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Much has been written about the origins of pain medicine
as a distinct discipline, and anesthesiologists have played
a primary role since the beginning. It started with the
introduction of effective general anesthetics in the mid-19th
century when surgical pain could be separated from operation.
Almost 100 years later, the late John J. Bonica, M.D., an
anesthesiologist and recognized father of the specialty
we now call pain medicine, developed his career promoting
multidisciplinary pain care and formal training of specialists.
From his life's work, we now have extensive ongoing efforts
to recognize and treat pain effectively, to train subspecialists
and to conduct basic and clinical research to further our
understanding of pain and its treatment. The International
Association for the Study of Pain (IASP) was founded in
1974; its U.S. chapter, the American Pain Society (APS),
and the journal Pain are legacies left by Dr. Bonica for
our patients.
"Dr.
Bonica's experiences during World War II led
him to believe that each medical specialist
had unique expertise to bring to suffering patients;
hence his consistent and effective promotion
of a multidisciplinary process for pain care."
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Accredited fellowship training in pain medicine is a relatively
recent development. Prior to 1992, training was obtained
in academic anesthesiology departments, including those
of Dr. Bonica, Phillip O. Bridenbaugh, M.D., Harold Carron,
M.D., Frederick P. Haugen, M.D., Daniel C. Moore, M.D.,
Phulchand Prithvi Raj, M.D., Alon P. Winnie, M.D., and others,
and subsequently in programs run by their trainees. These
unaccredited programs advanced the specialty, widened interest
in pain medicine as a career and propagated pain care in
the smaller communities across the country. The American
Board of Anesthesiology (ABA) developed an interest in certifying
pain medicine training. Through the leadership of William
D. Owens, M.D., in his roles in both ABA and the Residency
Review Committee (RRC) and through his representations of
the subspecialty to the American Board of Medical Specialties
(ABMS), formal training programs were accredited and physicians
certified. Stephen E. Abram, M.D., and John C. Rowlingson,
M.D., were both key members of the group that assisted Dr.
Owens in moving the new subspecialty forward.
The first programs recognized by the Accreditation Council
for Graduate Medical Education (ACGME) were accredited in
1992. The number of ACGME-accredited programs [Figure
1] and the number of trainees in accredited programs
[Figure 2] have grown steadily over
the past decade. ABA, working in conjunction with ACGME,
developed a subspecialty certification examination in pain
medicine, first named the "Certificate of Added Qualifications
in Pain Management" and now titled "Subspecialty
Certification in Pain Medicine." The first examination
was given in 1993. The number of candidates sitting for
the examination has grown steadily, and the pass rate has
declined steadily since the first examination was given
[Table 1].
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Figure 1: Number of ACGME-Accredited
Pain Medicine Training Programs
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Number of ACGME-accredited pain medicine training
programs each year since the initial programs
received accreditation in 1992. The first
accredited trainees completed training in
1993. (Data provided by the American Board
of Anesthesiology.)
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Figure 2: Number of Pain
Medicine Trainees
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Number of pain medicine trainees
each year since ACGME-accredited training
programs were established in 1992. All data
represent year-end reports except 2002 (mid-year
report). (Data provided by the American Board
of Anesthesiology.)
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Pain and its consequences draw on resources from all medical
disciplines. Dr. Bonica's experiences during World War II
led him to believe that each medical specialist had unique
expertise to bring to suffering patients; hence his consistent
and effective promotion of a multidisciplinary process for
pain care. Also, it was largely due to Dr. Bonica that anesthesiology
has been a leader in the development of formal training
programs. Indeed, all currently accredited programs reside
within academic anesthesiology departments, and the majority
of program directors are anesthesiologists.
Specialists from other disciplines also have focused their
clinical and research efforts on pain. The most obvious
example is neurology, where the majority of clinical treatment
and research about headache has arisen. Physical medicine
and rehabilitation has long had a focus and expertise in
functional restoration, and many chronic pain rehabilitation
programs are led by physiatrists. Of course, psychiatrists
have been closely involved in treating patients where pain,
depression and substance abuse overlap. During the last
decade, specialists from these other disciplines have been
seeking subspecialty training in pain medicine with increasing
regularity. The historical development of pain medicine
training within anesthesiology departments, however, has
left us with a problem to solve.
