March 1999
Volume 63 |
Number 3
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| Preliminary Results
of the Committee on Pain Management Survey |
Douglas G. Merrill,
M.D., Chair
Committee on Pain Management
In an ongoing effort of ASA to assess the needs and interests
of its membership, the Committee on Pain Management created a
questionnaire that was intended to elucidate the membership's
level of interest and activity regarding pain management. It was
mailed in the May 1998 issue of the NEWSLETTER.
As might be predicted by this relatively "quiet" and low cost
approach to such an assessment, return rate was low. A total of
35,406 NEWSLETTER issues were mailed, including an international
circulation of 2,200 and 375 sent to nonphysicians. We received
a total of 219 replies. This represents a return rate of .06 percent
of the physician recipients. Nonetheless, here are the results
(numbers are a percent of the total answers for the question unless
otherwise noted):
1.In answer to how many clinical hours are worked per week:
| a. 0-20 |
2.7% |
| b. 21-30 |
1.3 |
| c. 31-40 |
7.3 |
| d. 41-50 |
28 |
| e. 51 or more |
61 |
2.What percentage of that time is spent in pain management which
is not postoperative?
| a. 0 |
12% |
| b. 1-25 |
35 |
| c. 26-50 |
16 |
| d. 51-75 |
8 |
| e. 76-100 |
29 |
3.In answer to the question as to whether or not pain management
was a valuable service which anesthesiologists provide patients:
| a. yes |
97.5% |
| b. no |
0.5 |
| c. no opinion |
1.8 |
4.The question regarding activity offered the choices of weekly,
monthly or rarely. Often the respondents would write in that they
did not mark one because they "never" did it. I think that would
be an acceptable analysis of any nonresponse and so is noted as
such below:
| Procedure |
weekly |
monthly |
rarely |
never |
| Lumbar epidural steroid |
73% |
7% |
14% |
6% |
| Cervical/thoracic epidural steroid |
50 |
16 |
28 |
6 |
| Stellate block |
33 |
33 |
29 |
4 |
| Lumbar sympatholytic block |
25 |
32 |
39 |
4 |
| Facet joint blocks |
35 |
17 |
36 |
12 |
| Fluoroscopy |
47 |
10 |
33 |
10 |
| Epidural stimulators |
3 |
18 |
57 |
22 |
| Spinal/epidural pumps |
3 |
17 |
67 |
13 |
| Selective nerve root blocks |
25 |
25 |
33 |
17 |
5.In response to the question as to whether ASA should devote
more resources to pain management issues and education:
| a. yes |
74% |
| b. no |
13 |
| c. no opinion |
14 |
6.This question asked for a ranking (of 1-8) of the importance
of the following issues in pain management. Here were the point
breakdowns (lowest point total is considered most important):
| Rank |
Point Total |
| 1. Validation of treatment regimens |
475 |
| 2. Outcome measurement techniques |
537 |
| 3. Recognition of pain management as a specialty
by insurers |
704 |
| 4. Credentialing of physicians |
802 |
| 5. CPT code revision |
887 |
| 6. Physician fraud and overtreatment |
957 |
| 7. Definition of pain subspecialty certification |
975 |
| 8. Nurse anesthetists involvement in pain management |
1,373 |
Item number eight may be a little misleading, as the choice
of the nurse anesthetist was very often associated with extremely
negative conclusions. In other words, many respondents placed
it last as they did not want the concept even to be considered.
7.The responses to the question of whether or not the responding
physician had achieved American Board of Anesthesiology (ABA)
certification with Added Qualifications in Pain Management were:
8.Percentage of respondents belonging to other specialty societies:
| American Society of Regional
Anesthesia |
58% |
| American Pain Society |
30 |
| American Academy of Pain Medicine |
29 |
| International Association for the Study of Pain |
29 |
| Invasive Spinal Instrumentation Society |
15 |
| (Other) |
12 |
I believe the low return rate reflects either general apathy
or failure to see the questionnaire, rather than disinterest in
this topic. The reason for this "optimism" is that not one of
the six partners in my own pain management practice returned a
questionnaire! I know their interest is quite high.
