The Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists has published this report on the first Essential Pain Management workshop in India for undergraduate students. It has been reproduced in full.
Hyderabad is the capital and largest city of the southern Indian state of Andhra Pradesh. It has a population of 6.8 million and a metropolitan population of 7.75 million, making it the fourth most populous city and sixth most populous urban agglomeration in India. Established in 1591 by Muhammad Quli Qutb Shah, Hyderabad remained under the rule of the Qutb Shahi dynasty for nearly a century before the Mughals captured the region. In 1724, Mughal viceroy Asif Jah I declared his sovereignty and created his own dynasty, also known as the Nizams of Hyderabad. The Hyderabad State ultimately became a princely state during British rule, and remained so for 150 years, with the city serving as its capital. The city continued as capital of a new Hyderabad State after joining the Indian Union in 1948.
Relics of Qutb Shahi and Nizam rule remain visible today, with the Charminar—commissioned by Muhammad Quli Qutb Shah himself—coming to symbolise Hyderabad. That legacy is also evident in the city’s distinctive cuisine, which includes Hyderabadi biriyani and Hyderabadi haleem. The Qutb Shahis and Nizams established Hyderabad as a cultural hub, attracting men of letters from different parts of the world. Hyderabad emerged as the foremost centre of culture in India with the decline of the Mughal Empire in the mid-19th century, with artists migrating to the city from the rest of the Indian subcontinent. While Hyderabad is losing its cultural pre-eminence, it is today, due to the Telugu film industry, the country’s second-largest producer of motion pictures.
Hyderabad was historically known as a pearl and diamond trading centre, and it continues to be known as the City of Pearls. Many of the city’s traditional bazaars have remained open for centuries. However, industrialisation throughout the 20th century has also attracted major Indian manufacturing, research and financial institutions. Special economic zones dedicated to information technology have encouraged companies from across India and around the world to set up operations with the emergence of pharmaceutical and biotechnology industries. With an output of US$74 billion, Hyderabad is the fifth-largest contributor to India’s overall gross domestic product.
In 2013 Dr Vijayanand Palanisamy met Dr Goucke in Trivandrum, Kerala and discussion began about a follow up visit to Hyderabad. Dr Vijay and Dr Murali had significant experience promoting pain awareness with education through the Travelling Pain School (TPS). (http://travelingpainschool.com/). These discussions developed into the proposal that we run both an EPM full day program, an instructor workshop and then a series of EPM Lite workshops at one of the Hyderabad Medical schools. EPM partnered with the Travelling Pain School for this pain education program in India.
Dr Vijay introduced us to Dr Murali Joshi who was able to facilitate introductions to the Heads of two of the undergraduate medical programs Dr SM Patil, Principal, Kamineni Academy of Medical Sciences, Dr Shruthi Mohanty, Principal, Kamineni Institute of Medical Sciences and Dr Amaresh, Medical Superintendent, Kamineni Institute of Medical Sciences.
We also met with the Secretary of the Indian Society of Anaesthesiologists Dr MV Bhimeswar and Vice President of the Indian Society for the Study of Pain Dr BB Mishra, together with some other senior practitioners. All were very supportive of running both EPM and EPM Lite.
A well attended press conference was held to promote EPM and video clips can be seen at Hybiz.tv A total of 33 press reporters assembled and the EPM programme was covered in seventeen newspapers and ten television channels. The press notes came in various local languages and one English Language Newspaper the New Indian Express.
Dr Murali and Dr Vijay had preselected the participants for Day 1 and Day 2 so that it was more likely that EPM/EPM Lite would be taken back to their states and hospitals from here they came.
External course Instructors for the first workshop:
Dr Linda Huggins, Palliative Care Physician, Auckland
Dr Lynda De Souza, Anaesthetist, Adelaide
Dr Roger Goucke, Pain Medicine Physician, Sir Charles Gairdner Hospital, Perth
On day 1, Friday 24th January 2014, the course was run with 26 participants.
The following day most of the Day 1 participants and some observers made for 30 people attending the instructors’ workshop.
On day 3, Sunday 26th January 2014 which was coincidentally both Australia day and Indian Republic Day, four parallel workshops containing a total of 88 participants were run. Four groups of the newly qualified instructors consisting of a team leader, time keeper and 3 presenters delivered the course.