Pain medicine training programs, by and large, are led
by anesthesiologists, and they reside solely within anesthesiology
departments. Specialists from disciplines other than anesthesiology
who apply for fellowship training are, on occasion, overlooked
in favor of anesthesiologists who have weaker academic credentials.
Program directors struggle with how to train nonanesthesiologists
within existing programs. Most anesthesiology-based programs
incorporate neural blockade, regional anesthesia and acute
postoperative pain into the fellowship training. However,
how can we train nonanesthesiologists to safely perform
regional anesthetic techniques that the anesthesiology-trained
fellows are familiar with when they begin fellowship training?
Should we train nonanesthesiologists to perform neural blockade
at all? Other disciplines question whether anesthesiology-based
programs are providing adequate training in nonanesthesiology
topics relevant to pain medicine. For instance, should the
trained pain specialist be familiar with the appropriate
use and interpretation of diagnostic imaging studies? How
about electrophysiologic testing?
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Table 1: Percentage of Candidates
Passing ABA Pain Medicine Examination
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Percentage of candidates receiving a passing
score on the ABA subspecialty examination
in pain medicine. The examination was first
offered to candidates from the American Board
of Physical Medicine and Rehabilitation (ABPMR)
and the American Board of Psychiatry and Neurology
(ABPN) as well as ABA recertification candidates
in 2000. (Data provided by the American Board
of Anesthesiology.)
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So, we are at a crossroads. Nonanesthesiologists want access
to subspecialty training in pain medicine, and the anesthesiologists
leading existing training programs just do not know how
to train them. ABA has opened the subspecialty examination
process to other specialists through the American Board
of Psychiatry and Neurology (ABPN) and the American Board
of Physical Medicine and Rehabilitation (ABPMR). Candidates
who have board certification in a primary specialty recognized
by the ABMS can sit for the ABA pain examination by applying
through one of these two agencies (ABA will only accept
applications from trainees with primary board certification
in anesthesiology). For the next several years, there is
a "grandfather" process in place that allows specialists
from these other disciplines who are already practicing
pain medicine to sit for the examination without completing
formal fellowship training. Many nonanesthesiologists have
already taken the examination [Table 1]. Once the window
of time to enter the examination through the grandfather
process elapses, all trainees will be required to complete
formal fellowship training.
ABA and ACGME as well as the other two parent boards, ABPN
and ABPMR, recognize the problems with access to training
programs and the difficulties that program directors face
when training nonanesthesiologists. They also feel firmly
that patient care in the United States will be improved
by finding a way to make pain training truly multidisciplinary
and capable of training specialists from various disciplines
in a uniform way, always with the patient at the center
of the decisions being made.
Under the leadership of past chair Steven "Butch"
Thomas, M.D., and current chair James F. Arens, M.D., of
the Residency Review Committee for Anesthesiology, ACGME
has assembled a task force to develop a unified curriculum
for pain medicine training. We (Drs. Brown and Rathmell)
represent anesthesiology on this task force along with representatives
from all of the other disciplines. The task force had an
easy time deciding what needs to be taught; with minor modifications,
the group unanimously recommended that the Core Curriculum
for Professional Education in Pain assembled by Howard Fields,
M.D., and IASP be adopted by all training programs. During
the coming year, the group will grapple with how to structure
the fellowship to allow training of physicians from different
specialties in the most effective and pragmatic way. It
is a challenge, but one from which our patients will benefit.
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James
P. Rathmell, M.D., is Associate Professor, Department
of Anesthesiology, University of Vermont College of
Medicine, and Director, Pain Management Center, Fletcher
Allen Health Care, Burlington, Vermont. |
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David
L. Brown, M.D., is Professor and Head, Department of
Anesthesia, University of Iowa Health Care, Iowa City,
Iowa. |
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