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11 Articles in Volume 21, Issue #1
Advanced Practice Matters with Theresa & Jeremy: Mentorship
Ask the PharmD: What is a true opioid allergy?
Behavioral Medicine: How Clinicians Can Reduce the Stigma Attached to Chronic Pain
Chronic Headache: How to Conduct a Virtual Neurological Examination
COVID-19 Long Haulers: A Look at Cardiovascular Risk
How COVID Has Changed Pain Practice and Policies
How to Conduct a Pain Evaluation Using Telemedicine
Inside the Potential of Biologics for the Treatment of Rheumatoid Arthritis
Managing Pain in Parkinson’s Disease
Spinal Cord Stimulation Shown to Improve Pain and Movement in Parkinson’s Disease
TeleRheumatology Before and During the COVID-19 Pandemic

Advanced Practice Matters with Theresa & Jeremy: Mentorship

Who are the APP leaders in pain management that have inspired you most? An intimate interview series on tenacity, advocacy, and choosing the right supervisor.

I, Theresa, was recently approached by a woman who was new in her career as a nurse practitioner in pain management – she sought me out as a mentor. Even though I have spent the past 20 years of my career as a clinician, researcher, and educator in the field of pain management, I never really thought of myself as a “mentor.” I have always acknowledged the importance of educating and leading by example, with the goal of projecting a symbol of excellence in practice that is visible to my patients, peers, and MD colleagues. The idea of being a mentor had me reimagining my role in our profession and led me to reminisce about those who have had a great influence on my career. When I talked to my co-columnist, Jeremy, he had similar positive memories.

So as we optimistically move forward into 2021, Jeremy and I would like to share with you the highlights of some intimate, yet COVID-19 compliant, conversations with some of our mentors. There have been so many APP leaders in the field of pain management – the few that we chose to feature here are absolute professionals and innovators in the specialty. They have trailblazed advanced pain practice while inspiring all of us along the way.

We asked each indiviudal – Barbara St. Marie, PhD, ANP-BC, GNP-BC, FAANP, Marsha Stanton, PhD, RN, and Chris J. Kottenstette, PA-C, CPE – the same set of questions. Their extraordinary bios are placed at the end.

Trailblazers in advanced pain practice interviewed by Jeremy Adler and Theresa Mallick-Searle. (Image: iStock)

Theresa & Jeremy: Would you briefly describe the journey that brought you to the field of pain management?

Dr. St. Marie: My career started out in pain management. During my undergraduate nursing program, I spent time at St. Christopher’s Hospice in London and learned about pain management using Brompton’s mixture. When I returned to the US, I became a pain management nurse in Minneapolis at a Level 1 Trauma Center, working for a group of anesthesiologists. Subsequently, I attained dual credentials as an adult and gerontological nurse practitioner with my master’s thesis comparing the amount of opioids used for orthopedic postoperative pain by persons with and without substance use disorder (SUD). I demonstrated through a retrospective chart audit that patients with active SUD used two to three times more opioid for postoperative pain than patients with no history or past history of substance use disorder. My life’s work has been focused on pain management that is safe and effective.

Dr. Stanton: I was working in the PACU at a small community hospital in Salt Lake City (Holy Cross) and Lynn Webster, MD, then chief of anesthesia, approached me about helping him start an acute pain service – my response “What exactly is a pain service”? He gave me the original Mosby Acute Pain Service Anesthesia Report supplement edited by Dr. Brian Ginsberg and that was it – I realized it was just what I needed and wanted to do!

Mr. Kottenstette: I started to play football in high school; I was not that good but enjoyed the work the trainer did, and so became an athletic trainer before graduating. When I went to college, I continued in t his role but found that I was lacking the knowledge needed to care for more serious injuries. So, I attended EMT school in Greeley, Colorado, after my first year of college and soon started working as an EMT. I enjoyed that work so much that every time I tried to return to school, I did not do as well. Eventually, I ended up back at Colorado State University working as a paramedic at Poudre Valley Hospital but realized this was not a lifetime career.

Through an incentive program at work, I was able to attend college and get my undergraduate prerequisites for PA school completed. This led me to the University of Utah where I was taught by Art Litman, PharmD, who was in charge of our pharmacology course. They have a strong background in pain management and palliative care at the University of Utah and the proper management of chronic pain was beaten into our head. When I graduated, I worked in primary care for a while; however, the physician I was working with wanted to try and do concierge medicine and was not sure he could afford my salary. Subsequently, I got a job in pain management due to my training and felt like I knew 2 cents more than the next guy. I really enjoyed the challenge of trying to figure out “is it real or Memorex” and became a “zebra hunter” trying to find out why people in chronic pain had seen so many providers without resolution. Doing pain management as a PA is an intellectual endeavor – and I've enjoyed it ever since.

