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Keywords:

  • Pain;
  • Pain Summit;
  • AMA

Abstract

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

Pain is ubiquitous. At some point in time it affects everyone. For many millions pain becomes chronic, a scourge that impacts every facet of life—work, hobbies, family relations, social fabric, finances, happiness, mood, and even the very essence of identity. According to the National Institutes of Health (NIH), pain is one of our most important national public health problems, a silent epidemic. In 1998, NIH reported that the annual amount spent on health care, compensation, and litigation related to pain had reached one hundred billion dollars ($100,000,000,000). Considering that health care costs have doubled since then, it is not unreasonable to assume that the costs related to pain care have doubled as well.

Millions of patients suffer needlessly with acute pain, with cancer pain, and with chronic pain. The ineffective management of pain results in an escalating cascade of health care issues. Acute pain that is not treated adequately and promptly results in persistent pain that eventually causes irreversible changes in the nervous system. This translates into progressive bio-psycho-social epiphenomena resulting in further pain and disability. It creates a vicious cycle transforming a functional human being into an invalid who becomes a burden to family, to society, and to oneself.

In the face of adequate medical science, adequate technical skills, and adequate resources the reality of delayed and inadequate pain care is paradoxical. This dilemma deserves close scrutiny and effective remediation.

The American Medical Association (AMA), long dedicated to the need to improve pain care in this country, has been faced with this reality. It was from this vision that the idea of holding a Pain Medicine Summit was conceived. Resolution 321 (A-08) set in motion a process that would bring together a diverse group of stakeholders for the purpose of discussing the present and future status of pain care; a process that culminated in a broad-based coalition of physicians and organizations dedicated to improving pain care, the first National Pain Medicine Summit.

The process began with the adoption of Resolution 321 (A-08) at an AMA Annual House of Delegates meeting in June 2008. Resolution 321 (A-08) states, in part, that “. . . the AMA encourages relevant specialties to collaborate in studying: 1) the scope and practice and body of knowledge encompassed by the field of Pain Medicine; 2) the adequacy of undergraduate, graduate, and post graduate education in the principles and practices of the field of Pain Medicine, considering the current and anticipated medical need for the delivery of quality pain care; and 3) appropriate training and credentialing criteria for this multi-disciplinary field of medical practice.”

The next step was delegating the responsibility for implementing Resolution 321 (A-08) to the Pain and Palliative Medicine Specialty Section Council (PPMSSC). The PPMSSC, under the direction of its chairman, Philipp M. Lippe, MD, FACS, assumed responsibility in November 2008 for identifying a process that would achieve the goals established by Resolution 321 (A-08).

The PPMSSC in turn established an Advisory Committee, charged with strategic planning, and an Implementation Committee, charged with tactical operations. The two groups began work immediately.

The process included three distinct phases centered on a Pain Medicine Summit. Phase One involved a modified Delphi process identifying the five most pressing and relevant themes in pain care. Phase Two consisted of the Pain Medicine Summit itself, including a gathering of representatives from across the pain care spectrum to address the previously identified five most pressing themes. Phase Three was the preparation of this report, which describes the conclusions drawn and recommendations developed by the attendees at the Pain Medicine Summit.

Based on a recommendation from the Advisory Committee, the PPMSSC decided to retain the services of a consulting firm to help the PPMSSC implement the Pain Medicine Summit process. In August 2009, PPMSSC selected Grey Matters, a New York-based advisory firm. The PPMSSC also appointed a Steering Committee to assist Grey Matters and to coordinate all activities. The Committee consisted of Charles Brock, MD; Ronald Crossno, MD; Jose David, MD; Michel Dubois, MD; Albert Ray, MD; and Philipp M. Lippe, MD, FACS (chair).

The consulting firm, Grey Matters, proposed a multi-phasic process in order to facilitate the implementation of the Pain Medicine Summit and to ensure a coordinated, efficient, and productive outcome. This process consisting of three phases—pre-summit, summit, and post-summit—is described in detail in the following section. All aspects of the project were closely coordinated and supervised by the Steering Committee, which included the selection of the team leaders of the five Workgroups, based on specific criteria.

The Pain Medicine Summit, adhering to the dictates of Resolution 321 (A-08), explored the body of knowledge and the scope of practice of Pain Medicine; the education and training in medical school, graduate, and postgraduate programs; and the credentialing and certification processes in the field of Pain Medicine. It addressed the barriers hampering delivery of high quality pain care. It recognized the need for clarification and consensus in many areas.

Several points of consensus emerged:

  • • 
    The continuum of medical education in the field of Pain Medicine is inadequate and fragmented. It needs to be fortified in scope, content, and duration.
  • • 
    Credentialing and certification processes in Pain Medicine are variable, diverse, and deficient in many instances.
  • • 
    Deficiencies in these areas lead to suboptimal and fragmented pain care having a negative impact on direct patient care and public health.
  • • 
    Effective and prompt remediation is desirable and essential to achieving the goal of high quality pain care.
  • • 
    Barriers exist inhibiting or retarding progress toward the common good.

There are several viable avenues to achieving our stated goal, “excellence in the delivery of high quality, cost-effective pain care to the patients we serve,” including the development of Pain Medicine as a distinct specialty with ACGME accredited residency programs and ABMS certification.

The Pain Medicine Summit concluded with a number of recommendations, including the following:

  • • 
    That the pain community remains engaged in addressing the issues raised and in mitigating the barriers.
  • • 
    That the recommendations be referred to the AMA and the PPMSSC for support and implementation.
  • • 
    That another national Pain Medicine Summit with enhanced participation be convened.
  • • 
    That consideration be given to convening an International Pain Summit in conjunction with the IASP World Congress in Montreal.
  • • 
    That the final report of the Pain Medicine Summit be widely disseminated.

“To strive for excellence in the delivery of high quality, cost-effective pain care to the patients we serve.”

–––Philipp M. Lippe, MD, FACS

Implementation Process

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

Grey Matters, the consulting firm, began in August 2009 to implement the three-phase process in coordination with the Pain and Palliative Medicine Specialty Section Council's Steering Committee. Phase One would identify the five most pressing themes in pain care. Phase Two would be the Pain Medicine Summit itself. Phase Three would be a report describing the results of the Pain Medicine Summit.

Phase One: The Five Most Pressing Issues

The first phase began with a convening of the Steering Committee, which identified a need to seek input from a wide range of stakeholders—in fact, a much broader group than would actually be attending the Pain Medicine Summit—in order to build as large a consensus as possible in identifying the five most pressing issues facing pain care practitioners. Appendix O contains a list of those people and organizations invited to participate in phase one.

The Steering Committee and Grey Matters also decided to seek input from this large group by using a modified two-stage Delphi process. The Delphi process is a forecasting method in which a panel of experts answers questions in the first stage and, after hearing summaries of what the experts said in the first stage, are given the opportunity in the second stage to revise their answers and reach a group consensus.

In this Delphi process, participants were first shown an extensive list of topics and issues that might or might not be relevant to the delivery of effective pain care and were asked to select which ones they felt were the five most pressing items. From their responses, a series of “themes” were identified, and the group was asked to comment on and rank each of the themes based on their importance to the future of effective Pain Medicine delivery.

Delphi Round 1

The first round of Delphi activity involved reaction from the Delphi participants to an extensive questionnaire developed by the PPMSSC Steering Committee (see Appendix C in the online version of the article) using elements of material generated by other groups involved in Pain Medicine education, training, and certification, including the American Academy of Pain Medicine, the American Board of Pain Medicine, the Accreditation Council on Graduate Medical Education, and others.

The purpose of the initial questionnaire was to identify areas of consensus and disagreement related to a definition of what skills, knowledge, and experience are required of Pain Medicine specialists, to identify how well each of those areas are addressed in different phases of training (medical school, residency, and post-graduate training), and to identify barriers to delivering effective Pain Medicine and evaluating the competency of those who deliver it.

Some of the more interesting results gleaned from the first round of the Delphi process were the following:

  • • 
    All the suggested treatment areas were seen by most participants as an integral part of Pain Medicine (e.g., the lowest score was given to acupuncture/acupressure, with 67% of respondents agreeing that it is an integral part of Pain Medicine).
  • • 
    Training was seen as poor or “not leading to competency” in all areas at the undergraduate and residency levels; the best rating was for pharmacologic therapy training at the residency level, with only 53% of the respondents agreeing that the training led to competency in that area.
  • • 
    When asked if adequate care is being provided in each of the treatment areas, not a single area garnered a majority of “yes” votes; when asked why, respondents agreed almost unanimously across 19 of the 26 areas that lack of patient-centric care is one important reason; in 3 out the 26 areas there was almost unanimous agreement that a lack of knowledge and/or evidence of clinical effectiveness preclude the delivery of adequate care.
  • • 
    The top three barriers to receiving adequate patient care were 1) workforce issues with lack of competent pain providers, 2) lack of knowledge by peers and/or patients regarding the field of Pain Medicine, and 3) lack of public knowledge regarding pain issues; all three were seen as barriers by more than 90% of the respondents.
  • • 
    The average score to the question: “How well does the present system of credentialing and certification ensure competency” was 2.65 (where 1 was “not at all” and 5 “completely”).

There were almost 30 pages of comments from the participants (see Appendix D). From those comments, 10 themes were selected by the Steering Committee to be further discussed and prioritized in the next round of the Delphi process. The 10 themes were:

  • 1
    How should Pain Medicine be defined?
  • 2
    How can a useful description of a competent Pain Medicine provider be created and why and with whom should that description be shared (hospital administrators, other physicians, patients, regulators, legislators, law enforcement, lawyers, and others)?
  • 3
    How should Pain Medicine be taught?
  • 4
    Why does not the presence of competent physicians result in better pain care delivery?
  • 5
    What mechanisms do we need to establish the competency of a physician who wishes to practice Pain Medicine?
  • 6
    What should all physicians know about Pain Medicine? That is, where is the line drawn between primary Pain Medicine competency and specialty Pain Medicine competency?
  • 7
    Why is Pain Medicine delivered better in some places than in others?
  • 8
    Why is patient-centric care so difficult to deliver?
  • 9
    What are the barriers, besides the absence of competent Pain Medicine physicians, which prevent patients from receiving adequate pain care?
  • 10
    What is the role of the Pain Medicine specialist in the management of patients with pain?
Delphi Round 2

The second round of Delphi activity centered on the narrowing and prioritization of the list of themes identified in Round 1 into a list suitable for in-depth discussion at the one-day Summit. The 10 themes from Round 1 were circulated to all Delphi process participants, who were asked to vote for the five themes that they thought were most crucial to discuss at the Summit (see Appendices E and F).

