|Year : 2016 | Volume
| Issue : 2 | Page : 77-79
Pain education in India
Department of Pain Medicine, Sri Ramakrishna Hospital, Coimbatore, Tamil Nadu, India
|Date of Web Publication||18-Jul-2016|
Department of Pain Medicine, Sri Ramakrishna Hospital, 395, Sarojini Naidu Road, Siddhapudur, Coimbatore - 641 044, Tamil Nadu
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Vijayanand P. Pain education in India. Indian J Pain 2016;30:77-9
A central character in Candide, ou l'Optimisme, a French satire by Voltaire, was Dr. Pangloss - professor of "métaphysico-théologo-cosmolonigologie." Optimistic regardless of the circumstances, and ignorant to all philosophy and reasoning that does not support optimism, he believed that "we live in the best of all possible worlds." Voltaire's magnum opus-a blend of sharp wit and insightful portrayal of the human condition-stands testament to philosophical optimism giving way to painful disillusionment in the title character's mind as he scuttles from one disaster to the other.
Pain education in India has been on a similar turf and almost Panglossian for many years. If pain education was delivered as it has always been done and if the optimism was kept high, one hoped that somehow it should all fall into place. It cannot be the best of all possible worlds where medical undergraduates are asked to serve rural communities with very little pain knowledge, or where postgraduates struggle to differentiate neuropathic from nociceptive pain. And that world, certainly, would neither have the pain physicians known disparagingly as "injectionists" nor the 10-day long poke, inject, and forget courses masquerade as pain fellowships.
| The Problem of Pain|| |
The influence of pain in an individual's life is far greater than that of any other neurological processes. From a societal perspective, a Lancet survey of 500,000 physician consultations in India suggested that pain is a major reason to seek health-care consults.  A fifth of urban Indians suffer from pain, and the prevalence was not very different in our rural communities. Its impact across professions, across geographical regions from rice field farmers in West Bengal to oil drill workers in Gujarat, and from dentists in Mangalore to nurses in Maharashtra is not exactly discriminatory. Its severity and impact, too, could be so much so that a significant proportion of pain sufferers in India would like to quit their job if they have not already done so. Together, these statistics suggest a looming public health crisis.
| The Challenges|| |
Pain education across the world
A survey by the British Pain Society concluded that the veterinary undergraduates were taught better pain management than students who would be dealing with humans in the future.  Our four-legged or feathery friends comparatively had better trained doctors caring for them. A Europe-wide research in 242 medical schools across 15 countries found that 82% of the medical schools did not have compulsory pain education, and when pain education was compulsory, it accounted for an average of 0.2% of medical undergraduate teaching.  The future doctors in Europe were clearly ill equipped to manage or treat their 75 million pain sufferers. A similar situation prevails in North America. India's premier institution AIIMS offers more than double the number of hours of pain-related teaching, mainly in the domains of pain physiology and pharmacology, but precious little for students to better understand clinical pain care.  Collectively, these data suggest that undergraduate pain education is uniformly poor across the world.
The difference between developed and developing countries is much more evident in postgraduate and sub-specialty pain training programs. The modular training, well-thought-out curriculum, accreditation criteria, in-training assessment, faculty development, and clearly defined examination pattern of the various Boards and Faculty of Pain Medicine are lacking in India. There exist a handful of pain fellowships in India that are 12 months or longer and offer the trainee a stipend. These university-accredited fellowships and private fellowships is a start, but woefully inadequate to meet the ideals of equitable health care for India. A standardized, nationwide pain training program is an experiment in the making by the Indian Society for Study of Pain (ISSP), the success of which depends on developing a culturally sensitive, common minimum criteria without going overboard with the model of developed countries.
Learning from mistakes
The developed world, if one accepts the term, means that there is little scope for improvement - a sobering thought. The Western model of pain management has its own challenges. For the millions of dollars pumped into pain care, the United States has very little to show in terms of improved productivity or reduced absenteeism. Driven by insurance lead payments and with not much consideration for quality multidisciplinary pain care, it might require a major overhaul. The "Pain is a V th Vital Sign," sloganeering has now been consigned to the bin by the American Medical Association. We, the gullible in India, parroted these sound bites; we can regret in leisure. That pain, whatever be the cause, could be treated with opioids is a Western invention of the 21 st century. That now, opioids are the biggest killer accounting for 25,000 deaths a year in the United States is the reality. The "lancinating" pain in the McGill Pain Questionnaire is something that even the British do not report despite the Brexit. Such descriptors are uninformative, hackneyed, and not validated in many languages of India. There was then the retreat from the impossible "Pain Relief is a Fundamental Human Right" declaration to the pragmatic "Access to Pain relief is a Fundamental Human Right." To be objective, none of the developed countries claimed supremacy for their model of care; we just aped them without a thought.
