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Douglas R. Bacon, M.D., Editor
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Painful Lessons
uring medical school, the one thing I learned was
that I disliked afternoon sessions in clinic. The
endless parade of patients while bouncing between
examining rooms lacked the drama and urgency of the
operating room (O.R.) or the intensive care unit.
Listening to a long litany of chronic complaints or
checking blood pressure, while important, lacked the
sense of significance I found in more invasive work.
Thus I approached my pain rotation during residency
with some trepidation. What would I find? My unending
fear was a long list of patients with complaints that
could neither be cured nor helped. Residents in my
senior year of training did not help as they told
me of the horrors of the pain clinic.
Yet the rotation was wonderful. It began with the
attending staff who ran the rotation. Young, energetic
and a marvelous anesthesiologist and physician, Gerald
Peer, M.D., had time for each resident and the patience
to teach us the nuances of pain medicine. He was diplomatic
in guiding our diagnoses and skillful in teaching
us the regional anesthetic adjuvants that were and
are so important to pain medicine. As we decided what
to do in our third year of residency, it was a great
temptation to spend more time in the pain clinic.
On my first job after residency, management of acute
postoperative pain was a critical skill as we built
an acute pain service. All of the anesthesiologists
were expected to care for these patients when on call,
and each of us took weekly turns running the service.
I learned a great deal about education that first
year and how important it is to see that all members
of the team caring for a patient understand the plan.
Patience was another virtue I slowly developed, trying
hard to remember that the nurse who did not know how
to restart an epidural infusion needed to be taught,
not criticized.
“As an anesthesiologist interested in pain medicine
but not formally trained in the subspecialty, I watch
on the sidelines and wonder what is happening to this
important part of anesthesiology.”
My next career stop was at a Veterans Administration
hospital. There was a desire on the part of the hospital
administration and the university chair with whom I
worked to develop a pain medicine program. Resources
were tight, and we could not hire any ancillary personnel
to help with the service. Several of the anesthesiologists,
myself included, saw chronic pain patients to try to
help sort out those with treatable conditions from those
who had other motivations for continuing to have pain.
It was far from ideal.
In my most recent job, I have almost daily interactions
with our excellent pain group. There is considerable
crosstalk among the acute pain service and the anesthesiologist
responsible for placing regional anesthetic blocks.
At one of the hospitals in which I practice, an aggressive
catheter service for lower extremity blocks has been
developed, allowing patients with total hips and knees
to ambulate better and have lower narcotic requirements.
To watch them in practice is quite impressive.
Yet, recently, there was a movement afoot to have these
anesthesiologists take only pain call and to leave O.R.
call behind. While this is the national trend, it greatly
saddened me. Anesthesiologists have been involved in
pain medicine since the 1920s and have been leaders
in the field for almost 85 years. Why is this separation
occurring, and is it inevitable? Should “mainstream”
anesthesiology be worried about this trend? A pain medicine
colleague of mine recently expressed to me the opinion
that there should be a certification for “interventional
pain medicine” much the way there is for interventional
radiology or cardiology. The field of interventional
pain medicine would encompass blocks, spinal cord stimulators
and like modalities and would be something unique to
anesthesiologists. Interventional pain medicine would
be consistent with anesthesiologists’ historic
role in the field as well. While this is not a new idea,
and it may be too late to implement, it is certainly
a proposal that deserves action.
As an anesthesiologist interested in pain medicine but
not formally trained in the subspecialty, I watch on
the sidelines and wonder what is happening to this important
part of anesthesiology. By establishing “pain
only” call and spending more and more of their
time in the pain clinic, O.R. anesthesiologists lose
touch with their pain medicine colleagues. Having pain
physicians in the O.R. environment is helpful, for they
serve as a resource on many matters and also a reminder
of another part of the mission of the anesthesiology
department. Lacking an O.R. presence, like the highly
successful basic science researcher, these physicians
lose touch with their home specialty, and the specialty
with them. It is always harder to look individuals in
the eye and tell them they are not part of the department
than it is to cut off a clinic outside the department.
As O.R.-based physicians, we need to be sensitive to
the issues that surround our colleagues in the pain
clinic. Their hours, while different from an O.R.-based
practice, may, in fact, be longer. Issues of office
space, which sound foreign to many in the O.R., are
of crucial value to our pain colleagues. Getting the
right equipment (such as fluoroscopy units) and finding
O.R. time, not at the end of the day, but at a mutually
convenient time, also is important. Salary and reimbursement
issues may be different, and they may challenge conventional
thinking.
In the end, we are all anesthesiologists regardless
of the subspecialty we practice. As such it is our undertaking
to eliminate pain whenever possible, either from the
scalpel or other painful conditions. It is time for
those of us in the O.R. to remember our colleagues in
the pain clinic and value their expertise; and pain
medicine physicians should understand that they are
needed and supported in anesthesiology. Only then will
we be able to begin to fulfill the promise unleashed
in the 1840s in the United States — freedom from
pain in modern anesthesia!
— D.R.B.
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