The votes were tabulated by raw score, average score, number of votes (percent of participants voting for a given theme), and number of high priority votes given to a theme. Five topics clearly dominated the voting. The final five, in order of first to fifth in voting, were as follows (for detailed results of the final tally, see Appendix G):

  • 1
    What should all physicians know about Pain Medicine (i.e., where is the line drawn between primary care Pain Medicine competency and specialty Pain Medicine competency)?
  • 2
    How should Pain Medicine be taught?
  • 3
    What are the parameters that define the field of Pain Medicine?
  • 4
    What mechanisms do we need to establish the competency of a physician who wishes to practice Pain Medicine?
  • 5
    What are the barriers that prevent patients from receiving adequate pain care, other than the absence of competent Pain Medicine physicians?

Phase Two: The Pain Medicine Summit

Once the five most pressing issues were identified, the next step was to convene a face-to-face Pain Medicine Summit for attendees to address the issues raised in the Delphi process. Grey Matters and the Steering Committee decided that the Summit itself should consist of five components:

  • 1
    An introductory session of all attendees to explain the process;
  • 2
    A working session of five separate workgroups, each assigned one of the five most pressing issues;
  • 3
    A second session of all attendees in which the group leaders of each workgroup would present their conclusions;
  • 4
    A third session of all attendees where a summary of a proposed set of consensus recommendations would be made; and
  • 5
    A fourth and final session of all attendees for the purpose of discussing how best to move forward.

The Pain Medicine Summit was scheduled for November 5, 2009, in Houston, Texas, and invitations were sent to participants. For a final Summit agenda, see Appendix H online.

Team leaders for each of the five workgroups were selected by the Steering Committee based on their expertise, availability, and interests:

  • 1
    Rollin Gallagher, MD, MPH—What should all physicians know about Pain Medicine?
  • 2
    Kim Burchiel, MD—How Should Pain Medicine be taught?
  • 3
    Albert Ray, MD—What are the parameters that define the field of Pain Medicine?
  • 4
    Kenneth Follett, MD, PhD—What mechanisms do we need to establish the competency of a physician who wishes to practice Pain Medicine?
  • 5
    Michel Dubois, MD—What are the barriers that prevent patients from receiving adequate pain care, other than the absence of competent Pain Medicine physicians?

Each leader was also asked to create discussion points that would guide the workgroup (see Appendix K), provide a list of reading materials to be read prior to the workgroup meeting, lead the workgroup in discussion at the Summit, and write a post-Summit statement summarizing the workgroups conclusions and recommendations. Once the full list of attendees was determined, they were split up among the five groups and were sent the reading materials. Grey Matters also developed a PowerPoint template for group leaders to use when presenting workgroup findings to the full group in order to ensure consistency among the groups (see Appendix L).

The Summit took place at the Hilton Hotel in Houston on November 5, 2009, just prior to the Interim Meeting of the AMA HOD. It was widely considered to be a success by those in attendance because it was characterized by goodwill, constructive dialog, synergy, and broad consensus in all the breakout and plenary sessions.

Phase Three: Pain Medicine Summit Summary

The third and final phase of the process involved capturing the results of the Pain Medicine Summit in a document. Grey Matters drafted a summary of Pain Medicine Summit experience and preserved the various planning documents, PowerPoint presentations, and narrative summaries of each workgroup's discussion in the Appendix.

Workgroup Summary Findings

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

Workgroup 1 (Rollin Gallagher, MD, MPH)

Discussion Topic: What Should All Physicians Know About Pain Medicine?

Present State.  Starting with the very basics, in most medical school education, pain is not acknowledged as a chronic disorder, but rather is treated as a symptom. No differentiation is made between “eudynia” (symptom, or normal pain) and “maldynia” (pain as a pathophysiologic disease of the nervous system or abnormal pain), and the differentiation is usually misunderstood by physicians.

Consistency does not exist across medical schools in the training of physicians in Pain Medicine. There are “15 different standards of pain care” (to quote a task force member), based on individual departments and even within departments, with no consensus on what physicians or other clinicians should know about pain and its treatment. Often what is taught is the area of special research or clinical interest of one specialist facility member or another, not a standard curriculum. It would be like instruction in the cardiovascular system only by the expert in peripheral vascular disease, hoping that a detailed examination of heart disease would be picked up elsewhere. Not only is there a lack of breadth in instruction, but there is also is a lack of integration of basic science and clinical knowledge. Students may learn some facts, but they do not obtain education and training in the clinical application of them because there are few clinical role models in academic training centers. With most rotations in hospitals, pain care is centered on acute pain, not chronic pain.

There is a lack of exposure to evidence-based Pain Medicine practice, and it is difficult to expect a student to learn this in a short 6-week rotation. The fourth year medical student comes into the clinical rotation without a foundation of the standard nomenclature for the physiology of pain and the pathophysiology and phenomenology of pain disorders and diseases. This lack of working knowledge about maldynia often creates negative generalizations about patients with chronic pain in the eyes of the medical student, leading to further alienation and misunderstanding of the patient and chronic pain.

The training of all physicians in Pain Medicine is fragmented, without a cohesive curriculum that is uniformly applied. It is difficult for physicians to access papers, professional presentations, and conferences on Pain Medicine.

With confusion about who is “in charge” of documenting and reporting “best practice” on pain care guidelines, there are no standards for measuring the effectiveness of treating pain in clinical practice.

Finally, the focus of Pain Medicine has been oriented toward adults and has not sufficiently addressed pediatrics, which is a significant shortcoming.

Desired State.  The workgroup concluded that a second-year curriculum should include pain as a disease, pharmacology, standard vocabulary, and clinical pathophysiology. The curriculum would create core knowledge and clinical competencies in Pain Medicine. The course block would cover physiology of pain transmission, perception, and modulation; the pathophysiolgy of pain disorders and diseases; and the epidemiology of persistent pain and its co-morbidities and their impact on the public health. The course would include simple evidence-based algorithms. Physicians would be trained in the phenomenology of individual pain disorders and diseases, the evidence basis for the different treatments proposed for specific pain conditions, and the purported mechanism of effect for these treatments. The curriculum would include a toolkit on how to train with clinical guidelines and would be interdisciplinary and integrated.

The workgroup sees the need for the creation of an elective rotation in an actual pain service, and with core competencies in pain management established by the Accreditation Council for Graduate Medical Education (ACGME) for every residency program, so there is consistency when medical students rotate on various clinical rotations.

Define Core Competencies.  The core competencies would include a working knowledge of: the physiology of pain transmission, perception, and modulation; the pathophysiology of pain disorders and diseases; the epidemiology of persistent pain and its co-morbidities and their impact on the public health; the phenomenology of individual pain disorders and diseases; the evidence basis for the different treatments proposed for specific pain conditions; and the purported mechanism of effect for these treatments. In addition, it would include knowledge about the medication classes specifically effective for specific pain conditions and the mechanisms of action for specific medications. All physicians should have basic knowledge about psychological treatments specifically effective for specific pain conditions, physical therapies specifically effective for specific pain conditions, and complementary and alternative medicine specifically effective for specific pain conditions.

Basic information about legal and economic factors that influence pain disability and the challenges facing health systems and society to manage pain will need to be addressed in the curriculum.

The Primary Care Setting.  The workgroup discussed one particular barrier to treating pain in the primary care setting—the pressure to see patients in 15-minute intervals. Developing a “how to” for the primary care physician to conduct effective pain management visits in 15 minutes is essential. A chapter on pain management in primary care by William McCarberg, MD, from Bonica's Management of Pain (2010) provides a good example of a practical approach that is needed.

A pamphlet and online patient education program on pain would be helpful, and there are several resources for that which can be used.

CME would be available to practicing physicians to study pain as a disease and understand the differences between eudynia and maldynia. The CME would also have mechanisms in place to measure the effectiveness of the training.

Implement an Evidence-based Continuum of Care.  The desired state of Pain Medicine includes an evidence-based stepped model of care. This approach is designed to deliver timely access to levels of care that are needed to prevent chronic pain from the beginning. When pain persists, the patient will visit their primary care physicians for evaluation and management using evidence-based algorithms. If disabling pain persists, the patient will be referred to a Pain Medicine specialist who will collaborate as needed with a team of providers, including nurse case managers, psychologists, physical therapists and other specialists, and, when necessary, a Pain Medicine specialist with subspecialty expertise. This approach would include trigger points for timely referral if there is a lack of progress and would use integrated models for collaborative care per co-morbidity, utilizing the Pain Medicine specialist to ensure optimal pain care for patients.

Next Steps.  The workgroup recommends several next steps:

  • 1
    The American Academy of Pain Medicine (AAPM) will pursue collaborative work (funded by grants) with the Association of American Medical Colleges in regard to undergraduate education.
  • 2
    There needs to be a focus at the graduate training level that should include the development of specific Pain Medicine competencies for each medical specialty through ACGME.
  • 3
    Pain Medicine must be recognized as a primary specialty by the American Board of Medical Specialties, to ensure adequacy and consistency of Pain Medicine specialty training and certification nationally and to assure uniform and reliable education for students in medical schools.
  • 4
    The workgroup suggests approaching the Council on Medical Education of the AMA with a resolution to develop a specific educational package on competencies for Pain Medicine.
  • 5
    Gaps in pain care in the ACGME programs need to be filled. The workgroup suggests a survey to the Association Program Specialty Directors of ACGME to determine what is currently being taught and what needs to be taught about Pain Medicine in their programs. The survey could be developed from the core competency standards for primary care indicated above as well as the VA's Pain Medicine competency standards for primary care.

A group needs to be named to address the above recommendations and then expand as needed. Workgroup 1 of the Pain Medicine Summit would be willing to review the work of the AAPM's medical student committee and make recommendations to the AMA Pain and Palliative Medicine Specialty Section Council (PPMSSC).

Conclusions.  The workgroup concluded that developing a complete pain curriculum for medical student education that is reliably taught, like other areas of basic and clinical science, is critical to the training of all physicians in Pain Medicine. The development of a coordinated medical school curriculum begins with basic definitions including differentiating pain as a symptom from pain as a disease. Clinical rotations with faculty in each specialty who teach the basics of Pain Medicine pertinent to their specialty will reinforce this core learning.

Outside efforts with ACGME and the American Board of Medical Specialties (ABMS) are needed to move the specialty of Pain Medicine forward, as well as continued collaboration with the AMA Council on Medical Education and the PPMSSC.

This work group is willing to be a sounding board for the AAPM medical student education committee and will make recommendations to the AMA Pain and Palliative Medicine Specialty Section Council (PPMSSC).