Such a low return suggests a need for alternative methods for
performing such a survey. The Committee on Pain Management is
considering the many options in this regard. Alternatives include
Internet-based techniques, random sampling mailings, "exit" sampling
at meetings and others. Most often, there is significant expense
associated with these, but we feel the information gathered to
be of great significance to ASA.
I believe the following information was gained from this survey:
- It is apparent that the practice of pain management outside
the operating room is one which is still considered an important
aspect of the practice of anesthesiologists who do not necessarily
consider themselves to be "subspecialists" in the field.
- The majority of practitioners consider ASA to be a particularly
important body for the promulgation of good pain management
practice and in the representation of those who practice it.
- The answers to the various questions indicate that most of
the respondents work in this area less than 25 percent of the
time and perform primarily what would be considered by most
as straightforward techniques (epidural steroid injections,
stellate blocks, etc.). Nonetheless, nearly half of the respondents
use fluoroscopy, presumably for placement of epidural injections.
This is notably different from a poll of attendees at an ASRA
meeting last May that indicated that the great majority of anesthesiologists
do not do so.
- Many respondents emphasized their desire for ASA to devote
more resources to pain management issues and education with
specific comments regarding: a) need for greater emphasis in
this area at the ASA Annual Meeting with hands-on workshops,
b) development of an ASA program to help practitioners study
their own outcomes, c) an ASA statement or position paper on
the ethical practice of pain management, d) many concerns about
what the ASA could do about fraud and abuse in this area, and
e) a call for ASA to sponsor more education in palliative care.
- The ranking of importance of issues in question 6 was gratifying
to the members of the Committee on Pain Management who have
been working on the creation of a Society-sponsored database
of outcomes in pain management.
Interest in the problems associated with coding issues
and the recognition of the practice of pain management by
payers and health agencies mirrors a joint effort in these
areas on the part of the committees on Economics and Pain Management
and the staff of the ASA Washington Office.
Moreover, the poll results also reflected the subject of the
majority of the mail that the committee receives annually from
members of the Society. These letters ask for advice and help
with regard to what they consider to be overly aggressive
and fraudulent care provided by some anesthesiologist pain
management specialists in their own communities.
- A concern was often raised that the ABA examinations for
Added Qualifications in Pain Management were held too infrequently
(annually).
- A random sample of other comments follows:
- The more pain management can be made into an objectively,
rather than subjectively measured service, the better it would
be.
- Formulation of acute and chronic pain control pathways
with studies of efficacy and cost outcomes is needed.
- "... Pain medicine these days is word of mouth medicine
with no scientific support or ...validation... I feel as though
I have become a chiropractor."
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- Fellowship training should be extended and more surgical
and radiologic training added.
- Accreditation of pain clinics by the Commission for the
Accreditation of Rehabilitation Facilities is a threat to
us as it puts rehab medicine in charge of pain medicine.
- There is a need for one to two week mini-residencies for
practicing pain doctors.
- Help is needed with the Drug Enforcement Administration
and state agencies regarding opioids for chronic nonmalignant
pain.
- Pediatric pain issues need to be emphasized more at the
meetings.
- Physician fraud and overtreatment are a huge problem; there
is rampant fraud and "upcoding" by some individuals, which
is hurting everybody.
- There should be acceptance of alternative medicine for
chronic pain.
- We need help with Medicare guidelines.
- Anesthesiologists need to do a better job with suffering
and not just practice technical medicine.
We appreciate the time and thought used by those who responded to
the questionnaire. We hope to make use of this information in promulgating
the education and practice of pain management within our Society.
Douglas G. Merrill, M.D., is Director
of Valley Analgesia Services, Valley Anesthesiology Consultants,
Phoenix, Arizona.
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