|Year : 2013 | Volume
| Issue : 1 | Page : 1-3
Specialty training in pain medicine
Sujeet Gautam1, Gautam Das2
1 Department of Anaesthesiology, SGPGIMS, Lucknow, India
2 World Institute of Pain Section (India) Director, DARADIA- The Pain Clinic Concord Tower, Ultadanga, Kolkata, West Bengal, India
|Date of Web Publication||10-Jul-2013|
World Institute of Pain Section (India) Director, DARADIA- The Pain Clinic Concord Tower, Ultadanga, Kolkata - 700067, West Bengal
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Gautam S, Das G. Specialty training in pain medicine. Indian J Pain 2013;27:1-3
Pain medicine is the medical discipline concerned with the diagnosis and treatment of the entire range of painful disorders. In recent years, we have witnessed beginnings of the emergence of 'Pain Medicine' as a distinct academic discipline, with delineated borders and aims. Interventional pain medicine is evolving as a distinct discipline that requires detailed new knowledge and expertise. Familiarity with the radiographic anatomy for the conduct of image-guided injection and the minor surgical skills needed to place implanted devices such as spinal cord stimulators and implanted drug delivery systems are just a few of the techniques that practitioners must master. As we set out to introduce new interventional techniques to our own pain practices, we must be sure that we have been properly trained to conduct these techniques, to assure safety and success.
Chronic, unrelieved pain is a major unsolved healthcare problem worldwide. It is universal, with no age, race, social class, national or geographic boundaries. It has enormous associated costs, financially (treatment compensation and lost productivity), as well as, is a tremendous burden in terms of degraded quality of life for the sufferer and his / her family and immediate society. Rough estimates place the costs of chronic pain, as a disease state, in the very substantial category of cardiovascular disease and cancer. The incidence of chronic pain tends to increase with age. With the success of curative and preventative medicine, and the consequent increase in the average life-span, the problem of chronic pain is likely to increase in the foreseeable future.
Given the enormous need, the time has come to focus, with greater awareness, on the problem of chronic pain as a disease, and to recruit the human, financial, and organizational resources required to face it. In the past decade, healthcare authorities of several countries all over the world have recognized this need and have begun to establish programs for specialist training and certification in the field of Pain Medicine. The time has come to broaden the scope of pain specialization, using uniform, agreed upon standards of training and certification for pain specialists. This will ensure higher professional quality, uniformity, and mobility among pain specialists, and ultimately better patient care. Such standards will also promote recognition among specialists and non-specialists alike, as also the boundaries at which patients with complex chronic pain ought to be referred to a pain specialist for treatment. Finally, they will create a body of trained professionals qualified to provide guidance and leadership in the areas of therapeutic modalities, resource allocation, research, ethical considerations, and public policy concerning chronic pain and its management.
John Bonica, an anesthesiologist and recognized father of the specialty we now call pain medicine, developed his career promoting multidisciplinary pain care and formal training of specialists. From his life's study, we now have extensive ongoing efforts to recognize and treat pain effectively, to train subspecialists, and to conduct basic and clinical research to further our understanding of pain and its treatment. The International Association for the Study of Pain (IASP) founded in 1974, its US chapter, the American Pain Society (APS), and the Journal of Pain are legacies left by Dr. Bonica for our patients.
Accredited fellowship training in pain medicine is a relatively recent development. Before 1992, training was frequently obtained in the Academic Anesthesiology Departments, including those of Bonica, Bridenbaugh, Carron, Haugen, Moore, Raj, Winnie, and others, and subsequently in programs run by their trainees. These unaccredited programs advanced the specialty, widened interest in pain medicine as a career, and propagated pain care in smaller and smaller communities across the country. Outside of the United States, this type of informal training remains the rule for those seeking expertise in pain medicine. In the United States, the American Board of Anesthesiology (ABA) developed interest in certifying pain medicine training. As a result of this, the American Board of Medical Specialties (ABMS), accredited formal training programs in pain medicine and the physicians were certified. 
The first programs recognized by the Accreditation Council for Graduate Medical Education (ACGME) were accredited in 1992. The ABA working in parallel with the ACGME developed a subspecialty certification examination in pain medicine, first named the, 'Certificate of Added Qualifications in Pain Management' and now titled 'Subspecialty Certification in Pain Medicine'. The first examination was given in 1993. The number of candidates sitting for the examination has steadily grown since the first examination was given.
Dr. Bonica's original push to develop multidisciplinary pain care recently evolved into a collaboration between four specialties agreeing to a single and unified set of program requirements for all ACGME-accredited Pain Fellowships, regardless of the sponsoring specialty. The Residency Review Committees (RRCs) for Anesthesiology, Neurology, Physical Medicine, and Rehabilitation and Psychiatry, agreed on these requirements in late 2005, and the ACGME Board approved their implementation for 2007.  These requirements will standardize Pain Fellowship training and hopefully produce a more comprehensive and multidisciplinary focused physician.
The Fellowship Training Program is 12 months long and begins after satisfactory completion of a core residency in anesthesiology. The majority of time in the Fellowship Training Program must be spent managing pain patients, in contrast to the Operating Room or Obstetrical Anesthesia. The Association of Anesthesiology Pain Program Directors (AAPPD) has suggested that a total of 180 days of acute, chronic, and cancer pain patient care be the minimum provided during the course of the Fellowship. This represents four days a week of clinical care, with accommodation for vacation and meeting time. If this minimum cannot be met during the course of a year because of research or other clinical work, the program should be extended for that individual. Although there is no mention specifically of laboratory research conducted during the training period, such activity should not substantially reduce the trainee's time spent in the care of pain management in patients. 