Workgroup 2 (Kim Burchiel, MD)

Discussion Topic: How Should Pain Medicine Be Taught?

Present State.  The workgroup consensus was that the present state of training in Pain Medicine is unacceptable. The variance in training and trainees is too great, the training period is too short, and there are not enough high quality training programs. Pain training is also not inclusive enough, in that some disciplines are not central enough to the discussion, for example, palliative care medicine and cancer pain treatment.

Desired State.  The consensus was that our goal is to improve the quality of pain care, and ultimately serve the cause of advancing the public health. To accomplish this end, we need to improve the general knowledge of pain care in the medical community and to provide competent and caring pain specialists to provide consultation and, in some cases, primary pain care. We need to change the model of pain training to make this more comprehensive, incorporating the needs of the primary care practitioner and the pain care specialist. Medical school and allied health curricula must include pain care. Further, we need better definitions of what the core competencies of Pain Medicine are and how to achieve these competencies through curricula for pain training.

The evidence base for pain care, particularly the evidence for clinical efficacy must be augmented. This evidence base should be reflected in the public's expectations for pain care, as well as the desire of insurance providers for cost effective care.

In addition, Pain Medicine practitioners must not be one-dimensional. While no pain specialist can be “expert” in all aspects of pain care, all should be broadly “competent” in the full spectrum of Pain Medicine.

Bridges from the Present State to the Desired State.  The workgroup consensus was that there are primarily two viable potential choices for training in Pain Medicine: One being to continue to develop the training pathway championed by the American Board of Anesthesiology (ABA) and to evolve more comprehensive training programs incrementally, and the alternative, to develop a primary Pain Medicine residency. An incremental approach, using the ABA pathway would almost certainly be easier, building upon the tradition that has been established in the field of anesthesiology, in collaboration with psychiatry, neurology, and rehabilitation medicine. Building Pain Medicine residencies de novo would present some daunting challenges, but this approach might also have the advantage of allowing for a comprehensive opportunity to restructure the Pain Medicine curriculum and training requirements, unfettered by the context of a primarily procedural specialty.

Obstacles to Achieving the Desired State.  As discussed, the future state of Pain Medicine training could take two directions: The continuation of the ABA process or the establishment of new Pain Medicine residencies, presumably under a new primary or conjoint ABMS board.

Both mechanisms share some potential challenges. Funding sources for training, faculty development and recruitment, core curriculum, and both the public and payer attitudes to the concept of Pain Medicine are concerns shared by either approach to future training. The ABA process has the disadvantage of prolonging time in training, since the ABA fellowships in Pain Medicine are added on to existing ABMS certified training programs in anesthesiology, psychiatry/neurology, and physical medicine and rehabilitation (PM&R). Primary Pain Medicine residencies would be challenged to find adequate numbers of potential trainees, given no prior track record for the residency graduates in this field. The issues of where potential trainees might come from and the potential interest level in the field of Pain Medicine are untested.

Conclusions.  What is reflected in this summary represents the consensus of the workgroup. These were not unanimous opinions, but this narrative attempts to synthesize these discussions into a coherent narrative that reflects the opinions of the majority of participants in this session.

In our opinion, there is a need to reconvene the PPMSSC to begin to explore where we agree and disagree on future approaches. To that extent, this first work product is a starting point for future discussions. This discussion should proceed expeditiously in 2010. The next discussions should be more inclusive of palliative medicine and cancer pain management. There is a major unmet need to define the national need for pain care, to define and improve the model of Pain Medicine, and to define the goals of new pain training and practice.

Workgroup 3 (Albert Ray, MD)

Discussion Topic: What Are the Parameters that Define the Field of Pain Medicine?

Present State.  Our group concluded that there is a diverse group of physicians and organizations within the field of Pain Medicine, with the result that the public has no standards available to them. In addition, many physicians have some familiarity with eudynia (pain as a symptom), but very little experience or training in how to deal with maldynia (pain as a disease), if they are not a pain physician. Ongoing care, follow-up, and education of patients are neither uniform nor available in a standardized way. The lack of uniform training and other barriers to treatment prevent many caregivers from working in the field and treating patients beyond an acute treatment level. This further adds to the lack of uniformity in helping our patients receive appropriate and integrated care, rather than segmented and disjointed approaches to dealing with the totality of the life experience of living with persistent pain.

Desired State.  The desired state for the field of Pain Medicine would be one that offers collaborative continuity, with patients having easy access to well-trained pain specialists through their network of treating physicians. These pain specialists would be able to offer longitudinal follow-up, serve as better educational resources for their patients, have knowledge of which treatments work and how to select the best patients for those treatments, help colleagues provide better systematic management of eudynia in order to prevent the development of maldynia, teach medical students the clinical aspects of pain care, and improve the overall understanding of all physicians of where and to whom to refer for appropriate pain care, thereby raising the quality of life for their patients.

Our group agreed that the field of Pain Medicine includes the following:

  • 1
    Anatomy, physiology, and neuropharmacology of pain sensation; transduction, transmission, modulation, and perception of pain;
  • 2
    Taxonomy of pain and pain syndromes;
  • 3
    Psychological aspects of pain, including ethnic, gender, and socio-cultural factors;
  • 4
    Understanding and management of pain in pediatric and geriatric populations;
  • 5
    Understanding and management of pain in substance abuse populations;
  • 6
    Psychiatric aspects and management of pain;
  • 7
    Addiction medicine, including drug testing, collection procedures, and interpretation of results;
  • 8
    Pathophysiology and clinical aspects of a wide range of pain disorders, including headache, orofacial/craniofacial, rheumatological pain syndromes, neuropathic pain syndromes, myofascial pain, cancer pain, postoperative pain, and pain of spinal origin (orthopedic and neurogenic);
  • 9
    Hospice and palliative care;
  • 10
    Medico-legal aspects on pain care, including compensation and disability systems, evaluation and ratings of impairment, health record documentation requirements, and compliance of health care laws, regulations, and policies;
  • 11
    Recognition and management of ethical issues in pain care;
  • 12
    Organization and management of a pain center, including economics, business management, safety, compliance with employment laws, and quality improvement;
  • 13
    Pain research in animals and humans, including study design, analysis and reporting of data, interpretation of clinical and basic studies, and ethics of pain research; and how to read journal articles and how to publish research/clinical papers;
  • 14
    Assessment of pain, including the general physical examination, neurological examination, musculoskeletal examination, mental status examination, pain assessment tools, and diagnostic studies (laboratory, imaging, psychologic, and electrophysiological);
  • 15
    Identification and management of the pain patient with co-existing addiction, including knowledge of available resources for addiction treatment;
  • 16
    Knowledge of treatment guidelines and outcomes data germane to interventional and non-interventional techniques, so as to apply these modalities in an ethical and cost-effective manner;
  • 17
    Pharmacological therapies, including opioid and non-opioid analgesics and adjuvant pharmacological therapies (e.g. anticonvulsants, antidepressants, etc.);
  • 18
    Physical medicine and rehabilitation, including physical therapy and functional restoration;
  • 19
    Nonsurgical neuroaugmentation/counterirritation modalities;
  • 20
    Psychiatric/psychological therapies, including cognitive-behavioral, biofeedback, relaxation therapy;
  • 21
    Multidisciplinary Pain Medicine;
  • 22
    Complementary and alternative therapies;
  • 23
    Acupuncture/acupressure;
  • 24
    Diagnostic and therapeutic injection techniques, including peripheral, regional, and sympathetic nerve blockade/neurolysis; subcutaneous, intravenous, perineural, and intrathecal drug injection/infusion; and other injections (e.g., trigger points, zygapophysial joint, epidural, large joint, bursa, etc.);
  • 25
    Ablative procedures such as neurectomy, cordotomy, and cranial and spinal rhizotomy;
  • 26
    Nonablative procedures, including spinal cord stimulation and neuraxial drug administration, microvascular decompression;
  • 27
    Chiropractic and manual medicine;
  • 28
    Prevention of pain and pain disorders;
  • 29
    Genetics in relation to pain perception, pain disorders, treatments, etc.;
  • 30
    Endocrine aspects of pain;
  • 31
    Surgical pain procedures; and
  • 32
    Expansion of the depth of all of the above.

Our group also agreed that well trained pain specialists in the “desired state” would have adequate knowledge and training in all of the above components to be able to administer the appropriate treatment of pain to their patients, including the physical and psychiatric aspects of pain care.

Bridges from the Present State to the Desired State.  In order to reach the desired state, we agreed that there needs to be improved training and understanding regarding collateral symptoms, with expansion/revision of medical school curricula, expanded funding into research, and funding for training and fellowships. The ultimate desired goal would be Pain Medicine departments in medical schools, with joint faculty appointments, in order to fulfill the multidisciplinary nature of the training of a Pain Medicine physician, with expansion of existing programs with programs that are ACGME defined to include all of the aspects of Pain Medicine listed above. Another bridge is to broaden CME offerings in the field of Pain Medicine through medical schools and Pain Medicine specialty societies. This could serve to improve pain education for non-pain physicians, as well as pain specialists.

Obstacles to Achieving the Desired State.  Currently, there are no Pain Medicine departments in medical schools, and therefore little GME support for training. Rather than the motivation for advancement to come from quality medical education of Pain Medicine from medical schools, the motivation must come from within the physicians themselves to seek whatever education they can in order to develop competency in Pain Medicine care. This can include formal fellowships, as they currently exist, with their current limitations, but this also leaves physicians dependent on the influences of specialty societies to provide quality CME courses. Physicians are also vulnerable to outside influences from pharmaceutical and medical device companies for education and training. One consequence with all of the above sources of learning is the variable levels of quality in all programs, be they fellowships, CME courses, or industry supported education.

This lack of quality control over education results in diffusion of knowledge, and we continue with difficulty for non-pain physicians and the public about proper referrals for differing aspects of care. There are no “complete” pain physicians in current practice, which then keeps the care segmented. It also continues to favor encroachment into the field of Pain Medicine from other specialties, as there is no well-delineated field of Pain Medicine yet defined.

Lack of departments of Pain Medicine, with the resultant degradation or even absence of Pain Medicine education is a major obstacle today. This creates obstacles to all levels of Pain Medicine education and continues a lack of needed pain research data. Funding is more difficult to obtain without a department to house researchers.

Another major obstacle is the current payment landscape. There is poor reimbursement for pain care of patients with persistent pain and often acute pain. The current payment system is also financially slanted toward interventional pain care. Today's reimbursement discourages physicians from entering the Pain Medicine field.

