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?
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.
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.
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.
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.
- 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.