The new specialty of pain medicine has developed during a time when medicine and society are re-examining their commitment to caring for pain. Public demand for improved medical attention to pain is growing in parallel with increasing regulations and standards for pain-related assessment and treatment. Likewise, mandates for primary and continuing education in pain care for medical students and physicians also are escalating, and administrative and legal actions against physicians who do and do not treat pain are receiving increased media attention. The identity of pain medicine is evolving against this backdrop.

Defining the Specialty
Pain medicine presently encompasses specialized knowledge, education and training that are not clearly defined or organized within the existing structure of specialties recognized by the American Board of Medical Specialties (ABMS). Although pain medicine is largely practiced as a subspecialty, it remains controversial as to which, if any, of the ABMS boards is the parent specialty. Currently the Accreditation Council for Graduate Medical Education (ACGME) views pain medicine as potentially falling under either anesthesiology, physical medicine and rehabilitation, neurology or psychiatry. Neurosurgery, pediatrics, internal medicine, family medicine or others might lay claim as well. At many levels, this new specialty parallels the evolution of other multidisciplinary specialties, such as emergency medicine, that were initially fragmented and became primary medical specialties because of the inability of existing specialties to integrate in the best interests of patients and medical science.

Unlike other recognized medical specialties, there is no clear consensus on the content or duration of specialized training and experience required to become a proficient pain specialist. To date, the many primary disciplines that contribute to the knowledge base and clinical application of pain medicine have been unable to consolidate the complexity of pain into comprehensive curricula or universally accepted training requirements.

Certification
Two distinct pathways for specialty certification in pain medicine began at almost the same time. The American Board of Anesthesiology (ABA) approved a certificate of added qualification (CAQ) in pain management in 1991. This certificate was followed by applications for subspecialty certificates in pain management from the American Board of Psychiatry and Neurology (ABPN) and the American Board of Physical Medicine & Rehabilitation (ABPMR) in 2000. The American Board of Pain Medicine (ABPM) was formed in 1991 to address the multidisciplinary training and experience necessary for the specialty of pain medicine and to offer certification to qualifying physicians from all medical specialties. Medical licensure boards in California (1996) and Florida (1999) recognize the ABPM board certification as equivalent to ABMS board certification, and ABPM diplomates in the state of Texas have been determined to be qualified to advertise themselves as board-certified. ABPM is seeking ABMS recognition as a primary specialty. Currently ABPM certifies 1,768 diplomates, of which 1,048 are anesthesiologists.

The ABPM certification examination in pain medicine is an eight-hour, psychometrically validated, practice-related examination developed in conjunction with an educational testing organization. The examination tests the knowledge and cognitive skills necessary to provide comprehensive pain care as determined from surveys of pain medicine and pain management physicians from a variety of parent ABMS specialties. The examination is offered once per year to qualified individuals, and unlike the ABMS-recognized CAQ, sets a standard for passage that is fixed irrespective of the candidate’s primary training specialty. Basic eligibility requirements include completion of an ACGME-accredited residency program that includes identifiable training in pain care, board certification by an ABMS member board, at least 18 months of clinical practice of pain medicine and at least 50 hours of category 1 continuing medical education credit relevant to pain medicine in the two years prior to sitting for the examination.

The recent addition of ABMS-approved certification through ABPN and ABPMR indicates that organized medicine is recognizing the multidisciplinary nature of pain medicine, which does not fit under any present single ABMS specialty. ACGME and ABMS are attempting to resolve the problems with our current system of pain specialty training, especially the need for more comprehensive, multidisciplinary training of pain specialists. Proposed solutions include requiring more multidisciplinary input and lengthening current subspecialty-style fellowship programs from one year to two or more years.^1,2 The added time burden of extended fellowship training after residency, however, might be a disincentive for new physicians to enter the specialty at a time when more, rather than fewer, pain specialists are needed. Residency and fellowship training requirements for the field of pain medicine have been developed jointly by the American Academy of Pain Medicine (AAPM) and ABPM, which have made recommendations to an ACGME task force.³ Another ACGME task force also is considering recommendations from ABMS member boards to consider lengthening present fellowship requirements and requiring more multispecialty input.

Where Will Pain Fit In?
Pain medicine is currently practiced as a subspecialty of multiple medical specialties without any single specialty clearly being the most appropriate. How this new field is integrated within health care will greatly affect the ability of medicine to meet its mission and obligation to understand and treat pain. Without changing current practices of medical education and clinical care, medicine appears poised to continue to incur more regulations and laws that will require it to do so. The necessary changes will require unification of the disparate parts of pain medicine that currently reside within multiple specialties. Potential solutions include continued development of programs under the auspices of disparate disciplines that may not work well together to encompass the full scope and practice of pain medicine or development of pain medicine as a primary specialty. In either case, revising our current system of pain education and training for future pain specialists will not be painless.


References:

1. Gallagher RM. Pain education and training: Progress or paralysis? Pain Med. 2002; 3:196-197.

2. Lema MJ. What’s the name of the game? ASA Newsl. 2002; 66(5):1,22-23 .

3. American Board of Pain Medicine. Essentials of Pain Medicine. Evanston, IL: 2001.

Scott M. Fishman, M.D., is Professor of Anesthesiology and Chief, Division of Pain Medicine, Department of Anesthesiology and Pain Medicine, University of California-Davis School of Medicine, Sacramento, California.