Developing Pain Programs Challenging but Necessary

Cairns, Australia–Development of a pain treatment facility in a teaching hospital presents several challenges. Determining the characteristics of the facility and establishing pain medicine as a necessary field of education are key elements of the development process, according to a poster presentation at the 2001 annual meeting of the Australian Pain Society. Pain medicine is a neglected area of education for both medical and allied health graduates, reported Gajinder Oberoi, MD, FANZCA, Director of the Pain Management Unit, and John Hickman, MD, Director of Anaesthesia Services, at Royal Hobart Hospital, Tasmania, Australia. To remedy this neglect, they developed a multidisciplinary pain management facility there. Both are involved in teaching at the hospital and the University of Tasmania.

"The teaching of pain medicine to undergraduates, as well as to many postgraduates in medicine and related fields, is still not satisfactory and needs to be expanded and modernized," said Dr. Hickman. "Funding issues confront us continually and are a major problem, as they surely are in other units."

A comprehensive pain program should ideally serve community-based patients, hospital admissions and the medical school. Characteristically, community-based pain services include treatment for benign pain, psychiatric disorders, substance abuse and legal cases. Pain services for hospital admissions include management of acute pain, pain emergencies and cancer pain. Medical school pain services include teaching and research.

Various factors affect the outcome of the pain services, explained Dr. Hickman. For example, the waiting period may be different for patients with different types of pain.

Acute pain sufferers may need integration with chronic pain services. Patients with cancer pain may need palliative care. Factors are multifaceted and dependent upon different forms of intervention. They affect not only patient care outcomes but also educational and research outcomes. According to Drs. Oberoi and Hickman’s presentation, teaching about pain should include a biopsychosocial model, pain physiology and pain pharmacology. Without a broad base of education, pain services will be minimized. It is important that pain research be inclusive enough to explore pain expression, patient personality and the role of neuroplasticity in pain.

Comprehensive pain facilities might handle legal cases, such as motor vehicle accidents, workers’ compensation cases and medical treatment complications. Various factors affect pain service outcomes: the patient rehabilitation process, psychosocial elements, the patient’s fear of work-related activity and vocational counseling. The ideal pain service in a teaching hospital should include a multidisciplinary team, with each person participating in clinical and educational activities of the unit. Such organization will allow strong interdisciplinary communication and foster the unit’s role in patient care and education. The team, according to established requirements, will include a pain specialist, nurse, psychologist, physiotherapist, social worker, occupational therapist and psychiatrist. It may also include a rheumatologist, anesthetist, neurologist, orthopedist, oncologist, specialist in palliative care and pharmacologist.

Drs. Oberoi and Hickman reported that multidisciplinary treatment for chronic pain is mandatory for most pain patients. Even though a broad base of caregivers is ideal, a small team consisting of a pain specialist, psychiatrist and nurse may start a pain service in a teaching hospital. "When starting a pain center, it is imperative not to overlook the fundamentals of any start-up business proposition," said Marc E. Koch, MD, MBA. Dr. Koch is President and CEO of Resource Anesthesiology Associates, P.C., in New Rochelle, N.Y. Dr. Koch, with Solomon Halioua, serves as Administrative Director of Saddle Brook Pain Center in Saddle Brook, N.J. A pain facility should determine its market segment and then develop distinguishing features that appeal to this group. The facility should know what people consider important and then market to their needs. "Know your audience and what they want to hear," advised Dr. Koch. In addition, a facility should consider its options for advertising (e.g., print media, radio, educational seminars, broadcast fax to referring doctors, direct mailings to patients). "Although marketing is expensive, if you undertake it properly, then patients will come," said Dr. Koch.

"Don’t rest on the laurels of your department or hospital and, most importantly, do not assume that being the best pain doctor in the neighborhood will translate into more patients calling your office. It’s one thing to e a great doctor, it’s another thing for you audience to know you are a good doctor." Other services are important in developing a pain facility. Developers should secure a dictation service, a charting system and an on-call communication system for business efficiency. "Any breakdown in communication and documentation can cut off a revenue stream from a referring attorney or doctor," said Dr. Koch. Demonstrating positive clinical outcomes and developing pain education as an integral part of medical education should help a pain facility at a teaching hospital expand, said Drs. Oberoi and Hickman. –Marjorie McMinn Based on a poster presentation at the 2001 annual meeting of the Australian Pain Society and interviews with John Hickman, MD, FANZCA, and Marc E. Koch, MD, MBA.