I remember quite vividly my first day at medical school. Despite the nervous introductions in the morning, all done hurriedly, we were a hundred lost souls. The afternoon session had the Dean outlining what lay in wait for us in the next few years. The thing foremost in our mind was mathematics. We were for the first time applying probability in practical terms. Our year had more of the lesser sex – men. We out-numbered the girls easily. The competition was heavy, one girl for ‘three idiots.’ The years went by and before we knew we started our first day of our internships. The previous years had taught us a fair bit about medicine, surgery and all that lies in between. Importantly, the kind of issues which seems to affect everyone of a certain age, heartaches! About persistent pain, no one had taught us. My first patient, as an intern in orthopaedics, was an elderly man with persistent low back pain. My resident had previously kept him on anti-inflammatories. Long enough for him to have stomach ulcers. Now back pain had company – abdominal pain. We were, to say the least, clueless.
Reflecting back, I wonder whether the simplistic approach of ever increasing doses of anti-inflammatory medications ever benefited anyone. I guess not. Persistent pain is not a simple problem. Like heartaches it is complicated. Multiple factors contribute to the start of the problem, and even more complexities perpetuate and maintain it. Disentangling this intricate web, where there is interplay of social, psychological and emotional factors, entails a patient-centric multi-modal approach. It demands time, a sophisticated approach, and above all a big dollop of empathy. Not the kind of skills one is routinely taught at medical schools. It might be convenient, fashionable even, to point the finger at ‘Indian education system.’ But, like heartaches, the problem is worldwide. Devdas just has a different name. The primary reason for a vast majority of people to consult their doctor is Pain. We were, however, taught an over simplified biological approach to pain in our medical schools. The kind of approach – if there is an appendix cut it, if there is a stone blast it, if there is a block stent it – which rarely helps to expand ones horizon. This despite the recent understanding that persistent pain, due to the changes it brings about in the nervous system and the brain, is a disease in itself. It is no longer a symptom.
The dearth of medical professionals adequately trained in managing chronic pain has had its impact in terms of increasing disability, worsening economic burden and overuse of over-the-counter anti-inflammatory pills. All this, in turn, worsens the pain – a vicious cycle. We were taught to approach medical problems as black and white, ignoring what has been appreciated for ages, that medicine is as much art as it is science. We have routinely failed to appreciate the grey shades which inhabit pain and its sufferer. Call it ignorance or call it capriciousness, the less said about the approach to chronic pain and its treatment, the better. There is, in general, a lack lustre attitude towards pain education. When there isn’t much of an emphasis on young medical graduates to become scholars and collaborators, what hope there is for them to become advocates. These inherent drawbacks lend itself to comparison to what could positively be. Caring for the sufferer, understanding their disability and their emotional upheavals, and listening to their life altering situation – all brings out the human side of the student. Critical to their progress is the understanding that science and humanities co-exist – an understanding which could make them a humane doctor with benefits to the country.
On the one hand, few Indian medical schools have pain management taught in an ‘integrated’ manner. It is usually buried along with the myriad of other symptoms and acronyms of a particular medical condition, which are then rote learned to pass examinations. Fewer still have ‘mandatory’ pain education. On the other hand, there is the emerging evidence that one-in-five Indian adults suffer with chronic pain. The issue could just not be magicked away by continuing to do what we do. Buried still, in the long list of tick boxes the Medical Council of India (MCI) has mandated for post-graduate accreditation in medical schools, is the ‘Pain Clinic.’ It remains just that, to be ticked and forgotten about. A damning Human Rights Watch report in 2009 said:
Official curricula for undergraduate and postgraduate medical studies do not provide for any specific education on palliative care and pain management. As a result, the vast majority of medical doctors in India are unfamiliar with even the most basic tenets of palliative care or pain management.
In its bid to ensure the wellness of the great Indian public, the MCI has built the great ark of comprehensive medical curriculum. It seems packed and sufficient enough for Noah to get through forty days of drizzle and four months of deluge. When there is space enough for ‘seven pairs of every clean animal,’ then surely there should be some left for the singular RAT. As likely as the ark would sink, it is just as likely that the rodent would abandon ship. RAT – Recognize, Assess, and Treat – is the mantra around which ‘Essential Pain Management’ (EPM) is built. A simple framework for managing pain, EPM aims to increase pain knowledge among healthcare professionals. Supported by the Australian and New Zealand College of Anaesthetists, the EPM has been run successfully in 20 different countries across the world. And as volunteers of Traveling Pain School, we are proud to be associated with it. Following successful pilot projects teaching under-graduates in different parts of India, its formal launch is upon us this January in Hyderabad. The exceptional potential of this programme to relieve the greatest malady of mankind is as good a siren song for educating our young doctors.