(Talk delivered under the same heading at ISSPCON 2014 by Palanisamy Vijayanand)
More than thirty years have passed since Liebeskind and Melzack posited that, ‘By any reasonable code, freedom from pain should be a basic human right, limited only by our knowledge to achieve it.’ Not that it has ever been unclear, but it is getting ever so obvious, that the time has come for Indian Society for Study of Pain (ISSP), to address thoroughly, systematically and vigorously the twin needs of including pain management in the curricula of medical schools, and imparting relevant training in pain management for all clinical specialties.
Pain education, particularly at the undergraduate level, is a critical step to ensure that the healthcare workforce is competent in managing pain. It behoves the Medical Council of a modern, independent, developing nation, to recognise as a priority, the imparting of knowledge and skills related to pain assessment and management. The uncertainties over the past few years at the MCI meant that it rarely had the time for a rethink on pain as an entity requiring assessment and management in its own right, and not just a symptom to aid in diagnosis. As a learned society, the ISSP too is guilty of half-hearted attempts to rectify the situation. Added to this conundrum, is the Ministry of Health’s decision to implement compulsory rural service, which would result in inadequately trained junior doctors dealing with complex pain problems. The curricula for pain, however, could only be shaped by the academic accrediting and professional regulatory bodies coming together with the required regulations.
It is tempting to think that this paralysis is typical of India. When one excludes nations such as Canada, Finland, France and Germany, depending on which shade of rose-tinted glass one wears, the situation is only slightly better or slightly worse compared to India. The recent APPEAL study, guided by a multi-disciplinary taskforce of experts from EFIC, and involving 240 undergraduate medical schools in 15 European countries, found that 82% of these schools have no dedicated courses on pain and only 0.2% of the studies were dedicated to pain. Observing that the amount of pain education in healthcare curricula to be woefully inadequate given the burden of pain in the general population, a 2009 British study, had a slightly better finding, ‘…education about the identification, assessment and treatment of pain represents less than 1% of the university based teaching for healthcare professionals.’
The challenge, even when the MCI is convinced, is how to make physicians aware that their current practice is less than optimal. Even more challenging is the difficulty in quantifying the hours of pain education required; the difficulty in identifying the specialties from which these hours could be acquired; and the difficulty in implementing an inter-professional learning environment. With each curriculum hour jealously guarded, it is guaranteed to be a hard climb. To build a pool of specialists, furthermore, a national consensus on whether pain should be taught as MD/ DNB or DM / FNB at a post-graduate level is required. There is a burning need for innovative approaches to meet these challenges. This includes an improved attitude among physicians to work together to diminish pain.
Despite the plethora of research in pain education, what constitutes an effective teaching methodology is unclear. CME’s, didactic teaching, hands-on workshops, modular training, and interprofessional collaborative learning have all proven to be effective in imparting pain knowledge. Little, however, is known about the interviewing skills or the pain evaluation done by the students. Formative assessment of pain learning, therefore, should include both pain knowledge and pain assessment skills. This is essential to help the students implement the learned knowledge in their practice. Much work is needed to integrate these aspects into the pain management skill set of healthcare professionals and to evaluate its impact.
As it stands, the ISSP has numerous responsibilities which it could no longer shy away from. Setting up a planning committee to chalk out the long term pain education plans is paramount. A standing committee could then oversee the implementation of the time-bound plans. More than three years have passed since a committee was set up to initiate the Academy of Pain Medicine. While the committee itself is now defunct, the idea has continued to move like a funeral hearse from one annual conference to the other, stopping only for the mid-term executive meeting. It is unbecoming of a progressive organisation to waver on an agreed principle. That too when such an academy has the potential to address the issues of faculty development, working with other medical organizations, creating clinical role models, educating patients, and educating the family of patients.
Pain is a public health burden. The Institute of Medicine report in 2011 estimated the cost to be $600 billion annually in the United States. That we have to parrot data from developed nations does not distract from the fact that the prevalence of pain is much the same in India. The cultural attitudes and cost of treatment might differ, but a burden it certainly is. The answer to this enormous public health problem lies in education. Widespread ignorance and apathy about the problem of pain must be overcome. The physician must at all times be conscious of the dictum: salus aegroti suprema lex (the good of the patient is the highest law).