|Year : 2020 | Volume
| Issue : 2 | Page : 85-88
Unique challenges and opportunities faced by pain physicians during COVID-19 crisis
Babita Ghai1, Sidharth Verma2
1 Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Pain Clinic, Painacea Spine, Wellness and Pain Relief Center, DY Patil University School of Medicine, Mumbai, Maharashtra, India
|Date of Submission||03-Jun-2020|
|Date of Decision||08-Jun-2020|
|Date of Acceptance||01-Jul-2020|
|Date of Web Publication||06-Aug-2020|
Prof. Babita Ghai
Department of Anesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
The COVID pandemic has affected pain practice throughout the world. It has now become amply clear that the pandemic is here to stay for long. Pain physicians have a very important role to play in the pandemic and that is taking care of the chronic pain patients to avoid complications. This responsibility falls in the essential service category and cannot be shrugged off the shoulders by practitioners of pain medicine. Initially, various associations, societies, and organizations came up with various guidelines recommending management options following a conservative approach. However, the stance has changed almost on a real-time basis, and the current approach is to decide management on a case-to-case basis. This unique scenario has put up a lot of challenges ahead for the budding superspecialty of pain medicine. However, it also offers some opportunities which can pave the way for a bright future for the pain physicians and more importantly for their patients.
Keywords: Challenges, COVID-19, Opportunities, Pain Physicians, Pain practice, SARS COV 2
|How to cite this article:|
Ghai B, Verma S. Unique challenges and opportunities faced by pain physicians during COVID-19 crisis. Indian J Pain 2020;34:85-8
| Introduction|| |
In the era of SARS-COV-2 (COVID-19) pandemic, for all in the health-care community including pain physicians, the practice of medicine has changed substantially in numerous ways; from extremes of temporary closing or postponing all elective consults to shifting most of the practice to telemedicine. Frequently, we are managing chronic illnesses inclusive of chronic pain from afar, with patients also learning the use of technology., These all pose many challenges to the pain physician practicing chronic pain management. While the technology presents its challenges, it also offers some opportunities as well. This article will summarize the challenges faced as well as opportunities offered in the current scenario of pandemic and technology usage.
| Challenges Faced and Possible Solutions|| |
Major challenges that chronic pain professionals are facing right now and their possible solutions are as follows:
Maintaining relevance and value to our patients and fellow colleagues
As an upcoming specialty, pain practice runs the risk of not being perceived as an essential service. As such even before COVID, we needed to demonstrate our value with good diagnosis and broad array of management options. This has become more challenging with the current pandemic as most of the pain practice consults and procedures are either postponed or deferred. This may give a false sense of feeling to administrators and our colleagues that our services are not essential. According to the Ministry of Health and Family Welfare, Government of India (GOI), essential services include “maternal, new born and child health, prevention and management of communicable diseases, treatment of chronic diseases to avoid complications, and addressing emergencies.” Hence, the management of chronic pain is not an optional service but an essential service.
The solution to this challenge is the creation of more awareness among the pain physicians, followed by other doctors and general public.
Majority of the pain physicians in India (and in most countries) are anesthesiologists. Being the first responders for emergency, trauma, intensive care, and COVID patients, they are being utilized in these areas. Hence, they are left with less time for chronic pain management during the current scenario. As such, we as pain physicians have been facing challenges (especially in public setups) of being regularly getting posted in pain clinics and pain operation theatre (OT) and providing services to our chronic pain patients due to frequent reallocation to other areas. This has definitely become more challenging during the current pandemic. Furthermore, the anesthesiology residents who are rotated through the pain clinic and chronic pain services are now being reallocated to COVID duties. This has resulted in shortage of manpower in the pain clinics. At present, since the patient load is low, the problem is not self-evident. However, as soon as the patient load increases, it will be difficult to manage the pain services.
A possible solution includes adequate provisioning for the staff and prompt reallocation to pain services as soon as the situation allows.
Setting up new infrastructure or expanding the existing one to meet new norms
Telemedicine is emerging as a key technology as sustainable solution to provide essential health-care services including chronic pain services in the current scenario. At present, in India, many government institutes either have one or two telemedicine units and many small and solo units may not have telemedicine facility. The infrastructure will have to be initiated or expanded to start official teleconsultation for the pain clinic outpatient department (OPD). The acceptability of the telemedicine among patients will dictate the future course of action in this regard.
Training of staff
The other front is to train physicians and staff for telemedicine who are accustomed to face-to-face working. In India, majority of the pain physicians are anesthesiologists reallocated to work in COVID pandemic and may be facing a time crunch to learn the technological issues of telemedicine. They should have adequate time to learn the technicalities so that they can start the chronic pain services effectively. A possible solution lies in a correct approach – starting with standard operating procedures for any given setup and then improvising over time can yield excellent results. One-size-fits-all approach should not be followed as each center or setup would have unique characteristics and requirements.
Separate outpatient department hours/sessions/days for teleconsultation and face-to-face consultation
Pain physicians in future need to have separate allotted sessions for in-person consults and tele-consults. As in future, after lockdown, full medical practice will be resumed based on locally prevalent conditions. Once resumed, it will be busy as many chronic pain patients might have been waiting for long to consult. Hence, pain physicians will not be able to provide simultaneous tele-consult and in-person regular consults. Separate OPD hours/sessions/days for teleconsultation and face-to-face consultation will be needed to manage the timings effectively.
Uncertainty about future
During the current tough period, all pain physicians are finding alternative ways of taking care of chronic pain patients. Although all of us are eager for rapid resolution of COVID-19 pandemic, we are uncertain as of how this pandemic will behave and affect our future life and practice indefinitely. This uncertainty poses huge anxiety among all physicians, more so for pain physicians who have exclusive pain practice. This time should be used to sharpen the skills and finish the nonclinical tasks to prepare effectively for the patient care in future. Like-minded colleagues in similar situations may be able to brainstorm for innovative solutions. Technological barriers can be overcome by investing time in learning about the latest updated solutions available. Constructive utilization of time shall yield tremendous opportunities for diligent pain physicians in future. Appropriate relaxation techniques including indulgence in enjoyable hobbies such as singing and painting can relieve the stress and help find a new direction in life!
Physician isolation in making difficult decisions and diagnoses
During this pandemic, social distancing and isolation is the new norm. Many pain physicians are working with reduced staff and reduced schedule. Many other offices are closed with many physicians conducting telehealth consultation rather than face-to-face consult., Hence, the usual support network may be missing for consultation or second opinion, especially when physicians have questions and need to talk to colleagues in making difficult diagnoses and decisions. Finding a clinicalbuddy may be difficult. In addition, pain medicine requires a multimodal, multidisciplinary approach, and the limited availability of colleagues makes the management difficult. Technology offers solution, but it is practically difficult to collaborate in treating patients due to different timings and priorities of the treating physicians. Investing more time in technology in order to gain proficiency in efficient utilization of communication-based technological tools can yield better results.
Amplification of burnout during the pandemic
A high incidence of physician burnout and critical consequences has been well reported even before this pandemic. One study conducted in Mumbai reported that the incidence of burnout was 66.67% in medical residents. This pandemic has introduced another level of stress and anxiety into an existing stressful clinical environment. Therefore, with professional isolation, physicians are working in conditions that could lead to a higher level of burnout. Physicians in small or solo practice and in stand-alone units may face more burnout. Financial issues may complicate the burnout and accelerate the process. As mentioned before, a holistic approach consisting of efficient time utilization coupled with relaxation techniques can yield the best results.
Prescription of medications in telemedicine guidelines released by the Government of India
Many drugs prescribed for chronic pain patients (like opioids) fall in the category of prohibited drugs in telemedicine guidelines released by the Board of Governors in supersession of the Medical Council of India (MCI) along with the NITI Aayog. An urgent suitable waiver process for these medications from competent authorities needs to be started soon by societies such as the Indian Society for Study of Pain, Indian Society of Pain Clinicians, and Indian Association of Palliative Care. Pain physicians shall face difficulty in managing the chronic pain patients who are on opioids. Possible solutions include networking with centers where the physicians are available to prescribe the medication and dispense them through pharmacy ensuring uninterrupted supply of the essential medicines. Alternatively, clinic scheduling techniques and patient education can help in achieving the objectives as well.
Lack of clear consensus guidelines on interventions makes choice even more difficult
The varying evidence on various pain interventions has led to poor consensus on the treatment approach for many diseases among pain physicians. This gap in clinical knowledge is due to the limited data on the subject matter. In COVID pandemic, this has been increased manifold. It is, therefore, important to stay updated with the latest modifications and updates in the scenario vis-a-vis clinical application for instant solutions. Guidelines should be interpreted in accordance with the local conditions for the best results.
Travel restrictions leading to no training in person
Pain medicine is a rapidly evolving branch. Most pain physicians keep on updating themselves with the latest clinical knowledge. This also includes new interventional procedures. Because of travel restriction, this free flow of knowledge transmission has now been limited to the online and distance learning only. Newer technological platforms make it easier to learn through distance education mode, but they should supplement and not substitute the offline learning. Medicine is both an art and science and cannot be learnt in absentia.
Travel restrictions leading to decrease in area of practice
Clinicians are known to offer their services across their area of practice by traveling to various points of practice. Freelancer pain physicians travel to cover some distance for serving their patients. Since the pandemic has imposed travel restrictions, such travel has been limited to essential travel only affecting the practice of pain physicians. Telemedicine offers a possible solution to this issue since now the patient acceptance has increased. Better Internet and mobile penetration has enabled uninterrupted access to many remote locations as well.
Limited availability of equipment
The current pandemic has affected the trade scenario, which has led to price and stock variation of many types of equipment. This can influence the treatment choice due to the nonavailability or steep pricing. The equipment is sourced from different areas, which complicates the situation. The manufacturers should be contacted directly to ensure adequate supply, and all orders should be placed well in advance to avoid stock outages. This will ensure adequate consumables as and when required.
| Opportunities Offered by Such a Challenging Situation|| |
Having mentioned all these confronts, we would like to emphasize that while the technology presents its challenges, it also offers some opportunities as well. For the optimistic, COVID-19 may be observed as a double-edged sword. On one hand, it poses lots of challenges as mentioned above, on the other hand, it may just be cathartic condition, which will finally lead to many opportunities.
Smart ways to help patients
COVID-19 has provided us with the opportunity to allow optimal use of technology to help patients. In fact, the GOI for the first time came up with two decade long-awaited telemedicine guidelines on March 25, 2020. This happened only because of this pandemic. Many physicians were skeptical to use telemedicine in India, especially after the 2018 judgment of the honorable High Court of Bombay. Now, after the release of these guidelines, it is legal to use telemedicine in India, in accordance with the norms of the guidelines. These guidelines should be used in conjunction with the other national clinical standards, protocols, policies, and procedures. Telemedicine can decrease the risk of exposure of the health-care workers to SARS-COV-2 and can ease the overtly burdened health-care system. Various applications are also available for patient's consultation, especially video applications, which allow patients to have visual contact with their physicians. Although it cannot replace in-person consult, it may provide enough information to deliver afar help and distinguish those patients needing urgent face-to-face consult. This will definitely reduce the burden on the health-care system in the current scenario and may work well in the future as well after this pandemic settles.
Learn soft skills and create awareness about pain services
Doctors are seldom taught soft skills such as presentation, technology, and finances. Pain physicians are no different. The COVID pandemic provides opportunities to learn these and update knowledge in this field because of the various restrictions. Pain physicians have to reach out to their patients with various activities, and there are ample opportunities in this regard as well. Due to decrease in elective work, the health-care workers who are not posted in COVID duties have time available due to isolation and travel restrictions, which can be positively channelized to learn these soft skills.
Burnout being recognized for what it is
Burnout of health care workers has been documented for the past few years, however COVID has made burnout being recognized for what it is. COVID made us realize that burnout is more of a symptom of mismatch between requirement and delivery of system, suboptimal utilization of technology such as telemedicine along with the high expectations of patients, and competence and capacity of workforce. This pandemic also made us understand that we have solutions for many issues; only we have not organized them properly.
Emphasis on biopsychosocial management using technology
Pain physicians are facing unique challenges in delivering multidisciplinary care due to social distancing norms. However, this is also an opportunity to enable and strengthen the interdisciplinary health-care delivery system through tools like telemedicine. Many self-pain management programs and multidisciplinary treatment modalities can be and are delivered online. Individual online pain management programs have been reporting excellent outcomes. A recent systematic review has found that the Internet interventions using psychological methods are very effective in the treatment of chronic pain.
Technology necessitating an objective model based on clear datapoints
The use of technology for consultation, treatment, and even decision-making has made the pain physicians well versed with the latest trends. This has led or will lead to more objective datapoints available for analysis and can be put to good use in the interest of the patient to deliver personalized, evidence-based medicine.
Increased innovation opportunities
The pandemic offers innovation opportunities to the unique challenges faced by health-care professionals. From mobile applications to unique business models, the pandemic has created a lot of problems which are opportunities inviting to be solved. Technologies such as augmented and virtual reality have been used to offer relief to pain patients. These newer technologies seem to offer promising results., Eccleston et al. have listed a 14-point list of research priorities for remotely supported (eHealth) pain management services. There was never a better time to innovate in the recent past as it is now.
| Conclusion|| |
Leonardo da Vinci once said-“I love those who can smile in trouble.”
Every adversity brings few opportunities along with challenges, and this pandemic is here to stay for long. Therefore, in spite of the challenges faced by the pain physicians, it is imperative that creative solutions should be innovated. Practical problems can have practical solutions; administrative issues can be ironed out with minimal disruption to the pain services. It is time to rise up to the occasion to ensure that no patient suffers from pain either by choice or by compulsion during the pandemic.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al
. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
Eccleston C, Blyth FM, Dear BF, Fisher EA, Keefe FJ, Lynch ME, et al
. Managing patients with chronic pain during the COVID-19 outbreak: Considerations for the rapid introduction of remotely supported (eHealth) pain management services. Pain 2020;161:889-93.
Shanthanna H, Strand NH, Provenzano DA, Lobo CA, Eldabe S, Bhatia A, et al
. Caring for patients with pain during the COVID-19 pandemic: Consensus recommendations from an international expert panel. Anaesthesia 2020;75:935-44. [doi: 10.1111/anae. 15076].
Cohen SP, Baber ZB, Buvanendran A, McLean LT, Chen Y, Hooten WM, et al
. Pain management best practices from multispecialty organizations during the COVID-19 pandemic and public health crises. Pain Med 2020;21:1331-46.
Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E, Chew-Graham C, et al
. Controlled interventions to reduce burnout in physicians: A systematic review and meta-analysis. JAMA Intern Med 2017;177:195-205.
Dhusia AH, Dhaimade PA, Jain AA, Shemna SS, Dubey PN. Prevalence of occupational burnout among resident doctors working in public sector hospitals in Mumbai. Indian J Community Med 2019;44:352-6.
] [Full text]
Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al
. Factors associated with mental health outcomes among health care workers exposed to coronavirus disease 2019. JAMA Netw Open 2020;3:e203976.
Smith J, Faux SG, Gardner T, Hobbs MJ, James MA, Joubert AE, et al
. Reboot online: A randomized controlled trial comparing an online multidisciplinary pain management program with usual care for chronic pain. Pain Med 2019;20:2385-96.
Buhrman M, Gordh T, Andersson G. Internet interventions for chronic pain including headache: A systematic review. Internet Interv 2016;4:17-34.
Eccleston C, Fisher E, Craig L, Duggan GB, Rosser BA, Keogh E. Psychological therapies (Internet-delivered) for the management of chronic pain in adults. Cochrane Database Syst Rev 2014;21:1331-46.
Garrett B, Taverner T, McDade P. Virtual reality as an adjunct home therapy in chronic pain management: An exploratory study. JMIR Med Inform 2017;5:e11.
Jones T, Moore T, Choo J. The impact of virtual reality on chronic pain. PLoS One 2016;11:e0167523.