| Models of Change|| |
The top-down influence for a change in pain education should involve the regulatory bodies such as the Medical Council of India, accrediting bodies such as the National Board of Examination and the Health Universities, and the Central and State governments. A crucial step in the process is to recognize pain as a public health issue that continues to eat away the scant resources at our disposal. With such recognition comes the will to implement changes that include:
A concerted top-down effort would not just benefit the 200,000 health-care professionals including 50,000 medical undergraduates India produces every year, but also its citizens. At an advanced pain training level, introduction of DM in pain medicine by the MCI and FNB in pain medicine by the NBE would be essential to create future leaders in what increasingly looks like an exciting branch of medicine.
- Training the required number of personnel to teach pain management through train-the-trainer workshops
- Creating awareness among public about self-management of pain and about seeking help
- Policy changes that make it mandatory for health-care professionals to learn assessment and treatment of pain, for example, pain management workshops for undergraduates in medicine, physiotherapy, and nursing, and implementing pain management as part of the curriculum
- Monitoring the changes. Not just to find how well it works, but to find the means to improve the process
- And finally, allocating the funds and resources to drive the program.
While the top-down influence sounds aspirational and something for the immediate future, the outside-in changes have been happening for many years. These changes, brought about by the national and international experts and learned societies such as the ISSP through training programs, public awareness events, and CMEs, have created a fertile ground for the proposed changes to grow and flourish. The Indian Academy of Pain Medicine, the academic wing of the ISSP, is on the verge of starting an 18-month pain fellowship across many accredited centers in India. The pilot project is bound to start in July 2016, with the formal admission of pain trainees scheduled later in the year.
There has been a flurry of voluntary activities in pain education targeting the medical undergraduates, nurses, and physiotherapists. A group of physician volunteers, Travelling Pain School, had collaborated with the Australian and New Zealand College of Anesthetists and the World Federation of Society of Anaesthesiologists to teach more than 10,000 health-care professionals across India in 3 years. The group has, in addition, 150 strong faculty across India that could travel to teach. Furthermore, they have collaborated with the Association of Physicians of India and the Indian College of Physicians to conduct pain management workshops for the physicians. The International Association for Study of Pain's pain curriculum is a good starting point for voluntary organizations to consider before the launch of such events.
The outside-in influence would do better negotiating with governments to provide cost-effective pain education for professionals involved in rural health care. The impact of local pain champions in resource-poor settings would likely influence the affordability, availability, and accessibility of pain care in rural India. The outside-in impact could, in addition, include advocacy efforts on patient education, setting up online learning resources and pain education research.
The most powerful driver for change, however, is the bottom-up model. The regular requests to conduct pain workshops in undergraduate national conferences are a case in point. When a common clinical problem is tackled through interactive lectures, brainstorming, and group discussions, with careful consideration of adult learning principles, success could be the only result. Organized by student volunteers with the enthusiastic participation of the student community, it is a robust bottom-up change. The postgraduates too have the opportunity to contribute to the Dr. Kop Award sessions in the anesthesia national conference. The frequent requests from the students during such events include online learning modules for pain management and a "Pain Prize" exam. These are the requests that the ISSP should consider.
| Conclusion|| |
Il faut cultiver notre jardin - the famous final line of Candide that translates to "we must cultivate our own garden" - almost certainly has an original meaning that is multi-layered. It is plausible that it means reflecting on what we already have can help discover the solutions for our problems. Another interpretation would be that a concept of togetherness, of "notre jardin," allows for a more sympathetic resolution that could prevent crises in the future. It may have been a call to follow our true passions, exercising our own judgments and choices. Probably, it is a swipe at religion - we should concentrate on cultivating our Earthly gardens rather than the Garden of Paradise. It is also possible that it is in the praise of honest and hard work without worrying and philosophizing all the time.
In the context of pain education, Il faut cultiver notre jardin certainly means "Make in India" - an opportunity to gather and incorporate the best models of pain education. Such educational strategy should be central to the National Pain Policy when it is formulated - a culturally sensitive policy of combinatorial creativity that would deliver social justice in the form of universal pain care. Dr. Pangloss's optimism, after all, was not misplaced. Pain education in India, perhaps, could be improved. The challenge, however, would be to shed the notion that once improved it could not get worse. Now, that requires selfless, unrelenting, and continuous hard work that seeks out the seed of triumph in every adversity.
| References|| |
Salvi S, Apte K, Madas S, Barne M, Chhowala S, Sethi T, et al.
Symptoms and medical conditions in 204 912 patients visiting primary health-care practitioners in India: A 1-day point prevalence study (the POSEIDON study). Lancet Glob Health 2015;3:e776-84.