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19 Articles in Volume 19, Issue #6
Arthrofibrosis: Targeting Hormones after Childbirth to Relieve Frozen Shoulder, Inflamed Joints
Can CGRP Help Clarify Why Migraine Is More Common in Women?
Case Report: Managing Chronic Pelvic Pain in Men
CGRP Monoclonal Antibodies for Chronic Migraine: Year 1 of Clinical Use
Chronic Pelvic Pain as a Form of Complex Regional Pain Syndrome
Correspondence: Continuing the “Pain Specialist” Dialogue
Endometriosis and its Misunderstood Etiology
Evolving Management Strategies for Osteoarthritic Pain
Gamma PEMF Therapy: A Pilot Study For Its Use in Managing Opioid Addiction
Guest Editorial: Sex Differences in Pain
How to Provide Effective Pain Management to LGBTQ Individuals
Interscalene Peripheral Nerve Stimulation for Post-Operative Chronic Shoulder Pain
New ICD-11 Codes Set to Improve Pain Care in the Primary Setting
Perspective: Could NGF Antagonists Be the Safest, Most Efficacious Class of Drug We Have to Treat Pain?
Rheumatoid Arthritis and Cognition: Is There a Genetic Link?
Targeting Nerves Provides Alternative to Opioids for Joint Arthroplasty
The Sex Question in Primary and Pain Care
What is capsaicin’s role in treating osteoarthritis?
When Pain Clinicians Have to Be the Villain: Communication Strategies to Bridge the Divide

Correspondence: Continuing the “Pain Specialist” Dialogue

September/October 2019 Letters to the Editor, including a dialogue around pain practitioner credentials.
Page 9

A Conversation Around the 600-lb Gorilla in the Room: The “Pain Specialist”

Dear PPM,

In your July/August 2019 issue (Vol 19, Issue 5), you published a well-written article by Katie Duensing, JD, on “Can I Call Myself a Pain Specialist?” The article makes significant points about who can call themselves a pain specialist, and that this varies from state to state, and how difficult it can be for someone in chronic pain to find a genuine specialist for their problem.

Duensing also points out the sad state of affairs of so many legitimate pain organizations closing down: The National Pain Foundation; The American Pain Foundation; the Academy for Integrative Pain Management (AIPM); and most recently, it seems, the American Pain Society (APS). These were organizations designed to help educate the public about pain and legitimate treatments, and some were designed to educate pain practitioners about the best pain treatments and research findings. The demise of these organizations will be felt for a long time.

However, if someone has a medical problem, it is one thing to talk about what might help the outward symptoms. But isn’t it far better to get at the root cause of that problem and fix it? That is where this article fails me as a pain physician (Of note, I am board-certified in Pain Medicine), and the American public in general.

There is no identification of the root cause of why this problem of “who is a pain specialist” exists. The 600-lb gorilla in the room is one that no one seems to want to address, yet that gorilla is why things can’t get fixed properly. And here is what the 600-lb gorilla is: the lack of recognition of a primary medical specialty of Pain Medicine, which would offer full 4-year residency training programs in Pain Medicine to medical school graduates, along with an American Board of Medical Specialties (ABMS) member board to certify Pain Medicine specialists.

This offering would solve many of the problems we face today in trying to care for those in chronic pain because it would provide a “home base” for the training of pain doctors, with consistency across training programs. Such a program would allow for comprehensive training of all areas of pain treatment, which currently cannot be completed in a 1- or 2-year fellowship. It would further allow for more doctors to join the specialty of Pain Medicine, as there would no longer need to be completion of a residency in another area first, followed by a one- or 2-year specialization in pain management afterward.

As it stands now, if a doctor wants to specialize in Pain Management, he or she needs to be willing to give up an extra one to two years of training, after they finish being trained for 4 to 7 years in a different specialty, most of which they will never use to be a good pain management provider.

Doctors who are willing to do that are truly dedicated to pain management, but there are many other clinicians who might be interested in pain management, who simply don’t have the time, financial reserves, etc, needed to give up extra years of their lives to do it.

By having a 4-year comprehensive, interdisciplinary Pain Medicine training program available right after medical school, young physicians could be recruited into the field directly, thereby increasing the number of pain specialists that are so badly needed. In addition to a comprehensive 4-year post-graduate training in Pain Medicine, a physician needs to have a board certification available to them and, due to pressure to limit recognition of board-certifying bodies, it should be an ABMS member board.

So, the solution to the 600-lb gorilla doesn’t sound so difficult to design, does it? Why then, hasn’t it been done: the answer is quite simple and disgusting to me: there is a medical turf war among existing specialties to avoid having any more specialties recognized or admitted to the ABMS, which, in my opinion, is a an example of a ‘good ol’ boys’ network.’ Some existing boards want to “own” pain management, while others are afraid of losing membership to a new board.

Are you aware that the American Board of Pain Medicine (ABPM) was founded in 1991 by the leading pain doctors in the US to certify physicians in Pain Medicine, with the goal of becoming an ABMS member board? Since then, it has been one “political” battle after another, with ABMS rejecting the ABPM application.

In fact, ABMS has not admitted a new primary clinical member board in over 35 years. Because the ABMS has become the de facto certifying group that hospitals, insurers, etc, rely on when choosing providers for their staffs and provider panels, this practice of not recognizing newer specialties and admitting a member board for those specialties makes one wonder if this isn’t a form of restraint of trade. The ABPM is not the only applicant to be denied ABMS membership. Other specialties have had their examining boards denied as well, including a primary board for both Sleep Medicine and Addiction Medicine. How can we justify this to the public and those in need of pain care, and act as though all the new advances taking place in medicine don’t create the need for new specialties?

