to be the optimal manner in which to treat patients in need of pain management. Comprehensive and multimodal approaches for pain reduction must be utilized to maximize outcomes, yet this is not practiced often enough. This may be one of the biggest challenges to the field. For example, some Web advertisements for pain practices tout, “We don’t prescribe medicine or offer any other treatment other than injections.” Yet evidence-based reviews show that the value of certain interventions, such as the commonly performed epidural steroid injections for radicular low back pain on average provides not only limited pain relief but also only for a limited amount of time. And considering how many people have been unsuccessfully treated with this procedure, one has to wonder how can a pain specialist not provide more comprehensive care—it just doesn’t make medical sense.
More funding needs to be available from both research and clinical perspectives to improve physicians’ ability to make precise diagnoses regarding the pain etiology and pathophysiology, so that we can increasingly target clinical care toward that mechanism or those mechanisms.
I direct a comprehensive pain program at Albany Medical College in Albany, NY—which includes anesthesia, physical medicine, psychiatry, and neurology—and we’re very fortunate to have recently received a translational research grant. But that’s not the way it always happens. Imagine if cardiovascular medicine was approached in such a way where the only thing you did was bypass people without medical management, or counsel patients about prevention, exercise, diet, or controlling their diabetes or smoking. Think of how difficult it would be for people to benefit from those procedures if that was their only treatment.
We need to move forward. Through education, we create well-trained individuals who appreciated a comprehensive view of pain management. There is an incredible need for more basic science work and better medical and nonmedical treatments. Clinically, one major goal is to develop and integrate therapies in an increasingly effective manner.
