Becoming a Pain Specialist

aristotle
                                                Where the needs of the world and your talents cross, there lies your vocation.

By Palanisamy Vijayanand

(Transcript of the talk delivered at the Annual Meeting of the Indian Society of Anaesthesiologists (South Zone) at Visakhapatnam, August 2014)

People, on occasions our own families, are only proud of our achievements and successes, not our struggles – in particular the struggles which happen in the heart and mind of a healthcare professional. One such is the struggle to create a harmonious union between pursuit of material wealth and values. The ancients might have had it right when they urged us to try our luck in combining values with talents. This idea comes courtesy of Aristotle, who is attributed with saying, ‘Where the needs of the world and your talents cross, there lies your vocation.’ When epidemiology suggests that 15-20% of the population suffer from pain, the world obviously needs a pain specialist, but how do we develop our talents and match it with the requirements of the world?

Virtues

In order to deliver highest quality of care with integrity, honesty and compassion, to practice ethically, and to exhibit appropriate personal and interpersonal professional behaviours, inculcating professional values is an integral part of being a pain specialist. In addition, the pain specialist should be a medical expert, who could demonstrate appropriate diagnostic and therapeutic skills, and provide effective consultation services with respect to patient care, education and legal opinions. Furthermore, to become a pain specialist one should be a communicator, collaborator and a scholar. Listening effectively and establishing therapeutic relationships with patients/ families is part of being a communicator. As a collaborator, the pain specialist should contribute effectively to pain management team activities, and consult effectively with other physicians and health care professionals. Critical appraisal of literature, developing and implementing a personal continuing education strategy, contributing to development of new knowledge, and facilitating learning of patients, students, junior medical staff, the pain management team, other health professionals and the community is part of being a scholar. To become a pain specialist is to become a health advocate. And, in learning to allocate and utilize the finite health care resources wisely, one should, in addition, possess the requisite managerial skills.

Challenges

On the one hand, the patient might present with co-morbidities, multiple failed treatments, disillusionment, helplessness, hopelessness, desperation, fear, anger, unrealistic expectations, and differing medical opinion regarding their predicament. These might, in turn, result in problems with communication, trust, and respect. On the other hand, as a pain specialist one might be well regarded in the community and have a reputation for being keen, enthusiastic, altruistic, self-sacrificing, generous, hard working, interested, self-motivated, with high personal and professional standards, community advocates, tolerant, uncomplaining, enduring and persevering. Witnessing the suffering of others, as a pain specialist, is a very powerful source of distress. This stress is amplified when the observer has accepted a duty of care, and even more so when it seems as though they are unable to fulfil this duty of care as the pain and suffering continues. This might result in burnout, and when it continues makes one prone to develop more conspicuous emotional disorders. It is essential to identify and intervene with such stress early. Speaking with friends and colleagues, and having personal stress management strategies in the form of sport, music, hobbies etc, is paramount.

Learning

It is important to identify a mentor who could act as a source of knowledge and skills relevant to pain medicine. Someone who could help you reflect upon your experiences; help you overcome professional, academic, career and personal problems; help organize training opportunities in specialized areas such as pediatrics, hospice, spinal cord injuries etc, organize a structured educational program; and importantly being your advocate. It is also important to have a learning plan which might typically involve -why you need to learn, what you need to learn, how to learn it, the time frame needed, methods to test how well you have learnt, and reflection. The objectives of training and the practice of pain medicine are elaborated in detail by the International Association for Study of Pain. The essential learning includes, among others, history and philosophy of pain medicine, taxonomy, epidemiology, neurobiology, genetics, medico-legal aspects, psychosocial aspects, substance abuse issues, rehabilitation medicine, theory of placebo, and pain in special populations. None of which, of course, is taught in India, where the main focus is either on creating a band of trigger-happy injectionists or morphine propagandists.

Indian Scenario

Pain Medicine, as an inter-professional endeavour, has matured in recent years. It has been recognised as a medical specialty in its own right in many countries. This recognises the importance of the problem of unrelieved pain in the community and to the need for a comprehensive medical response through education, training and practice. The status of pain medicine training in India – uncoordinated, undue importance to interventions, non-availability of opioids or unregulated opioids in certain instances, and two week courses which masquerade as fellowships – is less than ordinary. In terms of structured training, accrediting units of the highest standing, setting evidence-based standards, performance review and revalidation; India is way behind the developed world. It requires a professional body of highest standards to address these issues. The idea of an Indian Academy of Pain Medicine was floated by the Indian Society for Study of Pain some time ago, but it remains a lead balloon for reasons unknown. In the absence of such a body what would one do? A learned society such as the Indian Society of Anaesthesiologists could perhaps take the lead in bringing together the broad specialties including rehabilitation medicine, neurology, rheumatology, psychiatry, and neurosurgery, to advocate for pain medicine as a specialty.

