May 2002
Volume 66 |
Number 5
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VENTILATIONS
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| What's the Name of the Game? |
Mark J. Lema, M.D., Ph.D.
Editor
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Mark J. Lema, M.D., Ph.D. Editor
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Many established anesthesiologists remember the frenzy over securing
advanced training positions in cardiac anesthesiology during the
1970s and 1980s. Clearly, having a cardiac fellowship on one's
curriculum vitae paved the way for a more lucrative job or even
a department chair. Being a cardiac anesthesiologist was the mark
of distinction.
The new killer whale swimming in the shark tank of anesthesiology
fellowships is now pain medicine. With this decade being deemed
the "Decade of Pain Research," the need for pain specialists
in laboratories, at academic medical centers or in hospitals and
clinics is rapidly expanding. Salaries for pain specialists are
as high as $50,000 more than for a corresponding staff anesthesiologist
position. There seem to be 10 applicants for every pain fellowship
position unfilled. Despite the apparent success pain management
programs are currently experiencing, however, there are signs
and symptoms consistent with a poor prognosis for survival.
First, anesthesiologists have always been "needlers"
as Angelo Rocco, M.D., would say during our one-month pain rotation
obligations. In 1983, there were a few pain clinics, no accredited
fellowships and no board-certification process. Spine surgeons
or internists sent chronic back pain patients or reflex sympathetic
dystrophy patients for epidural injections or sympathetic blocks.
Certainly the multidisciplinary, multimodal therapy approach
experienced in many of today's pain centers was limited to a few
locations in the United States. The anesthesiologist practiced
pain medicine largely in the holding area where regional blocks
could be performed safely. Truly being a "needler" then
was an asset.
Pain management has transformed into a high-tech, laser-fast
practice of empiric invasive therapies that changes monthly when
the scientific journals are released. With the unprecedented emphasis
on both outcome-based therapy and mechanism-based pain research
studies by the government, this fledgling specialty will soon
change again. However, will it favor pharmacologic therapy, invasive
therapy or a balanced, combined approach? Moreover, what impact
will the specialties of psychology, psychiatry, physical medicine
and rehabilitation (PM&R), and neurology have now that their representation
is rapidly increasing? Will they, of necessity, transform into
"needlers" too?
The direction in which pain medicine is headed clearly does not
favor the "block first and ask questions later" approach
used by some "needlers." It is more distressing to think
that anesthesiologists who do practice evidence-based, cost-effective
pain medicine may vanish from the specialty over the next 20 years.
Consider the following elements that have given me reason to believe
that anesthesiology and anesthesiologists cannot afford to be
in the pain game.
1. As anesthesiology stays underserved, fewer residents will
reject attending physician salaries to spend another year in training.
These positions will then fill with visa-holding international
physicians who may be unable to practice in the United States
after training.
2. The likelihood of a two-year accredited fellowship program
makes salary gratification deferral even less of a possibility
for anesthesiology residents.
3. Now that the American Board of Anesthesiology also supervises
the accrediting examination for pain management in psychiatry,
PM&R and neurology, these specialties will expand their pain programs
and seek to meld with those existing in anesthesiology.
4. Other specialties see a pain fellowship as the brass ring
of career success. On the other hand, those anesthesiologists
who do not perform a large number of procedures are faced with
a salary reduction compared with surgical anesthesiology.
5. In some states, malpractice insurance for pain specialists
performing neurosurgical or orthopedic-style surgeries (intrathecal
pumps, spinal cord stimulators, intradiscal electrothermography,
percutaneous laser dissection, etc.) has reportedly tripled.
6. Reimbursement remains low probably due to the concept that
80 percent of all office visits in the United States are pain-related,
and rates are based on primary care clinic visits.
7. Pain specialists, unlike cardiac anesthesiologists, become
alienated from the operating room culture and begin to relate
to clinic-based, primary care-type medicine.
8. As most anesthesiologist-pain specialists become disenfranchised
from their parent specialty, they drop out of active participation
in and financial support of traditional anesthesiology issues.