The Pain Medicine Fellowship will provide the selected candidate exposure to a Multidisciplinary Pain Program. The candidate will be prepared to practice all aspects of Pain Medicine and ultimately manage a comprehensive pain program. The purpose of the Fellowship Program is to provide comprehensive pain medicine training. The learning objectives encompass training in a variety of areas of pain medicine including, acute pain, chronic pain, cancer pain, and hospice and palliative care. The Fellow will provide effective and compassionate care to patients with acute and chronic pain with the following objectives:
- Learn and perform thorough assessments of patients in acute and chronic nonmalignant and malignant pain
- Develop and implement treatment plans using clinical and scientific data and patient preference
- Competently perform all medical and invasive procedures considered essential for managing pain, which include, but are not limited to:
- Image-guided cervical, thoracic, and lumbar spinal injections
- Minor and major joint or bursa injections
- Trigger point injections
- Sympathetic blocks
- Neurolytic techniques including chemical and radiofrequency treatment for pain
- Intradiscal procedures, including discography
- Spinal cord stimulators
- Placement of permanent spinal drug delivery systems
- Communicate effectively with patients and their families
- Achieve and document the required number of patient interactions required in each of the disciplines described in the ACGME Pain Medicine Fellowship Program Requirements.
The Faculty of Pain Medicine Royal College of Anesthetists has prepared a 'Guide for Regional Advisors, Trainers, and Trainees' for providing advanced pain medicine training for anesthetists.  It has the following suggestions:
- Pain services within the training program must be sufficiently busy and employ sufficient staff to offer full-time training in Pain Medicine, as also, a wide, balanced range of clinical experience in the management of acute, chronic, and cancer pain.
- Commonly more than one center combines to create a comprehensive training program; the individual centers may offer training in only one particular aspect of pain medicine.
- Where the training occurs in more than one hospital, there is usually a single center that has a large, anesthetist-led pain medicine service, serving as the central focus for the overall training.
- At least one of the training centers must have links to a palliative care service. Training in the relevant aspects of Palliative Medicine may be from such links or from an attachment to a specialist Palliative Care Unit. Trainees must still obtain experience of the management of cancer pain in a general hospital setting.
- The Advanced Training Program is competency-based, but it is recommended that the program provide 12 months of training in Advanced Pain Medicine. Ideally this period should be continuous, but in special cases, could be completed in separate modules with the minimum acceptable continuous period being six months.
- Special arrangements must be made for trainees in less than full-time training posts, so that their equivalent training can be accomplished within an acceptable period.
- Trainees who express an interest in Advanced Pain training would still be expected to complete a three-month Higher Pain Training Module, but where possible, this would be arranged in a center offering Advanced Pain training, and opportunities to explore the specialty would be made available.
European Federation of IASP Chapters (EFIC) calls for the establishment of a framework for realizing pan-European training and certification standards in Pain Medicine,  which will include: (1) Creation of a core curriculum of basic and applied medical knowledge on pain. Some efforts have already been made toward this goal, including the core curricula developed by the IASP. These constitute a good starting point for the EFIC chapters, but there is a need to coordinate and further develop the existing knowledge, (2) Definition of a recognized toolkit of practical pain management resources including essential drugs and procedures, and (3) Subspecialty training (in some countries an alternative term might be adopted, such as, 'competence' or 'capacity') will include acquisition of clinical experience by candidates, under supervision, leading to recognized professional certification in 'Pain Medicine'. The typical duration of such a training program is two years, including the period of practical training, although this period may be adjusted. Candidates entering the program will be required to have already obtained accreditation in an appropriate medical specialty such as Anesthesiology, or Rehabilitation Medicine.
In India, efforts are going on, particularly from the Indian Society for Study of Pain (ISSP). They formed a task force in 2009, to outline the course content of courses of different duration. The ISSP also formed a committee to identify training centers and award a Fellowship of one-year duration, but it is still under process. To date, there are few private clinics who regularly conduct short courses and workshops. There are facilities for one-year Post-doctoral Certificate Courses (PDCC) providing training opportunities in the field of Pain Medicine; but there are only two institutes providing PDCC courses at present, one is the Institute of Medical Sciences, BHU, Varanasi (PDCC started in 2008) and Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow (PDCC started in 2010). The PDCC at both these places are recognized by the Medical Council of India. The Medical Council of India has also approved a three-year MD course in Palliative Care at the Tata Memorial Center, Mumbai, since 2012. Therefore, a lot of work is still required for the development of teaching and training in India.
| References|| |
|1.||Rathmell JP, Brown DL. The evolution of training in pain medicine in the United States. American Society of Anesthesiologists Newsletter, November 2002. |
|2.||Program Requirements for Fellowship Education in Pain Medicine. Available from: http//www.acgme.org/acWebsite/downloads/RRC_progReq/sh_multiPainPR707_TCC.pdf. [Last accessed on 2013 May 25]. |
|3.||Abram SE. Education and Training of Pain Management Personnel. In: Prithviraj P, editor. Practical Management of Pain. 3 rd ed. Philadelphia: W. B. Saunders; 2002. |
|4.||"Guide for Regional Advisors, Trainers and Trainees" by The Faculty of Pain Medicine Royal College of Anesthetists. Available from: http://www.rcoa.ac.uk/document-store/providing-advanced-training-pain-medicine-anesthetists-guide-regional-advisors. [Last accessed on 2013 May 25]. |
|5.||EFIC's call for Specialization and Certification in Pain Medicine. Available from: http://www.efic.org/index.asp?sub=1602e13G5R0a22 . [Last accessed on 2013 May 25]. |