Because there is no well-defined field of Pain Medicine, the specialty remains at the mercy of a frequently negative regulatory environment and allows for government intervention and intrusions into the field. Legislatures are now trying to control pain-related medical problems, because it is not being done from within the medical world. This legislation often creates further disincentives for physicians to enter the field.

Conclusions.  Our consensus conclusions reflect the following:

  • 1
    The field of Pain Medicine is not well defined in terms of scope and personnel, with a great deal of fluctuation.
  • 2
    There is an inadequate understanding by the public, government, and physicians as to what constitutes Pain Medicine.
  • 3
    There exists a need for a well-defined scope of practice.
  • 4
    We need to develop departments of Pain Medicine within medical schools that can adequately train all physicians in Pain Medicine, both as generalists and as specialists.

Next Steps.  We recommend the following next steps:

  • 1
    Track the results and follow-up considerations of this Pain Medicine Summit.
  • 2
    Make the results of this Summit available, and utilize them in a way to inform physicians and the public about the consensus reached.
  • 3
    Make the results available for advocacy within the AMA and at a federal level.
  • 4
    Produce a second Pain Medicine Summit in order to:
    • a. 
      Review any progress in the recommendations of this Summit;
    • b. 
      Cast a wider net and include a broader audience, including public representation, ACGME, ABMS et al.;
    • c. 
      Include non-AMA pain stakeholders and public pain-related groups; and
    • d. 
      Overcome some of the obstacles to progress identified in this Summit.

Workgroup 4 (Kenneth Follett, MD, PhD)

Discussion Topic: What Mechanism(S) Do We Need to Establish the Competency of a Physician Who Wishes to Practice Pain Medicine?

Present State.  The workgroup identified two recurring themes: 1) competency is not determined in a single step or at a single point in time but is established via on-going education, assessment, and documentation throughout the course of a physician's training and medical practice and 2) establishing competency is best accomplished through an approach that integrates oversight of education (accreditation) with oversight of practice through licensure, certification, credentialing, and maintenance of certification throughout the pain specialist's career. This necessarily requires the participation of several organizations and agencies.

The discussion began with agreement that the current system of Pain Medicine education, certification, and establishment of competency is “broken” and inadequate. However, several positive characteristics were identified. The group acknowledged efforts undertaken by several organizations to improve comprehensiveness and uniformity of pain training, which is fundamental to the competency of any physician. The existing multi-layered assessment of competency through accreditation of training programs, medical licensure, credentialing, certification, and maintenance of certification is recognized as providing a better mechanism for establishing competency than could be accomplished with only a single tool.

Significant gaps exist in the current system for demonstrating competency. Incomplete and nonuniform training in Pain Medicine presents a large obstacle to establishing competency. Despite oversight by the Accreditation Council for Graduate Medical Education (ACGME) and the American Osteopathic Association Bureau of Osteopathic Specialties (AOABOS), medical school education, residency training, and fellowship programs vary in quality and content. In many instances, Pain Medicine physicians are not taught the full scope of knowledge and skills that are necessary to address common kinds of pain that require treatment. Outside ACGME and AOABOS accredited training programs, physicians may learn and implement therapies taught in brief courses that are provided with no formal oversight of quality or content, such as weekend courses sponsored by industry.

There is no coordination of educational content delivered to pain care providers at different levels (e.g., primary care provider versus pain specialist), hindering smooth transition of patients from one level of pain care to another or from one pain care provider to another. Despite the potential strengths of the existing multi-layered approach for establishing competency, the process falls short of its goal on several fronts: state licensure is rudimentary at best; certification is not mandatory; a single certifying examination/process may not accommodate pain subspecialists and, considering the multidisciplinary nature of Pain Medicine, a single existing ABMS/AOA Board cannot adequately assess all facets of Pain Medicine competency; there is no mechanism for assessing skills acquired following primary certification; and credentialing (which should serve as the final safety net for establishing competency) may be superficial and does not apply to individuals who practice outside a hospital setting. Various steps in the process are not linked adequately (e.g., licensure and certification). Treatment of pain transcends the boundaries of any single existing medical specialty, and the competing, overlapping, and sometimes conflicting efforts of the various organizations involved result in a lack of “single-party” ownership of Pain Medicine that hinders the establishment of a uniform process for training, certification, and demonstration of competency. Patients and payors may be confused by the multiple routes and pathways of pain training and certification, a situation exacerbated by the presence of non-physician healthcare providers offering pain care, whose variable training and certification add even more disparity to the mix.

Desired State.  The foundation is comprehensive education, beginning in medical school, with training program quality and content overseen by national accrediting organizations and pain specialists. Core competencies and a common core curriculum for cognitive and psychomotor training in Pain Medicine should be established and should be consistent from medical school into postgraduate training and throughout professional practice. The process should acknowledge and accommodate the fact that Pain Medicine practitioners who treat different populations of patients require different sets of competencies. Subsets of knowledge and skills required by pain subspecialists could be developed as an extension of the core competencies to ensure uniformity of practice among pain subspecialists.

Evidence-based standards of care should be established and physician compliance with these guidelines should be monitored. The core curriculum could be abstracted and used as a framework for training nonpain specialists (e.g., primary care providers) to facilitate uniformity of pain care among providers and from one level of pain care to another. Uniformity of care and smooth transitioning of patients from one provider to another can be facilitated also by providing a role for pain specialists in the pain education of non-pain specialists throughout medical school, residency, and into professional practice.

The existing multi-layered approach to establishing competency can serve as a framework for the future, but activities of organizations that participate in the process should be better coordinated, beginning with medical school, progressing through residency, licensure, credentialing, and primary and on-going certification. Credentialing is an important safety net for establishing competency of individual physicians but the credentialing process must be more rigorous with greater scrutiny of physicians' knowledge and skills. Most importantly, credentialing must be mandatory for all pain specialists, including those who practice outside hospital settings and who are exempt from current credentialing processes. A centralized, uniform process for credentialing would be ideal, and could be based on a common core curriculum for training and evidence-based practice guidelines. Professional organizations might serve in some capacity to facilitate such a process (e.g., by developing data repositories in which physicians can report patient outcomes and which could be accessed by those physicians for the purpose of allowing them to compare their patients' outcomes to those of their peers, and perhaps providing access to outside organizations/agencies that participate in demonstration of competency).

Competency can be established also through physicians' actions. Pain Medicine specialists should be more willing to assume primary responsibility for pain treatment (as opposed to, for instance, recommending a therapy but returning the patient to a referring physician for implementation). Pain practitioners should demonstrate an ability to provide smooth transition of patients from one level of pain care to another. Pain specialists and professional organizations should work vigorously to educate patients and the public-at-large about the specialty of Pain Medicine and how to identify competent Pain Medicine physicians.

How Do We Reach These Goals?  We can begin with the development of more comprehensive, multidisciplinary, and uniform training. This should include development of a core curriculum and establishment of “levels of competencies” that define the knowledge and skill sets expected of practitioners at each level of pain practice.

Certification should be mandatory for every pain specialist, and the certification process should be strengthened. This could be accomplished by including a practical component to existing written certification examinations. The certification/maintenance of certification process should be revised to accommodate subspecialty as well as general pain practices. Development, coordination, and oversight of training and certification should be interdisciplinary, involving each of the medical/surgical disciplines that have roles in pain care. Professional organizations could have a greater role in establishing competency or coordinating activities of other organizations/agencies that evaluate competency, and could participate in the education of public, payors, and patients about pain care, the role of pain specialists, and the importance of specialized training for pain physicians. The nature of this involvement needs to be defined.

Efforts to achieve the desired state will likely be hampered by absence of many important features in the existing Pain Medicine environment. Missing or suboptimal features include the lack of a single voice for Pain Medicine to provide guidance about what constitutes good training and practice, lack of common practice standards (developed from evidence-based guidelines), lack of oversight of industry's involvement in pain training and practice, lack of funding of new initiatives (training or other), lack of a mechanism to evaluate newly-acquired skills, and lack of a mechanism for quality assurance in non-hospital settings. Workgroup members concurred that many of these hurdles could be overcome more readily if there were a single specialty of Pain Medicine recognized by physicians, regulatory and oversight agencies, patients, and payors.

Conclusions.  Workgroup 4 recommended retaining the existing multi-layered structure for establishing competency (accreditation of training, licensing, certification, credentialing, and maintenance of certification). We do not know that MOCertification, MOLicensure, or credentialing ultimately equal competency, but the existing structure provides the best framework for establishing competency. Credentialing should be uniform and should be required of all pain specialists, whether hospital- or office-based. The workgroup acknowledged that competency begins with education and supports development of uniform, comprehensive training programs based on a common core curriculum. It is not clear whether a new, more comprehensive system of training should be accomplished via development of Pain Medicine residency programs versus expansion of current pathways (group members acknowledged the inherent shortcoming of building uniform training and certification in the existing environment in which “ownership” of Pain Medicine is claimed by multiple groups who may have conflicting approaches to training and certification). Regardless of the approach, the process must be inclusive rather than exclusive. Standards of practice should be developed using evidence-based guidelines to promote uniformity of practice, and physician compliance should be monitored. Finally, Pain Medicine physicians should take ownership of the discipline to reduce the confusion among patients, the public, and payors that is introduced by nonphysician providers who offer pain management services, but who come from widely varying backgrounds and who possess widely disparate cognitive and technical skills.

Members of the workgroup concurred that the goals they proposed would be most readily achieved if Pain Medicine were a recognized ABMS/AOA specialty. A specialty of Pain Medicine would provide single-party “ownership,” a recognized authority, and a unified voice that is lacking in the current environment and that is fundamentally important to reaching the over-arching goals of protecting and serving the public and patients by ensuring the availability of comprehensively-trained pain specialists and providing a mechanism by which to identify competent, qualified practitioners. The workgroup recommendations should be discussed in greater detail in future meetings of AMA Pain Medicine Summit participants.

Workgroup 5 (Michel Dubois, MD)

Discussion Topic: What Are the Barriers, Besides the Absence of Competent Pain Medicine Physicians, Which Prevent Patients From Receiving Adequate Pain Care?

