am a former cardiac anesthesiologist who is now chair of an academically strong department of anesthesiology with excellent physicians specializing in regional anesthesia, acute pain management and chronic pain medicine. Three years ago, I chased an experienced physician assistant (PA) away from our pain clinic by implying that she was not seeing enough patients. Rather than hire another PA, I took responsibility for one of the 10 pain clinic sessions per week. My goal was to acquire practical experience with chronic pain patients, pain clinic management and the economics of pain medicine in order to make better executive decisions regarding the clinic. Although I had no formal training in pain medicine, I naively reasoned that I knew more about it than a PA and that I could easily attend to more patients in one session than the PA could in two. The jury is still out on the former, but not on the latter.

I have been doing this now for three eye-opening years. I see 12 to 16 patients per session, and my session tends to run late. I frequently schedule additional catch-up time in the clinic to keep the waiting list under control. All my patient visits are for evaluation and management (E&M) except for the occasional patient requiring triggerpoint injections. I refer patients who may benefit from invasive procedures to other physicians within the clinic. My learning curve is still very steep. When asked to write this article, my first step was to create a list of things I learned from my experience. I selected for discussion the 10 that were most significant from a management perspective.

1. Four Patients Per Hour: It is a challenge to see four patients per hour for routine evaluation of their pain medicine regimens or for follow up after interventional procedures. Part of the reason for this is that an assessment of a patient’s activities of daily living (ADL) is as, or more, important than his/her physical examination. These assessments take time and are difficult to standardize. It takes time to assess the patient’s level of analgesia at rest and with activity. It takes time to find out whether he/she can afford to get prescriptions filled and whether he/she takes them as prescribed. It takes time to answer the patient’s questions or those of his/her family members. It takes time to write a separate prescription for each month of opioid administration. Finally it takes time to dictate or record information. If I were to do everything myself, a routine visit by an uncomplicated patient would take me 23 minutes [greetings (1 minute), history and ADL assessment (4 minutes), analgesia assessment (2 minutes), physical examination (3 minutes), medication discussion (3 minutes), answering the patient’s questions (2 minutes), prescription writing and review (5 minutes) and dictation (3 minutes)]. Thus after the first patient, I would already be eight minutes behind, and at the end of the session, the clinic would run 96 minutes late. Almost everything that I do to shorten this time either increases overhead, decreases patient satisfaction or jeopardizes quality of care.

2. Ideal Care: We are not providing the ideal care. For most patients with pain, providing analgesia should be part of a comprehensive approach that includes counseling, physical and occupational therapy, biofeedback, diet control, sleep assessment or psychiatric help. Managing all this takes time and training that the pain medicine physician frequently does not have and resources that neither the clinic can afford to add to its overhead, nor the insurance cover nor the patient pay for out of his/her pocket. In most cases, our current therapeutic goal is not to eliminate pain, as it should ideally be, but to control pain sufficiently to enable patients to cope, stay out of emergency rooms, satisfy their insurance carrier and to not call the clinic between visits.

3. Work Hard, Lose Money: Pain clinics are a low-margin business unless they are a boutique practice or only perform interventional procedures. Anesthesiologists who specialize in pain medicine frequently collect more than an operating room anesthesiologist, but operating room anesthesiologists do not have the burden of a clinic’s overhead. For pain clinics to break even, continuous adjustments need to be made to the patient/payer mix, the ratio between E&M visits and procedures, the number of patients enrolled in studies and billing, coding, contracting, collecting and overhead costs. In most academic medical centers, these interrelationships are metastable. I am not as optimistic as I would like to be that pain clinics can survive in academic medical centers because the overhead is too high, the patient/payer mix too adverse, the dean’s tax too onerous and the collection systems too unresponsive. We may find it necessary to outsource this care and training.

4. Clinic Over, Work Not Done: When most anesthesiologists complete the surgical schedule, they are satisfied that their work is done. When pain medicine physicians see their last clinic patient, they still have dictation demands, charts to review, telephone calls from patients and pharmacies to answer, consults to see, letters to write to referring physicians, disability forms to complete, insurance and medication inquiries to answer and a higher likelihood of medical-legal inquiries to address.