 

Theresa & Jeremy: What do you think are the biggest, most current challenges facing new graduates who wish to pursue pain management?

Dr. St. Marie: Education, mentoring, and using scientific evidence to build knowledge into practice. As a starting point, I would recommend the Core Curriculum for Pain Management Nursing, attending a national pain conference, and networking with leaders in the field who are focused on mentoring the next generation of pain management practitioners.

Dr. Stanton: We have noticed in the past several years the decline in those who would choose pain management as a career path. Funding for educational endeavors, resources for learning, and policy issues are all important in this field. Unfortunately for those who would consider working in the pain area, there is such a tarnished view attached to both clinicians and patients due to the opioid crisis, coupled with the frustrations of providing quality care within formularies and health plans, making it increasingly more difficult to establish the necessary relationship with each patient.

I would be cautious about encouraging a new graduate toward the area of pain. The years of basic nursing practice definitely give nurses the necessary evaluation skills needed for quality pain care. The area of pain is so all-encompassing and covers many similar syndromes with overlapping symptoms that I would suggest a new graduate spend time on a med/surg unit, ortho unit, or other general care areas to build the necessary insights they will need for uncovering the subtle and discreet issues for those with pain.

Mr. Kottenstette: How to manage the use of opioid medications and other non-narcotic medications in the care of patients. There is so much “opioid phobia” out there, that I think people’s pain management takes a backseat to the dislike/fear of writing an opioid medication. (See also, “Opiophobia Meets Neophobia” with PPM Editor-at-Large Jeffrey Fudin and our Opioid Prescribing and Monitoring special editions)

 

Theresa & Jeremy: What qualities do you feel are important when interacting with patients with pain management needs?

Dr. St. Marie: There are three qualities that I feel are important in caring with those with pain:

  • being a good listener
  • having tenacity
  • performing through advocacy

Listen to the voices of the people who suffer in pain, as they are the greatest stakeholders in the efforts to manage pain. The voices of individuals suffering from pain reveal a world of coping and escape, of stigmatization and marginalization from society and from the current healthcare system. In pain management, we cannot forget that. Tenacity is a quality of someone who “hangs in there” for the benefit of others. A tenacious person stays with the patient and works through the challenges of caring for a population with complex needs. Advocacy is important at the local level, and national and international levels. Policies are in place that requires serious attention as they perpetuate disparities and prevent practitioners from providing safe and effective care. For example, policies that limit access to prescription opioids by limiting dose and duration of treatment will not solve the opioid crisis and overdose deaths. However, these policies  do impede healthcare professionals from providing individualized care to safely meet patient’s needs, especially when non-opioid and non-pharmacologic interventions are not covered by third-party payers.

Mr. Kottenstette: The time we can spend with patients, and the care that we are able to show patients within that limited timeframe. The understanding of people struggling in the difficulty they find themselves in on a day-to-day basis is key to a desire to help people globally and not just with a focused pain complaint.

Dr. Stanton: Without question, these are the abilities to significantly limit our judgmental perceptions, utilize active listening, build honest relationships, and be a trusted source of care for those in need.

 

Theresa & Jeremy: As a leader in the field of pain management, what advice would you give to young colleagues?

Dr. St. Marie: Be proud that when you relieve a patient’s pain you are providing the most compassionate service of our healthcare profession. Remember that pain is not just physical; recognize the emotional and spiritual suffering of those in pain. It is imperative to understand that there are many options used to treat pain and to not be confined to just one modality.

(Editor’s Note: See also our new sister site, Psycom Pro, for clinical strategies around integrated mental health assessments.)

Dr. Stanton:  I would never discourage a new graduate from pursuing a career in pain management, however, I would suggest they spend sufficient time “shadowing” or securing an internship that allows them to gain the insights, perceptions, intuition, instinctive judgment, and discernment to appropriately offer care. Given that pain is not black or white, experience with the individual patients requires more than a cursory knowledge of disease and its manifestation.

Mr. Kottenstette: Be very careful in picking your supervising provider. Someone who thinks you are the "Scut Monkey" and dumps all of their work on you will likely sour quickly. Someone who recognizes your value and expertise and the benefit that you provided in the clinic, and who is willing to teach you is very important. Also, "be self-motivated.” If you generate a question, find a book, article, or expert that can help answer your question and learn on a daily basis.

 

Theresa & Jeremy: Who inspired you or continues to inspire you?

Dr. St. Marie: There are many leaders in pain management who inspire me. Margo McCaffery comes to mind in my early career and I was amazed at her knowledge and impact. People who continue to inspire me are Marsha Stanton, Keela Herr, and Peggy Compton. I see these individuals as visionaries of the future of pain management and a constant inspiration as they continue to contribute to the knowledge of pain in those who are underserved, such as older adults and people with substance use disorder.