Present State.  Major systemic changes are required before patients can receive adequate pain care in the United States. The absence of a “medical home” for pain patients actively contributes to the lack of a global strategic approach for chronic pain management, while many physicians continue to think of chronic pain using an acute pain paradigm. The lack of government support for research focusing on pain, and the absence of recognition of pain as a public health problem, only aggravate these gross inadequacies. Further impediments to adequate care in the current practice of pain include a biased patient approach, due to, among other things, intervention-based reimbursement, confusion and fear about prescribing controlled substances, and a fragmented system of care where patients are referred from physician to physician without any medical coordination. Major existing obstacles preclude necessary changes: the failure to recognize chronic pain as an endemic health hazard and as an illness, and the preference of the present system for rewarding physicians performing treatments over physicians who make an effort to evaluate and manage their patients using an interdisciplinary approach. The bio-medical model is highly rewarded at the expense of the bio-psychosocial model. Misconceptions among the public about chronic pain also represent a significant obstacle to change. Patients believe that the cause of pain should be the object of treatment and do not usually consider chronic pain as a separate disorder (a concept usually reinforced by lack of physicians' awareness). Among physicians who prescribe controlled substances, frustrations have been maximized when no coordination exists between the public health need for reducing drug abuse and diversion and the need to treat efficiently severe chronic pain. Finally, the influence on health care of large profit-driven pharmaceutical and device manufacturers and of managed-care companies has been a major factor in steering pain practice, producing an intrinsic conflict of interest for physicians wishing to treat pain.

Desired State.  Acknowledgements of chronic pain as a disease (like hypertension or diabetes) and recognition of Pain Medicine as a new medical specialty are necessary, due to the enormous advances in medical knowledge and increased patient needs, and are imperative if we are to achieve adequate pain care in this country. The approach to chronic pain treatment should be truly interdisciplinary and integrated. Pain management should be a priority in the curriculum of all primary residency programs, especially in Primary Care. Reimbursement policy should emphasize an interdisciplinary approach and be based on functional outcomes. A clear distinction should exist between the need to reduce prescription drug abuse and diversion and the significant benefits patients receive from a prescription of controlled substance medication. Finally, government should recognize pain as a public health problem and also allocate research dollars commensurate with the extent of this problem.

How Do We Reach These Goals?  Medium- to long-term strategies to reach the above objectives include the intensification of lobby and advocacy efforts with consumers, physicians, public agencies, the government, and other stakeholders; the development of patient-centered, multi-disciplinary pain centers; the establishment of a pain curriculum in medical schools, including a residency rotation in Pain Medicine during residency training; an increase in CME programs and educational activities in general; and the systematic funding of basic science and clinical research in pain, including pilot trials of outcome-based treatments for chronic pain, which could also serve as a base for new payment modalities.

Short-term action items, which would help to “jumpstart” the above strategies, include:

  • • 
    Form a multi-organizational advocacy effort, which would request that the Surgeon General's office outline public warnings about wrong and right ways to treat pain.
  • • 
    Approach DHHS for an independent commission, which would establish a new reimbursement policy for pain care.
  • • 
    Form a consortium of existing stakeholder organizations in order to develop a comprehensive web-based information resource concerning chronic pain as a disease, its recognition, and its treatment.
  • • 
    Initiate comparative effectiveness research (CER) models for assessment of pain treatments.
  • • 
    Determine long-term efficacy and possible outcome-based payment.
  • • 
    Educate primary care physicians by offering step-by-step procedures for treating pain patients and providing them with the interdisciplinary tools necessary to manage pain.
  • • 
    Take the lead in educating healthcare providers about risks and benefits related to controlled substances.
  • • 
    Work with the AAMC to create a more robust pain education in medical schools.
  • • 
    Establish an appropriate competency credentialing system for Pain Medicine specialists.

All these important steps would be greatly facilitated by the development of a new umbrella organization composed of representatives from all pain-focused stakeholders and directed primarily toward public education and the development of professional competency.

Summary Conclusions and Recommendations

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

General Conclusions and Recommendations

The Pain Medicine Summit produced a broad and clear consensus on several issues that attendees felt that the field of Pain Medicine was lacking, including:

  • • 
    A single voice to provide guidance about what constitutes good training practice(s),
  • • 
    Uniformity of terminology,
  • • 
    Common practice standards,
  • • 
    Evidence-based guidelines and documented outcomes,
  • • 
    Recognition of pain as both symptom and disease by patients and physicians,
  • • 
    Recognition of Pain Medicine as a specialty by patients and payors,
  • • 
    A mechanism to evaluate newly acquired skills in Pain Medicine providers,
  • • 
    A mechanism for quality assurance in non-hospital settings,
  • • 
    Compensation for adequate patient care,
  • • 
    Access to care delivered in a congruent, focused, and nonfragmented delivery system,
  • • 
    Consistency in content and scope of material covered in all phases of training, and
  • • 
    Consensus about the most effective pathway(s) to the accreditation of training programs in Pain Medicine and certification of graduates of those programs as specialists in Pain Medicine.

With regard to the next steps for moving forward, attendees reached a consensus that the following steps need to be taken:

  • • 
    Continue constructive engagement by convening a second Pain Medicine Summit in 2010,
  • • 
    Seek assistance of the PPMSSC to implement the next Summit,
  • • 
    Seek broader AMA participation, sponsorship, and support, and
  • • 
    Continue planning for future engagement:
    • ○ 
      Create work plan and budget
    • ○ 
      Distribute Summit proceedings for review by participating groups
    • ○ 
      Track progress from this Summit
    • ○ 
      Obtain commitments for participation and support from Summit participants and potential new “members”
    • ○ 
      Clarify and refine the nearly 30 goals that were proposed as next steps
    • ○ 
      Consider convening an International Pain Summit

Future Summits

Summit attendees also agreed that the organizers of the next Summit should broaden specialty participation in future activities to include physicians involved in palliative medicine, cancer care, and other related fields as well as other non-physician constituencies including patients, the public, insurers, legislators, and allied health professionals. Input and participation of this expanded group is seen as critical to the success of creating an effective message about the scope and importance of Pain Medicine, as well as the group's ability to widely disseminate such information and advocate for its use in policy making, training, and integration into health care delivery systems.

Information Resources

In addition, Summit organizers should aggressively make results and information about the Summit available to the public and other audiences, and they should make results and information for advocacy to the AMA, to all participating organizations, and to stakeholders at the federal level.

A consortium of stakeholder organizations should develop a comprehensive, web-based, information resource for public education about persistent pain as a disease, its recognition, and its treatment. The Foundation for Pain Medicine could take the lead in organizing this effort.

Medical Education

There was agreement that the following steps should be taken:

  • • 
    Developing a new CME curriculum and distribution mechanism (e.g., online).
  • • 
    Developing in-career education: Educate primary care physicians and ancillary health care providers with step by step means of treatments, and support them with interdisciplinary tools.
  • • 
    Focusing on changing undergraduate and graduate education to increase exposure to Pain Medicine and develop specific pain care competencies for each medical specialty through collaboration with groups like the AAMC and ACGME, with input from all specialties.
  • • 
    Performing a survey of program directors of all ACGME training programs to find ways to fill the identified gaps in the field of Pain Medicine vs. current training standards.
  • • 
    Creating materials and strategy to help define Pain Medicine so that the public can understand what a Pain Medicine specialist does.
  • • 
    Exploring alternatives to improve post-graduate training in Pain Medicine, for example, expansion:
    • ○ 
      Creating a “burning issue” for medical schools to open the curriculum to include education in pain care, and
    • ○ 
      Ensuring that Pain Medicine specialists oversee the education of non-Pain Medicine specialists.

Credentialing and Certification

With regard to credentialing and certification, the following steps should be taken:

  • • 
    Approach the AMA, specifically the Council on Medical Education, with a resolution to develop a specific educational package on competencies.
  • • 
    Engage the ABMS and/or AOS to discuss the recognition of Pain Medicine as a distinct medical specialty, not a subspecialty, and ensure that “Medicine” takes ownership of Pain Medicine, rather than non-physician practitioners.
  • • 
    Establish levels of competency, improve the certification process, and help develop certification and recertification examinations, possibly including written and practical assessments in future credentialing processes.
  • • 
    Maintain the multi-layered structure for establishing competency: medical school, post-graduate training, accreditation by ACGME, licensing (state oversight), and maintenance of certification.
  • • 
    Ensure that professional organizations play an adequate and appropriate role in re-certification or re-credentialing processes through uniform credentialing mechanisms.
  • • 
    Explore development of an umbrella organization for all pain focused stakeholders for public education and professional competency.

Treatment Standards

Steps to encourage effective standards of care include the following:

  • • 
    Advocating for additional standards of care (evidenced-based medicine) and mechanisms for monitoring physician compliance;
  • • 
    Advocating, prioritizing, and helping organize comparative effectiveness research models to determine long-term efficacy and possible payment; and
  • • 
    Forming multi-organizational advocacy effort to advocate for “Surgeon General Warnings” about wrong and right means of treating pain.

Reimbursement Policies

Finally, Summit participants recommended approaching the Department of Health and Human Services for an independent commission to establish a new reimbursement policy for pain care.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

The Pain Medicine Summit was made possible by the focused and sustained effort of more than one hundred people and dozens of organizations; each played an important role in achieving the goals established by the AMA House of Delegates Resolution 321 (A-08). In particular, special thanks are extended to the following people and organizations for their vision, support, and contributions:

  • • 
    AMA's Pain and Palliative Medicine Specialty Section Council (PPMSSC) and the members of the Advisory Committee, Implementation Committee, and Steering Committee, all working under the dedicated efforts of the PPMSSC Chair, Philipp M. Lippe, MD, FACS
  • • 
    The Foundation for Pain Medicine
  • • 
    James Rohack, MD, President, AMA
  • • 
    Michael Cousins, MD
  • • 
    Break-out Session Team Leaders:
    • ○ 
      Kim Burchiel, MD
    • ○ 
      Michel Dubois, MD
    • ○ 
      Kenneth Follett, MD, PhD
    • ○ 
      Rollin Gallagher, MD, MPH
    • ○ 
      Albert Ray, MD

Appendices

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

Appendices

Appendix A: Delphi Round #1 Invitation Letter

Dear: Dr X

This message is to update you on the progress of the “Pain Medicine Summit” being convened by the AMA under the direction of its Pain and Palliative Medicine Specialty Section Council (PPMSSC). We are quickly filling up the roster for participants in the Delphi process and the Pain Medicine Summit (a limited number of spots are available for the Delphi process) and we want to make sure your organization has the opportunity to be represented fully in this discussion about the future of Pain Medicine.

As you will recall from our communication late last month, we are contacting you, and hopefully through you the leadership of your organization, to identify and provide contact information for two physicians that would be interested and willing to serve as a representative of your organization in this important event. The physicians you identify should either be engaged in the delivery of Pain care or knowledgeable in this area of practice.

To review, the AMA PPMSSC is sponsoring a “Pain Medicine Summit” to discuss scientific and socioeconomic issues affecting the delivery of Pain Medicine. This summit will take place immediately prior to the AMA's interim House of Delegates meeting in Houston, Texas. Grey Matters consulting firm has been engaged to facilitate a Delphi (consensus building) process involving representatives of over 30 professional medical organizations, including yours, that have an interest in the delivery of Pain Medicine.