The Foundation for Pain Medicine (FPM) has spoken with six medical schools that are willing and able to start a 4-year training program if there were an ABMS member board to certify their graduates. However, ABMS told ABPM it won’t admit a new member board without 4-year training programs in that specialty: hence, a catch-22. But this problem, too, may have a simple solution: start them both at the same time! Why this hasn’t happened may be due to the egos of those who do have a specialty recognition already, and their spin is placed in several directions, such as funding, Medicare recognition, etc, to avoid dealing with the issue at hand.

In the meantime, the public is losing out by poor pain care that is disjointed and uncontrolled within medicine. Instead, we have “crises,” like the current opioid crisis, that make the government try to find solutions. But one cannot legislate good medical care. One can only impose things on it, and these don’t change what goes on day to day in practice. We need better and more comprehensive training of pain physicians, who operate in a well-defined medical specialty. Then, the public, insurers, politicians, state medical boards, etc will know clearly who is a true pain specialist, and each state won’t have to invent its own wheels.

– Albert Ray, MD

 

Dear Dr. Ray,

I sincerely appreciate your letter, as this is precisely the type of thoughtful discourse I was hoping to provoke with my article. It is imperative that those with a deep understanding of pain management determine what is truly meant by “pain specialist” and when the term is appropriately applied. If not, legislators, regulators, and insurers will make those decisions, whether intentionally or by default. While I won’t attempt to offer a grand solution in this short space, I will offer a few thoughts to consider as we all strive to find the best plan.

Many current policies use the term “pain specialist” to define the professional to whom a patient should be referred when high dosage opioid prescriptions are being utilized. However, “pain specialist” should not necessarily be synonymous with “opioid prescribing specialist.” While current legal policies are using “pain specialist” in relation to opioids, the overall societal trend has been to move away from opioid use (as much as possible, depending upon the individual patient needs) in favor of a more comprehensive, integrative approach to pain management.

If we make the mistake of defining “pain specialist” largely in relation to prescribing, we may find a future in which insurers inadvertently skew reimbursement toward “pain specialists” who are highly trained prescribers of pain medication as opposed to reimbursing “pain specialists” who are effectively utilizing non-pharmacological treatments. Despite pre-existing policies that have attempted to co-opt “pain specialist” as a term purely related to opioid prescribing, we must not lose sight of the well-rounded qualities and training that make a truly effective pain specialist.

Thank you again for encouraging your peers to join you in getting engaged on this highly important issue.

– Katie Duensing, JD

 

Dear Ms. Duensing,

Thank you for your comment to my letter to the editor. Your observations about opioid prescribing and the confusion surrounding it provides an excellent example of what I tried to communicate in my letter.

Current fellowship training in Pain Management (some programs have changed their name to Pain Medicine) offer one or two years of training, which focuses heavily on interventional procedures and medication management, with a smattering of rehabilitation and psychiatry. However, doctors completing those fellowships cannot perform the cognitive-behavioral therapy, hypnosis, or biofeedback, recommend nutritional changes that can affect pain perception, or provide the manual therapies that work best on someone in pain. They, understandably, tend to rely on what they know best (interventional and pharmacological treatments) and refer their patients to PT or a “shrink” if they think there is an issue in those areas.

Without a comprehensive 4-year training program that would include ALL of the non-pharmacological and interventional issues related to pain, including, but not limited to, genetics, nutrition, supplements, acupuncture, sleep disorders, hospice care, addiction medicine, cultural issues, social issues, etc, we leave our current pain specialists with limited tools in their toolbox to work with in designing and offering pain care to our patients. Thanks for your cogent response.

– Albert Ray, MD

What's your take? Email the editors at ppmeditorial@remedyhealthmedia.com and we may add your response here.

 

Editor's Note: The following reader letter was submitted to PPM in response to the above dialogue in November 2019:

Thank you for your excellent insight into the problem of what is a "pain specialist". Ms. Duensing and Dr. Ray bring up excellent points for discussion. As a physician involved in pain medicine for over 40 years, I have seen the specialty evolve from a primarily invasive specialty using anesthetic techniques to a specialty focusing largely on medical management. The original pain medicine certification (I believe 1993) was taken primarily by anesthesiologists interested is better long term invasive therapies.The AAPM (later known as AIPM, which has since folded) created more confusion with the additional focus on integrative pain treatment, that at that point in time, had little evidence base.

The quick addition of the specialties of neurology and physical medicine/rehabilitation to the ABMS created categories of "pain specialists " who had entirely different perspectives on the pain patient. And then we had the confusion added by the ABPM who certified pain physicians who have "on the job" training.

Then in the early 2000s, we had the additional huge problems created by pharmaceutical companies pushing opioids as a panacea, and seriously denigrating the specialty. A 4-year residency makes good sense. It would need to be implemented over a long period of time, a joint effort of Anesthesiology, Neurology, and PM&R residencies, with additional training especially in psychology. And of course, we need pain physicians now to step up and expose those "pain specialists" who do little more than run pill mills staffed by many advanced practitioners who may be very inexperienced. A pain patient referred to a "pain clinic" who never sees an actual specialist and whose only option for treatment is chronic opioids is at a very significant disadvantage.

– Ken Lister, MD

 
Last updated on: November 12, 2019
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