What will the coming years bring? Will headache medicine continue on its astoundingly positive trajectory? Will the “stigma” of headache that Drs. Lipton and Bigal have addressed in this issue vanish entirely? More specifically, what role will genomics play in migraine diagnosis and treatment? Will gene array analysis enable us to “customize” therapy for the individual patient? Will we proceed beyond even this to manipulate the genes themselves so as directly to treat – even eliminate – the phenotypic expression of the primary headaches? Will we unravel the riddle of migraine “chronification”? Will we learn how to identify patients at risk for chronification and so prevent that malignant process? Or even reverse it after the fact? Perhaps most compelling among the many questions one could pose regarding the future of headache medicine, what will be the nature and quality of the environment within which a headache subspecialist plies his or her trade?
At first blush, I found it difficult not to bristle reflexively in response to the articulate and thoughtful commentary authored by Nash and Quigley. Surely there are few who would rush to embrace the loss of autonomy, and physicians have been – and continue to be – characterized by their independent natures and a highly developed sense of professional responsibility . . . ie, highly individualized responsibility of the “buck stops here” variety. To become a physician requires no small measure of personal sacrifice. To practice as a physician requires that one freely accept, without surcease, a degree of liability that the average citizen might find unacceptably daunting. That our professional autonomy is to be diminished – and for this apparently to occur without any lessening of personal sacrifice or liability – would seem destined to erode further the morale of physicians currently in practice and to discourage those who otherwise might have chosen to pursue a medical degree from doing so.
Yet, I believe that to closer inspection one may find some silver linings within this cloud. As a child of the 1960s, I can recall that amidst the hedonist excesses of those times there existed a sense of dedication to community, to the common good, to the concept of “giving back,” to caring for those in need . . . and to do so as individuals united in a common purpose: a community of caregivers, if you will. That these purposes motivated my own medical school classmates was clearly evident at the time. But somehow those lofty goals and the selflessness implied gradually have become obscured by a blizzard of DRGs and RVS codes coupled with concerns over escalating medical costs, declining physician reimbursement, conflicts of interest, and the perceived injustices of the existing tort system as it relates to malpractice litigation.
Few areas in health care lend themselves so well to multidisciplinary, evidence-based, and cost-effective management as does headache medicine. Given the magnitude of the chronic public health crisis that is migraine and the paucity of physicians truly adept at managing this disorder, there is an urgent need for affiliated clinicians to supplement the thin ranks of those who will administer to the afflicted citizens who seek medical attention. We have made spectacular progress in defining the primary headache disorders, discerning their pathophysiologies and developing evidence-based therapies and treatment strategies, but much remains to be done. What Dr. David Laurence terms “the seductive model of the autonomous independent physician craftsman” whose practice habits are based largely on personal experience is indeed ill suited to improve yet further the quality of care available to headache sufferers. Instead, what clearly is needed are innovative new paradigms for patient education, the delivery of care to headache patients, and the dissemination of knowledge to those who provide that care. Participation in developing and implementing those paradigms will require creativity, personal and professional flexibility, the ability to cast aside without rancor old patterns of behavior, and the willingness to labor as a valued and respected member within a community of caregivers. To cling stubbornly to the “old ways” is to abdicate to others perhaps less qualified the responsibility for correcting the deficiencies currently inherent in this nation's system of healthcare delivery. For the benefit of those we serve – our patients – we must act as the instruments of progressive change.