This process will take place from September 14th to October 14th: It will consist of completion of two brief, anonymous, on-line surveys, the results of which will guide the presentations and discussion at the November 5th Pain Medicine Summit. The Delphi process does not require travel and will be structured to require as little time as possible on the part of participants. The effectiveness of this consensus process and the success of the Pain Medicine Summit which follows depend largely on the commitment and intellectual contributions of the leadership of your organization and the representatives you provide.

The steering committee responsible for overseeing the execution of this event would like to finalize its roster of representatives by Friday, September 11th so time is clearly of the essence. If you have any questions about the details of the process, the November 5 Pain Medicine Summit or the selection of representatives from your organization please contact Grey Matters directly via phone at (773) 348-3667 or via e-mail chadmunger@sbcglobal.net. You may also contact the Chairman of the PPMSSC, Phillip Lippe, MD, at (408) 927-0802 or pmlippe@att.net.

Your representatives to the Delphi process are not being asked to agree to participate in the November 5th Pain Medicine Summit, though we strongly hope they will choose to do so. If your representatives to the consensus process do not wish to participate in the Pain Medicine Summit we will work with you between now and early November to identify appropriate substitutes.

Thank you for your attention to this time sensitive request. We look forward to working with your organization to frame a stimulating conversation about the future of Pain Medicine.

Yours sincerely,

Philipp M. Lippe, MD

Chairman, Pain and Palliative Medicine Specialty Section Council

American Medical Association.

Appendix K: Workgroup Discussion Points
Workgroup 1

To: AMA Section Council Pain Medicine Summit Participants  October 30, 2009

Dear Colleagues,

Our charge at the AMA Pain Medicine Summit is to discuss the issue of the competencies that should be expected of all physicians in the management of pain, with a specific focus on primary care physicians and other specialists who care for the large majority of patients with chronic pain. For purposes of the discussion and out of respect for your colleagues who are making the effort to come to the summit, please be make an effort to read these documents before the summit. If you like, print them and jot notes, or used a text editing tool to make comments on-line.

My own professional disclosures are listed at the end of the document.

I came up with the following set of specific questions as a stimulus. Please add to these but also think about your answers.

  • 1) 
    Should all physicians possess a general familiarity with:
    • a) 
      the physiology of pain transmission, perception and modulation?
    • b) 
      the pathophysiology of pain disorders and diseases?
    • c) 
      the epidemiology of persistent pain and its co-morbidities and their impact on the public health (costs, disability)?
    • d) 
      the phenomenology of individual pain disorders and diseases?
    • e) 
      the evidence basis for the different treatments proposed for specific pain conditions?
    • f) 
      the purported mechanism of effect for these treatments
  • 2) 
    Should primary care physicians possess disease-specific knowledge of pain treatments?
    • a) 
      Medications classes specifically effective for specific pain conditions
    • b) 
      Mechanisms of action for specific medications
    • c) 
      Psychological treatments specifically effective for specific pain conditions
    • d) 
      Mechanisms of action for psychological treatments
    • e) 
      Physical therapies specifically effective for specific pain conditions
    • f) 
      Mechanisms of action for physical therapies
    • g) 
      Injections specifically effective for specific pain conditions
    • h) 
      Mechanisms of action for injections
    • i) 
      Neurostimulation specifically effective for specific pain conditions
    • j) 
      Mechanisms of action for neurostimulation
    • k) 
      CAM specifically effective for specific pain conditions
    • l) 
      Mechanisms of action for CAM
  • 3) 
    What are the gaps in pain medicine care and function as perceived by primary care?
  • 4) 
    What are the gaps in pain education in medical school and how would you remedy them?
  • 5) 
    What are the gaps in pain training in primary care and how would you remedy them?

I look forward to seeing you in Houston.

Best wishes,

Rollin M. Gallagher MD, MPH

Documents (attached):

  • 1) 
    VHA Pain Management Directive
  • 2) 
    McCarberg W. Chapter on Pain Management in Primary Care in Bonica Textbook
  • 3) 
    Gallagher RM. Pain medicine and primary care: A community solution to pain as a public health problem. Medical Clinics of North America 83(5): 555–585, 1999
  • 4) 
    Pain Management Competencies: Veterans Affairs Health System
  • 5) 
    Harris JM et al. Educating Generalist Physicians about Chronic Pain: Live Experts and Online Education Can Provide Durable Benefits. Pain Med 2008;9(5): 555–563

Disclosures:

1) I am representing the Department of Veterans Affairs at this Summit, as Deputy National Program Director for Pain Management for the Veterans Affairs Health System. In this role I have helped construct a new Directive that is just this week been signed by the Under Secretary and sent to the field. This Directive, which is attached, calls for a system-wide change, based on a population approach, in how we manage pain in the VHA. As you will see, this Directive, which was sent to all VA Health Facilities today, focuses on the following:

  • 1.1 
    pain management in the primary care setting, delivered by integrated medical and behavioral treatment and based on evidence
  • 1.2 
    immediate and appropriate access to consultation and treatment, when required, from a competent pain medicine workforce, amongst other consultants in mental health and rehabilitation.
  • 1.3 
    patient—family education and participation in decision-making and treatment, fostering the “three-legged treatment stool” of patient, health care team, and provider, that is supported by a health care system that endorses positive functional outcomes, not just pain relief.
  • 1.4 
    systems support for competent management of pain and its co-morbidities.

2) I began my career in family practice, took psychiatry training, and with a joint appointment in these specialties, in 1982 started the pain clinic at the University of Vermont and took an epidemiology fellowship and MPH mid-career. I have been practicing pain medicine in academic settings since then, but always with an eye to a population-based, public health approach to pain management.

3) I am President of the American Academy of Pain Medicine, and former President of the American Board of Pain Medicine (2002-2004). The AAPM has taken the position that current pain medicine training is too short to develop competency in comprehensive pain medicine care and to meet the needs of primary care, which shoulders the large burden of pain management, for timely access to competent consultation and collaborative treatment. AAPM also believes that pain research has not provided answers to many vexing questions about how to manage pain in primary care and beyond.

4) I am Editor-in-Chief of Pain Medicine, the official academic journal of the American Academy of Pain Medicine (AAPM), the International Spine Intervention Society (ISIS), and the Faculty of Pain Medicine of the Australia New Zealand College of Anesthetists (FPM), which has published many papers on the subject of Pain Medicine training, clinical practice and research and in 2007 launched the Primary Care and Health Services Section which is dedicated to pain research in this domain.

5) I am not funded by industry, nor do I consult or speak for industry.

Workgroup 2

Discussion Topic: How should Pain Medicine be taught?

Who, What, When, Where?

  • 1
    Who?
    • ○ 
      Who should be trained in Pain Medicine?
      • ▪ 
        All health sciences?
  • 2
    What?
    • ○ 
      How should general pain training and specialty training be defined and differentiated?
    • ○ 
      Should the methodology of teaching vary with the level of training/practice?
      • ▪ 
        Undergraduate
        • • 
          classroom
        • • 
          small and large group sessions
        • • 
          standard patients
        • • 
          lectures
      • ▪ 
        Post-graduate
        • • 
          1-day workshop
        • • 
          small and large group sessions
        • • 
          standard patients
        • • 
          lectures
    • ○ 
      Should pain curricula and teaching methods/timing vary by specialty?
      • ▪ 
        Neurology, Neurosurgery, Anesthesiology, PM&R, Psychiatry, etc.
  • 3
    When?
    • ○ 
      When should the pain curriculum be delivered?
      • ▪ 
        Undergraduate? Which year?
      • ▪ 
        Postgraduate?
  • 4
    Where?
    • ○ 
      What role should the WWW. play in education and CME?
      • ▪ 
        Virtual textbooks?
Workgroup 3

Discussion Topic: What are the parameters that define the field of Pain Medicine?

Within that task is the assignment to cover the topic from six points of view:

  • 1
    Where are we now, i.e. the present state of the field;
  • 2
    Where do we want to be in the future, i.e. our desired state;
  • 3
    Why would our future state be a better state than the current one for both patients and physicians;
  • 4
    What are potential bridges to move from our present state to the desired state;
  • 5
    What are some of the concerns, risks, obstacles associated with going from our current state to our desired state;
  • 6
    What are possible next steps in achieving the desired state

In order to stimulate discussion on this topic in addressing all six of these questions, the following are recommended as areas to be discussed:

