n early 2001, I left an anesthesiology department chair position to become the Chair of the Division of Pain Medicine in the Department of Anesthesiology at the Mayo Clinic in Rochester, Minnesota. During my first presentation to the executive committee of the department, I noted that the pain clinic had a diverse staff, with representation from multiple departments (anesthesiology, complementary medicine [predominately acupuncture], neurology, psychiatry and psychology, physical medicine and rehabilitation, oral surgery and nursing).

Despite the diverse and talented group assembled, however, there was little structured communication between the different specialties, little national presence, no formal divisional goals had been articulated, and few advanced technical/procedural competencies existed. Although the group had been known for being innovative, e.g., introduction of intrathecal morphine infusion therapy,¹ there had been relatively little recent innovation. In an effort to be seen as practicing evidence-based medicine, the group had taken a “wait and see” attitude with respect to intradiscal access procedures, vertebral augmentation procedures, novel uses of spinal and peripheral stimulation implants and a variety of other potential therapies.

Due to an exploding patient population amid inadequate anesthesiology physician resources, the department of radiology had been invited in 1999 to assist in the performance of pain procedures. From 1999 to 2001, the number of pain management procedures performed in radiology had increased from less than 50 per year to approximately 2,000. During the late 1990s, buoyed by ample technological and personnel resources, the department of radiology innovated several unique practices, including vertebral augmentation (vertebroplasty), intradiscal thermal annuloplasty, cervical and lumbar selective root injections and tumor radiofrequency ablation.

The department of anesthesiology only had one fluoroscopy machine at the same time, a 10-year-old portable unit that had been procured from the radiologists. As the anesthesiology pain medicine physicians had little time or interest in becoming involved in the spine center, the radiologists quickly were seen as committed and interested by other departments interested in procedural therapies or diagnostics. At the same time, pain clinic access for opioid management and other chronic pain activities had pushed the clinic to a six-month backlog for lower-acuity patients (noncancer, chronic spine, etc.). As the Mayo Clinic has a unique national patient referral base, the corresponding no-show rate for new lower-acuity appointments increased to greater than 20 percent. The bottom line for our pain division had been that we were well in the red financially (>$200,000 per month) and were seen as dysfunctional within the otherwise prospering anesthesiology department. I would propose that this story is not dissimilar from those occurring at other academic centers throughout the United States.

What happened to all the promise of a career in academic pain medicine? Some of the issues include:

1) Frustration of our young, dynamic faculty. These rising stars wanted better access to operating rooms where they could operatively perform spinal stimulation and intrathecal pump implants. They wanted ease of scheduling, guaranteed timely starts and good equipment. The faculty also wanted to have better fluoroscopy and access to CT equipment and the ability to block schedule procedures when they were convenient. By batching similar procedures together, they could improve efficiency. With operator-driven toggle control switches, they could eliminate the need for fluoroscopy personnel. By receiving credit for a facility fee, they could balance their books better. The younger faculty also wanted nicely appointed and convenient areas to see their new patients, not the corner of a recovery room or other borrowed/second-tier spaces.

2) Competition increased from other specialties. Physical medicine and rehabilitation appears to be most interested, but as above, radiology has become interested as well. Spine practice in particular is one of the hottest areas for physical medicine and rehabilitation physicians, many of whom are being trained by anesthesiologists in fellowships, but more quietly at cadaver-based sessions of interventional societies. Indeed, while academic pain medicine has struggled, many of the true practice innovations have emerged from societies such as the International Spine Intervention Society or the American Society of Interventional Pain Physicians. Guidelines for best practices, standards and political advocacy (new codes and better reimbursement) have led to improved standardization.

3) More lucrative contracts were and are available. Compensation for a busy, procedurally rich private practice is generally higher than that for academic pain physicians. As the frustrations outlined above are present, those choosing private practices can truly have their cake and eat it, too. Many high-profile practices have become heavily involved in education and research through the multiple pain societies and attempt to improve pain practice in this way.

4) Lack of senior/mid-career leaders. Due to the well-described “academic brain drain,”² our young residents and fellows have had few physician mentors to emulate. A one-year fellowship is insufficient to prepare for a research career and learn the clinical care of pain patients as well. Although the residents hear lectures and read articles by their private practice colleagues, it is the daily exposure and admiration for their mentors that provide the experiences they would need to pursue an academic practice.

Future Challenges
What challenges are ahead for academic anesthesiology pain medicine programs? I will preface this by articulating several of my own biases. First, in order to be compensated highly for our work, we must continue to have our identities in procedural-based practices. At the Mayo Clinic in 2005, our evaluation and management (E&M) codes were 44 percent of our total volume but only 17 percent of our revenue. Conversely, despite being only 36 percent of our patient visits, procedures accounted for 80 percent of our revenue [Figure 1].