Dr. Stanton: Those who inspired me in the beginning were, Dr. Webster, along with Drs. Michael Ashburn, Perry Fine, and Timothy Houden. I was fortunate enough to have been one of the first members of ASPMN  and therefore became familiar with Dr. Betty Ferrell, Margo McCaffery, Chris Pasero, Barbara Reed, and others within the organization. I am still inspired by Drs. Judith Paice, June Dahl, Mary Lynn McPherson, Steve Passik, Scott Fishman, Jeffrey Fudin, Jeff Gudin, Kate Galluzzi, Sean Mackey, this article’s authors – and others. I am thankful and fortunate to have been able to learn from and enjoy the friendship of many of the past, current, and future specialists in pain.

Mr. Kottenstette: I appreciate all those in my career who took interest in me and helped provide me the information that I needed to succeed to care for patients well. In particular, Dr. Robert Wright, was one who truly stood out as an individual who held a high standard, held me to a high standard, and was constantly on a quest for more knowledge and improving the care we provide. Also, Dr. E. Jeffrey Donner, who is my current supervising provider, for again holding a high medical standard of care and maintaining a high ethical standard in a field where a lot of people would wish to cut corners to save money.

Conclusion

Webster’s defines a mentor as, “a trusted counselor, guide, tutor, coach.” Collectively, we, the authors, have more than 40 years of experience in the specialty of pain management. Although we came to the specialty from different backgrounds, we share common goals of advocating for the compassionate and just care of patients with pain, while continuing to educate, coach, and mentor our APP peers in a career dedicated to the specialty of pain management. We wish you all a happy, healthy, and successful 2021.

 

Mentor/Interviewee Bios

Barbara St. Marie, PhD, ANP-BC, GNP-BC, FAANP: Barbara St. Marie is a certified adult, gerontology, primary care nurse practitioner, and is pain management certified through ANCC. She serves as an assistant professor in the  College of Nursing, University of Iowa.As a nurse practitioner for more than 20 years, Dr. St. Marie has worked in pain management, palliative care and hospice, and internal medicine in a primary care setting. She has a PhD from the University of Wisconsin, Milwaukee, WI, and completed postdoctoral studies in pain and associated symptoms at the College of Nursing, University of Iowa. Dr. St. Marie has been editor of the first and second editions of the Core Curriculum for Pain Management Nursing through the ASPMN. Dr. St. Marie focuses on informing pain management practice across the continuum of care. She has received foundational grants to study patients with pain receiving opioids in a methadone clinic, primary care, advanced practice nurses prescribing opioids for those with chronic pain, and development of a decision support tool for pain management for primary care providers.

Marsha Stanton, PhD, RN: Marsha Stanton is a registered nurse with a bachelor’s degree in health services administration and education, a master of science in health & human services, and a PhD in health services administration and education. Her career has spanned clinical practice, program development, health professional education, publication planning, alliance development, advocacy for both patients and professionals, and legislative engagement. She is nationally known for her work in the area of pain management and the disease of addiction. In her industry positions, she was responsible for the professional education of healthcare prescribers and others, including consumer and community programming at national, regional, and international levels. In 2009 she received the first Educator of the Year award for Industry, given by the American Society of Pain Educators, and in 2010 was given the Educator of the Year award by the National Association for Drug Diversion Investigators. Dr. Stanton has been actively involved in the American Academy of Pain Medicine Foundation since its inception and was awarded the Distinguished Service award from AAPM in 2014. In  2018 she received the President’s Award from the American Society for Pain Management Nursing.

Chris J. Kottenstette, PA-C, CPE: Chris J. Kottenstette started in patient care as an athletic trainer for high school and college students and then moved to emergency services as a paramedic for 17 years. He then trained at the University of Utah Physician Assistant Program and has since worked in family practice, orthopedic surgery, and emergency medicine, and since 2001, in the field of pain medicine, currently as a clinical PA in spine surgery and interventional pain practice. Chris has been active in the PA community at a national level since 1998. In 2003, he founded the PAs in Pain Medicine Special Interest Group of the American Academy of Physician Assistants and is their current president. Chris was an invited member of the AAPM and APS guidelines for the management of chronic non-cancer pain and has participated in the creation of both state and national pain guidelines. He founded SI-Technology, a spinal implant development company and he is also the president of Abuse Tech, LLC, which provides engineered solutions for abuse deterrence and clinically-focused education in abuse prevention, mitigation, and compliance in the field of pain medicine.

Last updated on: January 5, 2021
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Advanced Practice Matters with Theresa & Jeremy: COVID, Pain, and Power
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