5. Referring Physicians: Referring surgeons, oncologists and primary care physicians frequently demonstrate an enormous reluctance to prescribed drugs for which you cannot circle refills, i.e., you must write out a separate prescription for each 30 days. Referring surgeons will go to great lengths to convince the patient and the pain medicine physician that it is the pain medicine physician who must prescribe opioids. Much of their reluctance is understandable. Unless pain clinic physicians make it very clear up front that the patient will return to the referring physician once a stable pain management regimen is established, however, there will be two undesirable consequences. First, the patient will begin to view the pain medicine physician as his/her primary care physician, a role for which the pain medicine physician is not adequately trained. Second, the delicate balance between E&M and interventional visits will be upset, and the clinic will lose money.

6. Patient Satisfaction: The percent of patients satisfied with their anesthesia is much higher than the patients who are satisfied with their analgesia. Chronic pain patients are more demanding, more manipulative and more dissatisfied with their lives than surgical patients. They challenge our professionalism more. When evaluating the clinical performance of faculty members, I cannot weigh complaints from chronic pain patients about their anesthetic experience the same way that I weigh complaints from surgical patients.

7. Substance Abuse: If you think the profile of a person who abuses opioids is someone between the ages of 16 and 40, poorly educated, poorly dressed with weird hair and poor personal hygiene, unemployed and with tattoos and body piercings, it would not take long in a typical university pain clinic before you recognized that abuse is not limited by age, gender, race, education, economic status or concern for personal appearance. If you think that pain clinic patients never sell or trade any of the opioids they are prescribed because they hurt so much, you also are in for a surprise. One of the reasons why pain clinic visits cannot be too abbreviated is because time must be spent with patients evaluating their social situations and following up on suspicious behavior such as involvement in frequent accidents, losing prescriptions, requesting early prescription renewals, trying medications prescribed for their friends or family and escalation of their pain scores. There is a fine line between trusting your patients so that a reasonable analgesic regimen can be established, being suspicious that demands for more opioids may reflect abuse or dealing, and giving people the benefit of the doubt. Some patients need oxycodone 80 mg by mouth four times a day, while others requesting 20 mg twice a day should not get it. Some patients can be trusted with medication for breakthrough pain while others cannot.

8. Physician Satisfaction: I look forward to seeing most of my patients on return visits. They are basically good people who are just trying to lead reasonably normal lives. A bond is established when you demonstrate commitment to helping them do this. When you succeed, there is enormous positive feedback and reinforcement. Pain medicine physicians do improve the quality of life of most of their patients.

9. Physician Frustration: There is too much about pain that I do not understand. I have yet to get a handle on fibromyalgia, myofascial pain or headaches. I have deluded myself into thinking that I understand enough about acute pain and such chronic pain conditions as osteoarthritis, failed laminectomy syndromes and herpes zoster-associated pain to be comfortable treating these conditions. In between are the complex regional pain syndromes and diabetic neuropathy. When I go to the literature for help, the best I can hope for is consensus opinions. There are too few good clinic studies evaluating either interventional or medical chronic pain treatment regimens. Pain medicine has a long way to go before it becomes as evidenced-based as I think pain physicians would like it to be. I also think we rely too much on our traditional anesthesiology journals for help and not enough on contributions from genomics, neurology, neurosciences, neurosurgery, nursing, oncology, orthopedic surgery, pharmacology, physical medicine and rehabilitation, psychiatry, radiology and rheumatology. Pain medicine is multidisciplinary.

10. Future: I think it is more important than ever for anesthesiology to find ways to invest in pain medicine. Basic research on mechanisms, translational research on drugs and pain assessment and clinical research on interventions and treatment protocols are needed. We are relying too much on opioids, which I believe will be considered gross and inelegant medications in the next century. We must develop systems that will enable us to treat pain in a way that payers can afford, patients can accept and appreciate and in which pain medicine physicians can have job satisfaction and make a reasonable living. Our current system is barely holding itself together.

Raymond C. Roy, Ph.D., M.D., is Professor and Chair, Department of Anesthesiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina.