his past year, I have found myself overwhelmed with challenges, including recertifying in pain boards, Accreditation Council for Graduate Medical Education fellowship program re-accreditation review (not only for certification but to increase fellowship size) and, questionably the most time-intensive, enrolling as a fellow in the Executive Leadership in Academic Medicine, or ELAM, program. This core program of the Institute for Women’s Health and Leadership at Drexel University College of Medicine is in its 13th year and is dedicated to training women in academic medicine to become leaders and agents of change in the clinical, educational, research and community academic medical center arenas. The entire year-long program supports women and minority leadership, involves completing individual and group projects and inducts women into an international network cheering women on in their professional lives.

Part 1: Becoming a Dixie Chick
By nomination of my dean, I found myself in a group of eight very motivated, highly articulate and intelligent women with whom I have the opportunity to retreat, reflect and learn many leadership tools in organizational dynamics, boundaryless structure, conflict management, and building bridges and teams. Extensive personality testing and 360-degree evaluations revealed many personal weaknesses, but my one identifiable strength — indeed, a record high score I was told never achieved by any other participant in the current or earlier classes — was my “warm personality” and “balance of personal and professional life.”

Right then my other less stellar scores were mitigated in the hope that I might have an achievable goal, i.e., to win the title “Miss Congenitality.” I also discovered that my personality type (NF) was called the “great harmonizer,” so I began getting to know my group members to find how we could possibly have the best time and still accomplish everything on our “to do” lists. Our first task was to settle on a name, and as my style is to always try to exceed expectations, we decided in this high-powered group to go for a name that we could surely exceed, and thus were born the Dixie Chicks. In addition most of us have strong emotional, if not physical, connections to the South, a spirit of fun and adventure; indeed, all that we lacked were matching chicken foot tattoos on our ankles.

Part 2: Discovering My Passion
In the ensuing weeks, isolated in conference centers, every traditional and experimental teaching method was employed on our group of eight and the other five groups to cajole, encourage, inspire and command us to find our passions, become agents of change, and then develop a battle plan to storm our individual academic health centers, a.k.a. “The Action Plan.”

Mine, of course, was pain medicine, a rapidly emerging, ever-changing, much-in-demand subspecialty that belongs mostly to anesthesiology, as did critical care and resuscitation in the very early years. But also like these disciplines, it has wide, overlapping areas with other specialties. Much like early anesthesiology at the beginning of the last century, newly evolving specialties are open to innovations and creative thinking. Early anesthesiologists experimented with rectal ether for thyroidectomy, sequestration anesthesia employing rubber tire tubing exsanguinations and electric shock anesthesia. So in the pain world, we have the standard nerve blocks with local anesthesia and steroids but also cognitive behavioral therapy, new applications for old drugs, innovative surgical and interventional procedures, and complementary medicine techniques. I have even been called on to talk to the puppets that a patient brought in, each one symbolizing a different doctor with whom she wanted me to discuss her pain. Mine was called “Dr. Cope-Well,” Magic Healer of Pain disguised as a golden unicorn. So the unicorn and the black cat (“Dr. Gato” for Dr. Katz, who spoke in a strange accent) discussed the patient’s arm pain. And who knows? She stated that she felt much benefit and has not returned. Maybe there is a study in there somewhere.

Anyway, I have long felt that the burgeoning subspecialty of pain medicine is just now defining itself and is often misunderstood by the world in general and by many operating room anesthesiologists in particular. Many think we are indeed magical and can cure many psychic troubles, including addiction, a history of childhood abuse, anxiety disorders and general sadness, with the application of an epidural needle. Others think our primary function is to dole out mind-altering euphorics with the chief benefit being to clear out their waiting rooms.

So my dilemma was clear: How can we as a division define ourselves and expand our clinical reach and influence to help patients, teach our fellows and residents, participate in collaborative research and, most importantly, let our colleagues know what we can and cannot do to help them practice better medicine by good pain control?

As I so often repeat our credo to my pain fellows, the first words out of a good physician’s mouth should always be, in every circumstance, “How may I help you?”

Part 3: The Evolution of an Idea
So what was I learning in hour after hour (one day lasting 17 hours!) that I could apply? First of all, and these lessons are highly personal and do not reflect on the comprehensiveness or expertise of the program but rather my selective retention:

Lesson 1: As eloquently described by Tom Gilmore, always work toward partnership. When things don’t go your way, one has the choice to “make up a story” with yourself in the center as victim, hero, innocent bystander or whatever and “they” doing or not doing something to hurt you or to get in your way. This sort of myth-making destroys any chance for partnership.¹

Lesson 2: We don’t have to live in silos. The best work is done through collaboration rather than competition (back to Lesson 1²). Certainly with pain medicine, which I envision as a hub in the wheel of health care, most of the medical disciplines intersect and are all important for clinical care, teaching and research.

Lesson 3: Whenever at all possible, “push things down.” I have been extremely blessed with a loyal and talented crew of pain physicians, many of whom I have “trained as pups.” It’s a delight to see them solve problems, grow academically and far surpass what I can envision or do alone.

Lesson 4: Explained by Jim Collins in his “Good to Great” studies of the best companies is the intersection of three circles as the best place to devote your efforts and find success. These three components are: 1) what you are deeply passionate about, 2) what you can be best in the world at and 3) what drives your economic engine.^3,4

In the pain medicine division, we are passionate about achieving the best pain care education and research, we are the pain “experts” at our institution, and we are driven by our reputation, which is defined in our credo, “How may we help you?”

Part 4: The Action Project: The Envoy Principle
When one wants to establish a diplomatic relationship with a foreign country, one sends an envoy, usually bearing gifts, to understand the culture, promote peace and explore opportunity for exchange of goods and services between countries. Pain, to many, is a new subspecialty and a foreign culture. So while I was planning a great campaign, as often occurs, serendipity trumped strategic planning. My epiphany dawned on the afternoon of my third son’s commencement from the University of Pittsburgh. As one of only three medical school faculty members processing with the other faculty in full regalia (necessary to secure a seat in the front section and simultaneously embarrass my son), I encountered the chief of GI medicine, David C. Whitcomb, M.D., Ph.D., who had a daughter graduating and was dressed equally ostentatiously for the very same reasons.

Pain, being my passion, was discussed, and we realized the commonality of our goals while waiting through the interminable processions and name readings. The Digestive Disorder Center, treating thousands of patients suffering from chronic pain, could use our expertise, and we could benefit from participation in their visceral pain research initiatives and understanding their world view. The first envoy posted, ZongFu Chen, M.D., will spend Wednesday afternoons not only adding new treatment options but learning the GI medicine culture and attending their didactic and research conferences with a pain fellow in tow. Already he is hard at work writing book chapters in an invited collaboration with this highly productive group.

Once the first envoy was identified and posted, the possibilities for cultural exploration out of our “Pain Silo” appeared everywhere.

Cheryl D. Bernstein, M.D., a neurologist and another of our pain fellowship graduates, is now infiltrating the Lupus Center one day every other week. Dean Mariano, D.O., and A.J. Carvelli, M.D., again former fellows, are forging links with the neurosurgeons and metastasizing to the spine center.

Other diplomatic missions that we are contemplating include forging links with oncology practices, family practice preceptorships and physical medicine training programs.

The Envoy Principle is my action project to break out of our pain silo and collaborate without boundaries between our program and the rest of the world. The goal is nothing short of excellence in patient care and the educational and research richness that cooperative learning and commonality of purpose can provide. My hope is that in providing physical proximity and face-to-face contact with a new set of physician colleagues and pain patients, we will gain the empathy and understanding to answer our own pain medicine division’s credo: “How may we help you?”


References:
1. Gilmore TN, Shea G. Organizational learning and the leadership skill of time travel. J Manage Develop. 1997; 16(4):84-93.
2. Ashkenas R, Ulrich D, Jick T, Kerr S. The Boundaryless Organization: Breaking the Chains of Organizational Structure. Revised and Updated. San Francisco, CA: Jossey-Bass; 2002.
3. Collins J. Good to Great and the Social Sectors: Why Business Thinking Is Not the Answer. A Monograph to Accompany Good to Great. 2005.
4. Collins J. Good to Great: Why Some Companies Make the Leap… and Others Don’t. New York: Harper Business; 2001.

Doris K. Cope, M.D., is Chief, Division of Pain Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.