EPM Workshop: the morning session consisted of a series of short interactive lectures and group discussions where “RAT” (RAT = Recognise, Assess, Treat) was used to consider the management of various pain problems. The group then brainstormed some strategies for overcoming pain management barriers.
EPM Instructor Workshop: this workshop was conducted over 4.5 hours and began with a series of short interactive lectures. These were followed by a session in which participants practised giving a lecture and running a discussion group. At the completion of the instructor workshop the new instructors planned for the one day workshop they were to run the following day.
The EPM Lite workshops were run in parallel with 4 groups of instructors, time keepers did their best to keep the busy morning on schedule and all the workshops finished by 1pm. At the conclusion of each workshop, participants were presented with a certificate of attendance, printed on heavy paper.
The workshops were conducted in the seminar rooms of the Kamineni Hospital administration block. This was an excellent venue with enough breakout space, air-conditioning and data projectors. The Kamineni Hospitals provided all the facilities to TPS organisers at a subsidised cost.
Course participants completed a test prior to and at the conclusion of the workshop to assess learning during the day. A new MCQ written test (pre and post) was used at this course. At the end of the course the answers were presented to the whole group on a ppt presentation. Scores showed improvement in knowledge for most participants. Subjectively there was great improvement demonstrated in both knowledge and its clinical application in case studies designed to practise the use of the RAT framework.
Morning tea, lunch and afternoon tea was provided by the Kamineni Hospital at a subsidised cost for TPS organisers and was very adequate and enjoyed by all in particular the students on day 3 were the lunch was provided in the large restaurant on the top floor of the building.
Participants and instructors were asked to provide written anonymous feedback at the conclusion of teaching on each of the three days. Overall feedback was very positive: Comments such as: “More frequent workshops, live video demo of patient and their relief after treatment would be good, It looks very simple but it is very difficult to conduct an EPM workshop. Time management is essential,
Pain management is one of the most important things which should not be neglected/underestimated. Misconception about opioid analgesics, that they should not be used because of fear of addiction is not a correct one. EPM shows us about the different types of pain”.
Constructive comments such as “participants must respect the schedule”. “Maybe put in place/to agree on the “game rules” before starting”, this reflected a feeling that holding the course out of town would improve a timely start. Several participants requested the course manual be sent to them before the course as pre reading.
The seniority of many of the participants of the day 1 EPM led to some in depth discussion of the major barriers to effective pain management in India.
Language, culture awareness and patient expectation were identified early.
The need for more “pain champions” and pain not being a priority needed recognising. The availability of opioids was a serious issue in some states and areas.
We are grateful to the Ronald Geoffrey Arnott Foundation for financial assistance for air travel and accommodation costs for Dr Goucke. Dr Huggins and Dr De Souza were able to use their hospital CME funds for travel and accommodation costs. The Kamineni Hospital co sponsored along with the Travelling Pain School costs for the venue, printing services, stationery, house keeping services and audio-visual equipment.
Success and relevance of the visit
The workshops were very successful. This was the first EPM Lite to run outside Auckland and we were very pleased with the reception by both the teachers/instructors and the participants /students.
Overall we trained 26 participants including nursing, occupational therapy, physiotherapy, psychology and anaesthesia in EPM. We ran the Instructors Workshop for 30 people, and ran four parallel EPM Lite sessions for 88 medical and nursing students.
The 3rd day workshops were run entirely by the local instructors.
The course instruction material worked well. The “RAT” approach to pain management provided a simple framework for managing a variety of pain problems. Course participants contributed enthusiastically, and some lively discussions ensued.
EPM is cheap to run, and emphasises low cost management strategies; quality of life can be markedly improved by some very simple improvements. Education and training to provide appropriate pain management earlier in the patient’s disease is more effective than waiting for severe pain to become established.
An important part of EPM is early handover of teaching to local instructors. This encourages co-operation between different levels of health workers as well as the development of local solutions to local problems.
A very big thank you must go to Drs Murali and Vijay for their commitment to this project and their organising skills in regard to venue, equipment, printing, catering and enrolment, despite the many other calls on their time. Thanks also to the management of the Kamineni Hospital and Group for their considerable support.
Thanks again to ANZCA and the Ronald Geoffrey Arnott Foundation for financial support.
Lynda De Souza