  • • 
    What is contained in your understanding of the current state of Pain Medicine as a field of medical practice?
  • • 
    What is not included that should be?
  • • 
    What is included that shouldn't be?
  • • 
    If you want to refer a patient for orthopedic, neurologic, physiatric, or neurosurgical consultation and treatment, you have a fairly good understanding of what comprises the specialty to which you are referring.
    • ○ 
      Where did you get that knowledge?
    • ○ 
      Do you have the same level of confidence as to what comprises the field of pain medicine?
    • ○ 
      Where would you find it out?
  • • 
    When you want to refer a patient for Pain Care, how do you make the decision as to whom to refer to?
    • ○ 
      Is it based on what you think the patient needs? How specific do you feel you must be in knowing what is needed in order to make the referral?
    • ○ 
      Is it based on what the physician offers?
    • ○ 
      Do you refer based on your assessment of what should be done, or do you refer for the pain specialist's opinion of what is necessary?
    • ○ 
      How do you know what expertise the pain care physician has? Where would you go to find out?
  • • 
    The AMA resolution states that Pain Medicine is a multidisciplinary specialty.
    • ○ 
      What areas do you consider are included in that understanding?
    • ○ 
      What areas are included that shouldn't be?
    • ○ 
      What new areas would you like to see included?
    • ○ 
      Do the current areas cover all of your patient needs?
  • • 
    Given the responses to the first phase of the Delphi process in terms of what is currently included in the field of Pain Medicine
    • ○ 
      How does it compare with your understanding of the current state of Pain Medicine before coming to this Summit?
    • ○ 
      Does it go beyond your current understanding of what is included in the field of Pain Medicine
    • ○ 
      Is it complete enough to serve the needs of pain care for your patients into the future?
    • ○ 
      If not, what needs to be added?
    • ○ 
      What might need to be subtracted?
  • • 
    Human perception of pain is a complex process felt to involve multiple areas of body function and parameters, including a physical nervous system input, a cognitive input, an emotional input, body memory input, and a spiritual input. This process involves both eudynia and maldynia that is both nociceptive pain and pain as a disease unto itself.
    • ○ 
      Does your current thinking on pain include these areas?
    • ○ 
      When you want to refer a patient for pain care, is it your understanding that current pain doctors are familiar with all of these parameters?
    • ○ 
      Is it your understanding that you expect your current pain doctor to be able to evaluate and treat these different parts of pain perception?
    • ○ 
      If not, what would it take for future pain doctors to be proficient in these different parts of pain perception in order to be able to deliver care to each one of these areas?
  • • 
    One description of the physical portion of a comprehensive pain medicine evaluation has included evaluating the nervous system, the musculoskeletal system, and performing a mental status examination. If this were to be adopted by CMS as necessary criteria
    • ○ 
      Do our current pain specialist doctors have the ability to perform all of these examinations?
    • ○ 
      Would the patient benefit better if they could?
    • ○ 
      How could we bridge the gap?
  • • 
    Treating the complex area of maldynia could require such things as nerve blocks, medications, functional restoration, myofascial release, strengthening, exercise, cognitive-behavioral counseling sessions, and possibly help with addiction problems.
    • ○ 
      Can current pain doctors offer treatment in all of these areas?
    • ○ 
      If not, would it offer better patient care if they could?
    • ○ 
      What would we need to prepare pain doctors to be able to offer these services to their patients?
    • ○ 
      What bridges can we see to accomplishing that?
    • ○ 
      What obstacles might there be?
    • ○ 
      What next steps could be identified to accomplishing this?
  • • 
    Currently, training programs offer fellowships of one or two years to teach pain medicine.
    • ○ 
      Is this an adequate training to become proficient in offering patient-centric pain care to cover all of the areas of pain perception that need to be identified and addressed?
    • ○ 
      If not, what would be needed to accomplish this?
  • • 
    If the field of Pain Medicine is to offer patient-centric care, where a patient who needs specialist help could get it through a physician who can handle all parts of pain perception, then
    • ○ 
      Why would this be a better state than the current one?
    • ○ 
      What would the ideal pain physician of the future look like?
    • ○ 
      How can we get them there?
    • ○ 
      What bridges can be offered to get us to the desired level of proficiency in pain specialists in order to provide patient-centric care rather than fragmented care?
    • ○ 
      What would be some of the risks?
    • ○ 
      What would be some of the obstacles?
    • ○ 
      What would be some of the concerns in going from our current state to the desired state?
  • • 
    If we are to go from our current state of Pain Medicine knowledge, scope of practice, and abilities to help our patients in pain (from a specialist point of view) to our desired state of those same parameters
    • ○ 
      What are the long range goals needed to accomplish this?
    • ○ 
      What is needed in the future to accomplish those goals?
    • ○ 
      What are possible next steps to achieving the desired state?
    • ○ 
      If you were going to construct the ultimate solution, how would you begin?
      • ▪ 
        What would be necessary?
      • ▪ 
        How would you get it?
      • ▪ 
        To whom would you go for your assistance and answers?
    • ○ 
      What would follow that beginning?
      • ▪ 
        Which steps should come first?
      • ▪ 
        What steps would come next?
  • • 
    If a young physician completing medical school wants to devote their career to research in Pain Medicine
    • ○ 
      How can they get into this field?
    • ○ 
      Who do they go to?
    • ○ 
      How do they get funded?
    • ○ 
      Where are there positions open?
    • ○ 
      What would be needed to offer research depts. for young interested students?
    • ○ 
      What bridges can we offer to get there?
    • ○ 
      What next steps can we describe to accomplish this?

References

  • 1
    Tollison CD. Practical Pain Management, 3rd edition, Lippincott Williams and Wilkins, 2002.
  • 2
  • 3
    ABPM training grid for Pain Medicine Residency training programs
  • 4
    ABA Fellowship training outline for Pain Medicine
  • 5
    PM&R Fellowship training outline for Pain Medicine
Workgroup 4

Discussion Topic : What mechanism(s) do we need to establish the competency of a physician who wishes to practice Pain Medicine?

  • 1
    Background
    • • 
      Physician Accountability for Physician Competence (now the National Alliance for Physician Competence) held a total of 7 summit meetings beginning in March 2005, the most recent in 2009. Participants from numerous national organizations attended the summits, representing academia, regulatory agencies, payors, the public sector, providers, and professional organizations.
    • • 
      The primary question driving the creation of the Alliance was: how does the healthcare community determine, measure, and assure the public concerning physician competence over the career of the physician?
  • In one of the summit meetings, the group examined how a “continuum of competence” encompassing the system that includes medical schools, residency programs, licensure, specialty certification, credentialing and privileging, the accreditation of institutions, and the long-term maintenance of the physician's competency throughout one's career might be impacted if something like a Good Medical Practice document and a Trusted Agent/Portfolio System were in use for ensuring physician competence. The following diagram illustrates the participants' perception of inter-relationships of the organizations involved in developing and documenting physician.

    • image

    [ The above figure was redrawn from a diagram developed by participants in the Physician Accountability for Physician Competence Summit IV, which took place January 14–16, 2007 in St. Petersburg, Florida. This diagram has been reproduced with the permission of InnovationLabs LLC. This diagram may not be reproduced for any other purpose without obtaining permission. ]

  • 2
    Participating Organizations Include:
  • The Association of American Medical Colleges AARP Accreditation Council for Continuing Medical Education Accreditation Council for Graduate Medical Education American Board of Internal Medicine Foundation American Board of Medical Specialties American Medical Association American Osteopathic Association American Osteopathic Board of Emergency Medicine Association of American Medical Colleges Association for Hospital Medical Education Blue Cross/Blue Shield AssociationChristiana Care Council of Medical Specialty Societies Crozer-Keystone Health System Educational Commission for Foreign Medical Graduates The Federation of State Medical Boards Iowa Board of Medical Examiners Michigan Board of Medicine National Board of Medical Examiners National Board of Osteopathic Medical Examiners Oregon Board of Medical Examiners The Robert Wood Johnson Foundation Texas A&M Health Science Center
  • 3
    Discussion Points
    • • 
      Which organization(s) should participate in the determination and documentation of physician competence (e.g., medical schools, residency programs, certifying boards, state licensing boards, hospitals, payors)?
      • ○ 
        Should determination of competence be the responsibility of a single organization or multiple organizations?
        • ▪ 
          If multiple, how should these organizations coordinate activities?
        • ▪ 
          If multiple, which organization, if any, should have ultimate responsibility for determining competence?
    • • 
      Should determination of competence be accomplished at the local, state, or at the national level, or some combination of these?
    • • 
      Some organizations assess competence of the individual (e.g., specialty certifying exam), others assess competence of training institutions (e.g., ACGME, RRC). What are the relative roles of these differing organizations and the relative roles of individual versus institutional competence in assessing the competence of an individual physician?
    • • 
      What should the process be for the determination of an individual physician's competence (i.e., specific organizations and steps)?
    • • 
      Is demonstration of competence a one-time process (if so, who/what body determines), step-wise, or on-going process?
  • Which organizations should be involved?

Workgroup 5

Discussion Topic: What are the Barriers, besides the Absence of Competent Pain Medicine Physicians, which Prevent Patients from Receiving Adequate Pain Care?

  • 1
    Professional Barriers
    • • 
      Difficulties in Assessing Pain
      • ○ 
        Subjective assessment, based on patient feedback, which varies with multiple factors such as cultural background, religious conviction, age (children, elderly), cognitive deficits
    • • 
      Non-existent or Insufficient Teaching of Pain Mechanisms, Assessment and Treatment
      • ○ 
        Lack of formal teaching in medical schools, no graduate education, disparate post-graduate teaching
    • • 
      Poor Initial Screening, Diagnosis and Treatment by Primary Care Providers
      • ○ 
        “Gatekeepers” have major responsibility for management of the majority of pain problems, and, when appropriate, for referral to Pain Medicine specialist.
    • • 
      No Official Recognition of Pain Medicine Specialists:
      • ○ 
        Pain medicine is represented by a wide variety of professional organizations
      • ○ 
        Is not an ABMS recognized specialty
      • ○ 
        Cannot therefore obtain full professional recognition
    • • 
      Disparities in Pain Management
      • ○ 
        Professionals cannot treat all patients equally
      • ○ 
        Disparities exist based on race, ethnicity, age, gender, social class and location of care (e.g. ERs)
    • • 
      Fear of Regulatory Scrutiny
      • ○ 
        By DEA, FDA, Medicare, and OIG
      • ○ 
        No coordinated prescribing information data bank
      • ○ 
        Affects clinical decisions.
    • • 
      Time and Reimbursement Pressures
      • ○ 
        Limit proper history taking diagnosis and treatment of pain patients
  • 2
    Patient Barriers
    • • 
      Belief that Pain Is Inevitable and not Treatable
    • • 
      Reluctance To Report Pain and To Take Pain Medications as Prescribed
    • • 
      Concern about Addiction and Side-Effects of Pain Medications
    • • 
      Fear of Masking Disease or New Symptoms
    • • 
      Lack of Access to Pain Management Professionals
    • • 
      Cost of Pain Medications and Lack of Insurance Coverage for Pain Management
  • 3
    System Barriers
    • • 
      Failure of Public Health Agencies to Make Pain Management a High Priority
      • ○ 
        DHHS, Agency for Healthcare, Research and Quality (AHRQ) and the U.S. Surgeon General are not making public education about pain a priority.
    • • 
      Present Fragmented System of Care Using Multiple Specialists
      • ○ 
        Sequential Care Model Lacks Interdisciplinary Plan of Care
      • ○ 
        Multiple physicians of limited skills provide non-coordinated pain care, and integration of such care is the exception
    • • 
      Regulatory Agencies and Controlled Substances Prescribing
      • ○ 
        At present, no coordination exists between the public health need of reducing drug abuse and diversion and the need to address the public health problem of unrelieved pain.
    • • 
      Lack of Structured Reimbursement Policies
      • ○ 
        The fee for service system makes no allowance for overall outcome of a treatment, but rewards individual acts independently leading to excesses and shortcomings.
    • • 
      Lack of Government-Supported Pain Research
      • ○ 
        Less than one percent of the NIH budget devoted to pain research in 2008
      • ○ 
        Share of NIH budget invested in pain research declined 9 percent between 2004 and 2007 leading to a lack of acknowledgment of the importance of pain as public health crisis among the scientific community and the public.
Appendix N: Ama Resolution 321 (A-08)
HOD Action: Resolution 321 Adopted as Amended

AMERICAN MEDICAL ASSOCIATION HOUSE OF DELEGATES

Resolution: 321

(A-08)