Second, we must retain access to imaging technology because in the future it will be more important than ever before. Third, we must do more with less. We are reimbursed only for the time we spend with patients, thus we cannot become “primary care” managers for chronic medications. We must develop new systems for managing chronic pain as a long-term disease by better partnering with our primary care colleagues, educating and supporting them during exacerbations and developing new team models of care with allied health personnel.

Fourth, we must remember our roots in anesthesiology — patient safety. We have been the specialty most lauded for our improvement of patient safety.³ Undoubtedly the use of pulse oximetry, end-tidal capnography and other technologies have been important. Likewise, though, our courage in reporting our complications, learning from them and devising new and better methods for improving our practice has been even more important.

Research
The next decade promises to be a time of tremendous change with growing demands for evidence-based practice and the looming specter of pay for performance. As we look ahead to the next decade, there are several things we must do. One could say that all of anesthesiology pain medicine practice evolved from a single procedure (epidural steroid injection). This procedure has been commonly practiced since the middle 20th century, but via a standard interlaminar approach, still has no prospective type I data that demonstrates a reduction in need for surgery. Likewise, even though the evidence for transforaminal epidural steroid injections is better, there is no consensus.

It appears that the best summary of the evidence for lumbar epidural steroid injections is that they may provide transient improvement for a few weeks to selected patients with acute/subacute disc herniations and radicular pain. Although small trials of cervical transforaminal injections appear promising, there have been significant complications, and the trials also have not been validated. Only in the last five years have we garnered some type I evidence that celiac plexus blocks for pancreatic cancer pain are effective.⁴

Similarly we have but one good study demonstrating efficacy of intrathecal drug infusion devices in terms of decreasing opioid toxicity, improving pain scores and possibly extending life.5 A randomized, controlled, prospective study completed last year comparing re-operation on failed back patients versus spinal stimulation is one of a select few that show efficacy of that technique.6 For pain medicine to continue to grow, we must demonstrate that our procedures work, or accept that they do not and find new drugs, new therapies or new technologies that do work.

Technology and Safety
For anesthesiologists to compete with other departments, we need to have access to superior technology. Only when our department purchased its first fixed-base, multi-diagnostic monoplanar fluoroscopy unit were we able to perform procedures quickly and efficiently. Further, the advent of digital subtraction imaging has been a tremendous safety tool, picking up several potential vascular injections that had not been seen with conventional real-time contrast injections.

Many of these units now offer computed tomography acquisition capabilities with mere seconds of delay, which can give three-dimensional information. This capability could be a tremendous tool for safety in the future, particularly for deep visceral, intradiscal or intravertebral targets. Recent uses for ultrasound offer the ability to see certain vascular (ischemia/embolism), visceral (lung parenchyma) or nerve structures that cannot be seen with conventional fluoroscopy, either. Our department is beginning to utilize this technology as well.

Education
Academic departments that have benefited from clinical research that provides evidence for our procedures and that have obtained the necessary technologies and personnel to offer comprehensive pain medicine care to patients must then bring the education of our future physicians back to the universities. We have seen tremendous improvement in the quality and interest level in our residents as we have obtained the necessary equipment and personnel to make pain medicine exciting again.


References:
1. Wang JK, Nauss LE, Thomas JE. Pain relief by intrathecally applied morphine in man. Anesthesiology. 1979; 50:149.
2. Schwinn DA, Balser JR. Anesthesiology physician scientists in academic medicine: A wake up call. Anesthesiology. 2006; 104:170-178.
3. Hallinan JT. Once seen as risky, one group of doctors changes its ways. Wall Street Journal. June 21, 2005:A1.
4. Wong GY, Schroeder DR, Carns PE, et al. Effect of neurolytic celiac plexus block on pain relief, quality of life, and survival in patients with unresectable pancreatic cancer. JAMA. 2004; 291:1092-1099.
5. Smith TJ, Staats PS, Deer T, et al. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: Impact on pain, drug-related toxicity, and survival. J Clin Oncol. 2002; 20:4040-4049.
6. North RB, Kidd DH, Farrokhi F, Piantadosi SA. Spinal cord stimulation versus repeated lumbosacral spine surgery for chronic pain: A randomized, controlled trial. Neurosurgery. 2005; 56:98-106.

Marc A. Huntoon, M.D., is Associate Professor and Chair, Division of Pain Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota.