Harry J. Gould, III, MD, PhD
Pain occurs in both acute and chronic forms. In its acute form, pain is a modality that is essential for survival and is the signal that most frequently brings people to the attention of the healthcare professional. Many cases of simple acute pain are readily treated without difficulty by physicians, practitioners in paramedical fields, and in many instances, by the lay public. Unfortunately, all too frequently problems that present as simple complaints of acute pain are the result of more a significant problem that if not accurately diagnosed and effectively treated can become a chronic condition that destroys the fabric of existence, not only for the individuals suffering the pain, but for families, loved ones, and society as a whole. In spite of its prevalence, there is a general lack of recognition that unassessed or poorly managed pain in and of itself is a problem about which we should be concerned and because of its prevalence the problem is also accompanied by substantial disparity for patient access to adequately trained providers, early evaluation and proper treatment.
For proper pain control and rationale management, society relies heavily on trained physicians and healthcare professionals for guidance. Unfortunately, the number of patients needing relief from intractable pain far exceeds the number of healthcare providers who are adequately trained to meet that need. The management of complex pain problems, thus, all too frequently falls to those with limited training in assessment and treatment strategies and little familiarity with modalities used for pain control.
In the early part of this century, the predominant treatment offered for pain control was largely a pharmacologic modalities. Unfortunately, a significant portion of the pharmacologic options included agents used by a section of society for unintended reasons e.g., affecting changes in sensory and emotional perception and cognition for recreation, which led to inconsistent, often inadequate, management of pain for those in need and the current “opioid crisis.” Because of concern for legal reprisal and the recognition that the additional time required to comply with important monitoring regulations is not accompanied by a comparable increase in compensation, fewer practitioners have been willing to treat pain or they have shifted focus and limited the offered treatment modalities to more lucrative, unidimensional approaches, thereby further exacerbating the already significant disparity between practitioners and patients for access to comprehensive evaluation and care. The problem is further exacerbated by social limitations related to direct cost of physician visits, necessary absences from employment responsibilities to make and keep appointments, potentially additional need for care of children and transportation to care. These limitations result in delays in obtaining expert assessment, in the timely implementation of appropriate treatment and the increased likelihood of establishing chronicity of the problem with its inherent increase in co-morbid health conditions, higher costs for prolonged treatment and the development of maladaptive behaviors associated with the recognition of secondary gains.
Oddly enough, the COVID-19 pandemic and its requisite need to adapt in order to provide “social distanced” care for patients, may have enabled more physicians and healthcare administrators to recognize a possible next step in the reduction of healthcare disparity in that that when appropriately applied, telemedicine platforms can be very effective in organizing and implementing routine care in their practice and provide more uniformity of care in the communities they serve. Clearly, in person visits will always be essential in patient care and remains the preferred option for many patients and physicians alike, but it is also recognized that the virtual-visit can provide a viable option when offered for practices where access to care is limited and widespread disparities prevail.
Practitioners have noted that with the virtual-visit platforms, patients seem to be more compliant with their follow-up visits. They have also found that the virtual-visit platforms can make it possible to more easily manage schedules in the event of patient tardiness or failure to show. The primary weakness of virtual platforms is the lack of a physical exam and a significant reduction in the practitioner’s ability to assess patient affect and body language, making it more difficult to recognize undisclosed problems that should be addressed.
Patients also have found virtual-visits satisfying. Although many continue to prefer in person visits, many have noticed improved convenience and a significant reduction in associated costs related to needs to take time off from work (visits can be done on a break at the office), to arrange for daycare, to lost time related to traveling significant distances and dealing with heavier than accustomed to traffic often found in urban centers where the specialists tend to locate their practices. There is also less downtime spent in waiting rooms especially when times are greater than normal when the doctor is delayed or other patients have arrived late or have extra needs.
From the specialist’s perspective, especially for specialists in pain medicine, a limitation to broader utilization of virtual technology to improve the patient to specialist ratio is that frequently referrals for specialist evaluation and recommendations are assumed, even for routine pain problems, to be a complete transfer of care accompanied by assumption of responsibility for the patient’s primary care, implementation of pain care and routine follow up. Because referrals for pain issues can come from virtually all medical specialties, this approach rapidly fills the specialist’s available appointment slots thus limiting the ability to accept new referrals because of the requisite need for maintaining routine follow-up visits to monitor response to care and patient compliance.
A more effective approach might be to gather a team of specialists that could work with primary providers to evaluate a patient, develop an appropriate treatment plan and in the process impart many of the basic skills of assessment and treatment thus empowering the physician to be able to care for his/her own patient. Potentially, the patient could be exposed to a broader range of treatment options, experience less long-term morbidity related to frequent and extended trials of an ineffective “hammer and nail” approach to care and would benefit from the earlier implementation and response to appropriate management options provided closer to home by a physician with whom they have developed a relationship. Because of the collaborative relationship that is established between the primary physician and the team of specialists, the patient would have access to a network of additional treatment resources, if needed, and the specialist would benefit from having more time to be available to collaborate with other primary providers and to work on more complicated, less routine, pain problems.
Coincidentally, just such a program, Project ECHO, has been developed, trialed and was successfully launched in 2003 at the University of New Mexico Health Sciences Center in Albuquerque. For those who are interested in learning more about Project ECHO and how it might help your practice while contributing to a reduction in the disparity of pain care for many in our community, we will have the good fortune to hear Joanna Katzman, M.D. speak on “Pain Management in 2021: Exploring the Benefits of ECHO Pain Telementoring and Direct Telehealth for Your Practice” at the upcoming annual meeting of the Southern Pain Society. The meeting will be held in person in New Orleans, from September 10-12, at the Astor Crowne Plaza. I encourage you to register for the meeting on our website, www.southernpainsociety.org, and join me in the ‘Big Easy’ to hear more. I look forward to seeing you there.