Introduced by:California Delegation
Subject:Promotion of Better Pain Care
Referred to:Reference Committee C
 (David M. Lichtman, MD, Chair)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41Whereas, Widespread inadequacy and disparity of pain care persist, resulting in deteriorating public health, needless patient suffering and loss of productivity despite efforts of the medical profession, regulatory agencies, and the public; and Whereas, The limited availability of education in pain care at the undergraduate, graduate, 6 and post graduate levels results in suboptimal training of all physicians; and Whereas, Inconsistencies in the training and credentialing requirements for self-designated “pain specialists” promotes misunderstanding of their capabilities and limitations; and Whereas, Inconsistencies in existing standards of care and fragmentation in the delivery of pain care results in confusion among patients, payers, regulators and physicians; therefore be it RESOLVED, That our American Medical Association express its strong commitment to better access and delivery of quality pain care through the promotion of enhanced research, education and clinical practice in the field of pain medicine (Directive to Take Action); and be it further RESOLVED, That our AMA encourage relevant specialties to collaborate in studying the following: (1) the scope of practice and body of knowledge encompassed by the field of pain medicine; (2) the adequacy of undergraduate, graduate and post graduate education in the principles and practice of the field of pain medicine, considering the current and anticipated medical need for the delivery of quality pain care; (3) appropriate training and credentialing criteria for this multidisciplinary field of medical practice; and (4) convening a meeting of interested parties to review all pertinent matters scientific and socioeconomic. (Directive to 27 Take Action)
Received: 05/13/08

RELEVANT AMA POLICY

D-120.976 Pain Management

Our AMA will: (1) support more effective promotion and dissemination of educational materials for physicians on prescribing for pain management; (2) take a leadership role in resolving conflicting state and federal agencies' expectations in regard to physician responsibility in pain management; (3) coordinate its initiatives with those state medical associations and national medical specialty societies that already have already established pain management guidelines; and (4) will disseminate Council on Science and Public Health Report 5 (A-06), “Neuropathic Pain,” to physicians, patients, payers, legislators, and regulators to increase their understanding of issues surrounding the diagnosis and management of maldynia (neuropathic pain). (Res. 809, l-04; Appended: CSAPH Rep. 5, A-06)

D-170.999 Barriers to Appropriate Pain Management

Our AMA, in cooperation with relevant medical societies and organizations, will serve as an educational resource to the media by providing objective information regarding the management of pain disorders so that information presented to the public will be factually accurate reflecting appropriate medical perspectives. (Res. 506, A-01)

D-295.966 Pain Management Standards and Performance Measures

Our AMA, through the Council on Medical Education, shall continue to work with relevant medical specialty organizations to improve education in pain management in medical schools, residency programs, and continuing medical education programs. (CSA Rep. 4, A-02)

D-295.982 Model Pain Management Program For Medical School Curricula

Our AMA will collect, synthesize, and disseminate information about effective educational programs in pain management and palliative care in medical schools and residency programs. (Res. 308, A-01)

D-300.996 Model Pain Management Program For Medical School Curricula

Our AMA will encourage appropriate organizations to support voluntary continuing education for physicians based on effective guidelines in pain management. (Res. 308, A-01)

Appendix O: Participating Organizations and Individuals

Pain and Palliative Medicine Specialty Section Council (PPMSSC)

Last NameFirst NameTitleOrganization
LippePhilippMD/ChairAAPM
CrossnoRonaldMDAAHPM
KollasChadMDAAHPM
RayAlbertMDAAPM
JamiesonAndrewMDAASM
ChediakAlejandroMDAASM
HauserHarrisMDACNS
NuwerMarcMDACNS
BryantGaryMDACR
MoynihanEileenMDACR
GitlowStuartMDASAM
KurthDonaldMDASAM
BailesJosephMDASCO
McAnenyBarbaraMDASCO
ShwachmanBenMDISIS
SnookLeeMDISIS
ManchikantiLaxmaiahMDASIPP
BenyaminRamsinMDASIPP
Table 1. Advisory Committee
Last NameFirst NameTitleOrganization
LippePhilippMD/ChairAAPM
ArnoldBobMDACP
BailesJosephMDASCO
BrockCharlesMDAAN
BryantGaryMDACR
BurchielKimMDAANS/CNS
CrossnoRonaldMDAAHPM
DavidJoseMDAAFP
DuboisMichelMDAAPM
DunnJoeJD/Sen.CMA
GitlowStuartMDASAM
HelmStanMDASIPP
HubbellSusanMDAAPMR
JamiesonAndrewMDAASM
McIntyreJackMDAPA
NeeldJohnMDASA
PanRichardMDAAP
TallyPhilMDAMA/SSS
ToddKnoxMDACEP
VincentHughMDCMA
WhitworthMichaelMDISIS
Table 2. Implementation Committee
Last NameFirst NameTitleOrganization
RayAlbertMD/ChairAAPM
KurthDonMDASAM
KollasChadMDAAHPM
ShwachmanBenMDISIS
SnookLeeMDISIS
Table 3. Steering Committee
Last NameFirst NameTitleOrganization
LippePhilippMD/ChairAMA/PPMSSC
DuboisMichelMDAAPM
CrossnoRonaldMDAAHPM
BrockCharlesMDAAN
DavidJoseMDAAFP
RayAlbertMDAPA
Table 4. Pain MedicineSummit
Last NameFirst NameTitleOrganization
LippePhilippMD/ChairAMA/PPMSSC
DavidJoseMDAAFP
McGahaAmyMDAAFP
CrossnoRonaldMDAAHPM
DriverLarryMDAAHPM
PortenoyRussellMDAAHPM
KollasChadMDAAHPM
BrockCharlesMDAAN
ChelimskyThomasMDAAN
KincaidJohnMDAANEM
PeaseWilliamMDAANEM
BurchielKim J.MDAANS/CNS
RosenowJoshua M.MDAANS/CNS
GlassNancyMDAAP
ZeltzerLonnieMDAAP
PanRichardMDAAP
FollettKennethMDAAPM
DuboisMichelMDAAPM
BloodworthDonnaMDAAPMR
ChiodoTonyMDAAPMR
GraboisMartinMDAAPMR
HubbellSusan L.MDAAPMR
JamiesonAndrewMDAASM
ToddKnoxMDACEP
Weltge,ArloMDACEP
AbrahmJanet L.MDACP
ArnoldBobMDACP
AltmanRoyMDACR
AmakerLisaMDACR
BryantGaryMDACR
ClauwDanielMDACR
WitterJamesMDACR
DunnGeoffMDACS
ReilingRichardMDACS
FerrellBruceMDAGS
TangalosEricMDAGS
BarrJeffreyMDUSAF
CarterToddMDUSAF
NiemtzowRichardMDUSAF
SmuckerWilliamMDAMDA
CarronAnnette T.DOAOA
HahnMarcDOAOA
McIntyreJackMDAPA
YudofskyStuartMDAPA
RayAlbertMDAPA
DragovichAnthonyMDUSA
GriffithScottMDUSA
RosenquistRichardMDASA
WarnerMarkMDASA
NeeldJohnMDASA
KurthDonMDASAM
MalinoffHerbertMDASAM
FerrisFrankMDASCO
WardJefferyMDASCO
BailesJosephMDASCO
BenyaminRamsinMDASIPP
HelmStanMDASIPP
SnookLeeMDCMA
SterlingMelvynMDCMA
VincentHughMDCMA
ShwachmanBenMDISIS
WhitworthMichaelMDISIS
WilliamsNeciaMDUSN
TallyPhilMDAMA/SSS
BurgessFrederick W.MDVA
GallagherRollin M.MDVA
BarkinBobPharmDPharmacy
CousinsMichaelMDAustralia
StantonMarshaPhDIndustry
Dunn,JoeJD/SenatorLaw
RohackJamesMDAMA/Pres
HeadAlvinMDAMA/CSAPH
DickinsonBarryPhDAMA/CSAPH
LevinSaulMDAMA
ChediakAlejandroMDAMA/PPMSSC
GitlowStuartMDAMA/PPMSSC
HauserHarrisMDAMA/PPMSSC
NuwerMarcMDAMA/PPMSSC
MoynihanEileenMDAMA/PPMSSC
McAnenyBarbaraMDAMA/PPMSSC

Glossary

AMAAmerican Medical Association
AMA/CSAPHCouncil Science& Public Health
AMA/PPMSSCPain& Palliative Medicine Specialty Section Council
AMA/SSSService& Specialty Societies
AAFPAmerican Academy Family Physicians
AAHPMAmerican Academy Hospice& Palliative Medicine
AANAmerican Academy Neurology
AANEMAmerican Association Neuromuscular& Electrodiagnostic Medicine
AANS American Association Neurological Surgeons
AAPAmerican Academy Pediatrics
AAPMAmerican Academy Pain Medicine
AAPMRAmerican Academy Physical Medicine& Rehabilitation
AASMAmerican Society Sleep Medicine
ACEPAmerican College Emergency Medicine
ACPAmerican College Physicians
ACRAmerican College Rheumatology
ACSAmerican College Surgeons
AGSAmerican Geriatrics Society
AMDAAmerican Medical Directors Association
AOAAmerican Osteopathic Association
APAAmerican Psychiatric Association
ASAAmerican Society Anesthesiology
ASAMAmerican Society Addiction Medicine
ASCOAmerican Society Clinical Oncology
ASIPPAmerican Society Interventional Pain Physicians
CMACalifornia Medical Association
CNSCongress Neurological Surgeons
ISISInternational Spine Intervention Society
USAUS Army
USAFUS Air Force
USNUS Navy
VAVeterans Administration

Supporting Information

  1. Top of page
  2. Abstract
  3. Implementation Process
  4. Workgroup Summary Findings
  5. Summary Conclusions and Recommendations
  6. Acknowledgments
  7. Appendices
  8. Supporting Information

Appendix B. Delphi Round #1 Instructions.

Appendix C. Delphi Round #1 Questionnaire.

Appendix D. Delphi Round #1 Comments.

Appendix E. Delphi Round #2 Instructions.

Appendix F. Delphi Round #2 Ballot.

Appendix G. Delphi Round #2 Results.

Appendix H. Summit Agenda.

Appendix I. Letter of Preparation for Workgroup Leaders.

Appendix J. Letter of Preference for Workgroup Discussions.

Appendix L. Format for Workgroup Presentations to Plenary Session.

Appendix M. Final Invitation to Make Workgroup Comments.

Slide: Workgroup 1.

Slide: Workgroup 2.

Slide: Workgroup 3.

Slide: Workgroup 4.

Slide: Workgroup 5.

Slide: Consensus—Final Slides.

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