Acknowledgements

  • Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists (ANZCA) Trainee Resource Kit.
  • International Association for Study of Pain, Educational Resources.
  • Faculty of Pain Medicine, Royal College of Anaesthetists.
Dr. Palanisamy Vijayanand

Post author

FCARCSI, DPainMed (RCSI), MSc (Pain), FFPMCAI, FFPMANZCA | Hyderabad, India

There are 6 Comments

  1. Posted by Dr Ashish Korgaonkar Reply

    Sir how do you see the prospects of Pain Physician training as a full time course in India?Especially cost of therapy, generalised unawareness, unusual। work atmosphere as compared to other specialities, radiation hazard make it last choice to pick up as a full time course.

    • Dr. Palanisamy Vijayanand
      Posted by Dr. Palanisamy Vijayanand Reply

      Dear Dr. Ashish Korgaonkar

      Full time pain training already exists in India. The prospects (if employment value is what you mean), is not that fantastic. This is mainly because it is not recognised as a specialty in India. Much work needs to be done with regards to this. Cost of therapy, lack of awareness, radiation hazard are all barriers, I agree. The same could be said for interventional cardiology too, but that doesn’t stop young doctors taking it up as a specialty.

      Regards
      Vijayanand

  2. Posted by Rajendra Sahoo Reply

    Well written sir. Fabulous. .depicting the indian scenario and the challenges in its true manner. .I wish you become the president or secretary of the ISSP. Definitely there will be good days for our society. .best wishes

    • Dr. Palanisamy Vijayanand
      Posted by Dr. Palanisamy Vijayanand Reply

      Dear Rajendra Sahoo

      Thanks for your kind words. Much could be done without the politics.
      What baffles me, however, is why should the ISSP waffle around with such a simple thing as an academy. Hope for better days ahead.

      Regards

  3. Posted by Dr. Hirachand S Mutagi Reply

    Dear Dr. Palanisamy, Dr. Rajendra and Dr. Ashish.
    i applaud your blog and am intruiged about the discussion about taking on a carrer in pain medicne.
    Your arguments about the challlenges are facinating and true.
    Pain Medicine as a speciality has many internal and external challenges. We are quick to point out external factors, but miss out on the internal. Introspection is necessary.
    Dr. Palanisamy has eloquently elaborated on the external factors predominantely centered on lack of awareness in the general public and the medical faternity.
    The internal factors among pain specialists are evident in the questions raised especially cost of therpay, radiation hazards. Every speciality has a range of personalities and wide variance in skills and ethos of practice. In well established specialities, there is ample leeway for such variance. In pain medicine, it adds to the struggle in acquring its due credit. WE need commited passionate, well informed, ethical pain physicians to hasten this process. National organisations and ISSP have a large role to play in promoting awarness, concentrating our efforts towards general public is more likely to provide traction.
    Pain medicine will eventually thrive and the patients deserve it. While a large proprotion of patients are served by modern medicine that is currently taking on business models similar to factory production line , in the name of maximal cost efficiency; my heart weeps for a significant proprotion of patients offered unwarranted inappropriate aggressive treatments /surgeries after they were starved of a meticulious assessment for nociceptive focus to begin with. Very likely resolvable by simple education and rahabilitation.
    We want young blood in pain medicine, young commited passionate blood, willing to shed the easy route of acute care and take on musculoskeletal medicine, shed physiology/ pharamcology and embrace biomechanics /musculoskeletal/ neurological themes and concepts.
    Becasue, the pateints deserve better……
    regards
    hira
    (Dr. Hirachand Mutagi)

    • Dr. Palanisamy Vijayanand
      Posted by Dr. Palanisamy Vijayanand Reply

      Thank you Dr. Hirachand Murtagi.

      Very well said.
      You’ve covered many left out aspects of the post. Chief among which are the return to the basics of meticulous examination, and education and rehabilitation of the patient.
      Much appreciate your thoughts.

      Regards
      Vijayanand

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