Soon they are no longer ASA or component society members.
9. The anesthesiologist-dominated pain societies are not working
together to form one large organization. Conversely, societies
promoting one facet of pain medicine are expanding. There are
at least nine societies that anesthesiologist-pain specialists
can join, many having redundant course offerings and all having
yearly dues assessments.
10. Hospital systems will not be able to financially support
pain clinics, especially in poor areas, as reimbursement rates
drop, thus resulting in clinic closings.
11. One day, family practitioners and internists will reawaken
and realize that they can perform the first few iterations of
pain therapy, reducing the pool of patients for those who "needle."
One pain organization recently asked if pain specialists needed
ASA. Its reply was, "…in the opinion of [their] Board…we
do need ASA." I was somewhat surprised at this half-sincere
response and felt that the authors failed to appreciate the umbilical
connection between anesthesiology residency programs and practicing
anesthesiology-pain specialists.
Consider this scenario: A department chair has three pain fellowship
positions. Recent dialogue among academic chairs and the Accreditation
Council for Graduate Medical Education (ACGME) has suggested that
anesthesiology open its fellowship doors to other specialties
with ACGME fellowships. Anything less may be considered a restrictive
practice strategy. Suppose that this chair is in need of surgical
anesthesiologists but also needs pain fellows as less expensive
providers. Also suppose that the chair is aware that once anesthesiologists
become pain specialists, their usefulness as surgical anesthesiologists
wanes markedly. They may even stop paying ASA dues. Given this
scenario, he or she devises a wonderful strategy. J-1 visa physicians
are recruited for the fellowship positions knowing that they may
not be able to remain in the United States or leave for an underserved
area. Even better, the chair can give two of the three positions
to other specialties that, of course, supply their own fellow
lines. In this way, he or she not only frees up two lines for
more anesthesiology resident positions but also contributes to
the development of a multimodal pain specialty that may even employ
less expensive physicians. This win-win scenario for department
chairs appears to be flawless. Who cares if anesthesiology is
no longer producing the lion's share of pain specialists? They
end up leaving the specialty, and the chairs need to fill anesthesiology's
ranks with fellowship-trained physicians who work in the operating
rooms or critical care units after residency, not in daytime pain
clinics.
So to those who wonder if pain specialists need ASA, the answer
is "no." There are plenty of rehab, neurology and psychiatry
physicians, with family practitioners looming near, to take up
the slack vacated by anesthesiologists. From my perspective, the
battle for control of the pain specialty is already lost, and
we have not yet begun to address damage control. The "we"
means pain practitioners (I include myself). Do not blame ASA
for our current state of confusion; it exists to provide the forum,
the meeting places and the resources when solicited.
There is always hope, however, for restructuring pain management
within the boundaries of ASA. First, anesthesiology-dominated
societies need to merge. Other pain specialists could become full
members and actively participate, but the organization would be
a subspecialty society of ASA. Second, ASA must impress upon the
American Medical Association that an ASA subspecialty pain society,
formed by the merger of several other pain societies, is the voice
of pain medicine for all physicians. Third, the media and the
politicians must be educated to accept this new pain society as
the voice of pain physicians nationally. Fourth, real change must
be pursued to obtain fair reimbursement for cognitive pain services.
Fifth, true evidence-based medical care must be practiced using
standard practice paradigms and not based on a procedure-oriented
approach. Sixth, fellowship training needs to be multidisciplinary
as the certifying board examination becomes the same for all specialties.
Seventh, when the time comes for pain medicine to become a new
medical specialty, ASA would counsel it as a sphere of influence,
not as a colony.
My views may be pessimistic and my solutions unattainable, but
this essay is a culmination of 15 years of participating in the
grassroots effort to make all types of pain treatable or preventable.
Progress seems to have stalled largely because of the current
medical turmoil. Science may provide the tools for effective pain
therapy, but medicine must provide the workshops that are efficient,
effective, available, affordable and unified.
– M.J.L.
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