The parliamentary elections are upon us in a short few weeks, where an eight-hundred million strong electorate would be casting their ballots to elect the sixteenth parliament. Traditionally fought along multiple axes (pun intended) such as class, religion, gender, caste, and region, this once-in-five year exercise is a smörgåsbord of emotions, people, and culture. All the more compelling are the shrill debates in the media, forecasting a future which is simultaneously reminiscent of a Stalinist Gulag, a Mussolinian nation and – because of the falling rupee – a Weimar Republic. None of these would happen, of course. Not when our timid rule makers are content with flirting with and pirouetting around Ms. Big Idea constantly, rather than asking her hand. Not when there is a constant disruption of parliamentary proceedings due to varying agendas, diversity of opinions and political turmoil. Not when cutting across party lines and come together on a common platform, for a worthy cause, is anathema. So much so that, to put a convenient gloss, the parliamentarians could not bring themselves together to make amendments to the draconian Narcotic Drugs and Psychotropic Substances (NDPS) act earlier enough, to simplify access to morphine for the suffering millions.
The need for under-graduate pain education
While these endless debates on arriving at a policy decision could pass off for attempts at idealism, the implementation of such policies could do with a bit of realism. Often the executive machinery would sport the look of a man on a flight home from a holiday, when the reality slowly dawns on him that he has left his house keys in the hotel safe. To fulfil the medical needs of the rural population, the Government of India is in the process of introducing compulsory rural service, following graduation, for medical under-graduates. India produces more than 40,000 medical graduates every year, but pain management is not part of the under-graduate medical curriculum. On the one hand, inadequately taught and ill-equipped junior doctors, under duress, might be left to tackle complex pain problems in resource poor settings. On the other hand, despite the good intentions of the government, patients might be at risk of sub-optimal care. To untie this Gordian knot, which involves multiple stakeholders, would be to empower the under-graduates with the requisite skills and knowledge to manage pain within a simple framework.
Essential Pain Management
To improve pain knowledge among Indian medical students, Traveling Pain School has launched a nationwide educational program utilising the teaching capabilities of locally available specialists. More than two hundred and fifty under-graduate students participated in the pilot projects which were held at Ahmedabad (Gujarat) and Theni (Tamilnadu). Delivered as interactive lectures and group discussions over five hours, it addressed the practical components of managing pain competently, including overcoming barriers for effective pain care. The curriculum, teaching content and delivery method were adopted from Essential Pain Management (EPM) of the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists. With the feedback from the students being overwhelmingly positive (with the occasional admonishment for not serving hot samosas), the formal inauguration of EPM for medical students has been planned for early 2014 at Hyderabad, India. The EPM faculty, traveling to teach from across the world, would be involved in the ‘Train the Trainers’ program, with which the multi-disciplinary delegation of medical and allied health specialists from across India are expected to benefit. This ecosystem of cross-pollination, we hope, would benefit close to three thousand medical students this year, with plans to scale it up to teach ten thousand students every year.
Pain in the virtual world
This year, with two hundred and fifty million internet users, India is poised to overtake United States as the second largest internet base in the world after China. A third of the online population are from rural India, three-fourths of the online population are under-35s, and seven out of eight access it from their mobile phones. Distributive justice, for a volunteer organisation such as ours, engenders the cost-effective use of the now not new-media. It has given us plentiful ideas about how to choose our emphasis and where to invest our energies – on education and advocacy. Drawing inspiration from the 2009 ‘Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom,’ of the British Pain Society and the recently published ‘Advancing the Provision of Pain Education and Learning (APPEAL),’ study by the European Pain Federation (EFIC®), an online survey of Indian medical students called IMPACT – Indian Medicos Pain Awareness Curriculum and Training, has been initiated. The results of which would be made available to the various stakeholders later this year. Another area of focus is to aid the exam preparation of post-graduates. The videos and webinars on exam-oriented chronic pain topics planned for the year, we hope, would supplement the teaching (if any at all) on the subject. The usual culprits – facebook, twitter, and the obligatory website – have all been made part of the social media strategy towards this.
Writing about the un-pigeon-hole-able frenzy that is Indian elections, without being prolix, is an onerous task. As bewildering as it could be wearying, under the Model Code of Conduct, no new projects with support from local political leaders could be launched close to the elections. The Election Commission of India, a powerful constitutional body, ensures this to provide a level playing field for all the contestants. The Traveling Pain School’s project to adopt a village in one of the most backward and poverty stricken districts in the country has, therefore, been put on hold till the party is over. For, any local politician in league with us would be barred from contesting the elections, and without the support of all concerned, projects such as this are non-starters. This does not, however, stop us from providing self-management tips and recent research on pain, in plain English, over the internet.
Inextricably tied to our advocacy efforts is our contention that it should be towards capacity building, increasing the knowledge base, and creating a medical force skilled in managing pain effectively. An online multiple-choice examination leading to an under-graduate prize in pain medicine is part of it. Similarly, part of the proceeds of the sale of the Textbook in Pain Management (3rd edition), edited by our core committee member and released recently, has been directed towards our efforts. The learned societies, in particular the Indian Society of Anaesthesiologists and the Indian Society for Study of Pain, had been steadfast in their support for our programme. We have, in addition, been in touch with other learned societies to evolve an inter-disciplinary strategy which could contribute to a national pool of dedicated teachers in pain medicine. Furthermore, strategies to utilise the services of the diaspora of pain management professionals across the globe are being put in place.
The journey so far
How far one should explore pain education and advocacy is hard to describe when it is the ocean and we are the plankton. A similar jeremiad from me was published in the spring edition of this newsletter last year, where the challenges specific for India were highlighted. The journey hitherto has been both exponentially difficult and exceptionally rewarding. The team work made sure that the ideas floated were not lead balloons. An important idea, then, was to reach out and teach a thousand practising physicians in a year. We managed that and beyond, reaching out to a thousand three hundred physicians. In doing so, the faculty collectively travelled a distance of more than a hundred and twenty thousand kilometres. More than hundred thousand pages of printed material on evidence-based pain management were distributed, and more than a thousand e-books on basic concepts in managing pain were delivered. This makes the endeavour by far the largest in scale, and reach, ever attempted in the country. The total expenditure stood at five thousand pounds, half of it coming from restricted educational grants and the rest from our savings. But to dwell upon this is to put too fine a point on too fine a point.
Inspired thereof, the leitmotif has been carried with conviction in other parts of the country as well. Karnataka, a state with a population of sixty million, is currently being criss-crossed by a team of dedicated teachers, not least by some who are fellows of the Faculty of Pain Medicine of the Royal College of Anaesthetists. To postulate a golden age for pain education – in our exuberance, though there is nothing irrational in it – would be to cast a jaundiced eye on all that came before. The brilliant Russian chemist Dmitri Mendeleev had a considerable penchant for Sanskrit – the liturgical and philosophical language of many a religion in India. One should excuse us for feeling like Dmitri in 1869, sitting in his study and organising the elements into a periodic table. Like Dmitri’s, there are as yet many more missing elements to our efforts. But, like him, we are sure enough that our table is right. We have no qualms about leaving the blank spaces. We hope that the future, full with the spirit of volunteerism, would prove us right by filling in the blank spaces. We hope that the Indian elections – that refreshing celebration of democracy – would still be part of that future.
The article was published in the 2014 Spring Edition of the British Pain Society Newsletter.
The sentence with reference to the NDPS act and the Indian elections have been modified to accurately reflect current circumstances.