Resident’s Corner: Climbing the Learning Curve in Pain Management
To those unfamiliar with the current landscape of medical training in pain management, there are no pain management or pain medicine residencies. To enter a pain medicine fellowship, an applicant must have completed a residency in anesthesia, physical medicine and rehabilitation, neurology, emergency medicine, psychiatry, or family medicine.
This multidisciplinary approach allows fellows entering (or residents rotating through) the subspecialty to get exposed to not just pain medicine but also to other specialties and the unique applications they bring to the field. While this is a clear benefit to the trainee, the first weeks of a pain rotation can be overwhelming due to the sheer volume of information the trainee is expected to learn.
As a physical medicine and rehabilitation (PM&R) resident, I remember struggling initially with understanding the pharmacodynamics and pharmacokinetics of the various drugs used in both medication management and in interventional procedures. Around that time, I saw my anesthesia colleagues have more difficulty with the physical exam maneuvers that I had practiced extensively during my training.
Working together in a true multidisciplinary fashion allowed all of us to elevate our knowledge base. However, working with aspects of other primary specialties unfamiliar to residents resulted in a significant learning curve.
The Explosion in Pain Care Knowledge
Adding to that curve is the ever-expanding knowledge base and constant innovation in medicine. As residents are focused on learning the history and backbone (no pun intended) of pain management, we are no strangers to the current climate of pain management and the challenges of the opioid crisis. With clinicians and researchers working to find alternative methods to treat chronic pain, residents rotating through the field are being exposed to new medications, techniques, and therapies.
For a resident, this rapid growth is both daunting and exciting. A good example is spinal cord stimulation (SCS). To learn this procedure, trainees must follow a stepwise approach that includes understanding the gate control theory of pain, the techniques for lead placement, the differences between tonic versus burst stimulation, and the technical parameters around pulse width, frequency, amplitude, and charge per pulse.
Another example is regenerative medicine, which has seemingly moved back into public eye. This is exciting for residents, and especially for those with a background in engineering like myself. With regenerative medicine, trainees have the potential to get involved in a re-burgeoning field and to make lasting impacts.
To the trainee, injectates like protein-rich-plasma (PRP) and stem cells are at the forefront of clinical pain practice and current residents have an opportunity to potentially find new and exciting aspects within this specialty to practice and research.
By keeping up with novel techniques and technology such as SCS and PRP, residents and fellows can position themselves to help advance a rapidly growing field even faster – while also having a better overview of pain's complexity.
Anatomy Matters
In addition to interventional techniques, the resident is expected to have a firm grasp of both traditional and emerging pharmacologic options, as well as anatomy and its role in chronic pain generation. With distinct care approaches taken by different providers, it has been my experience that the resident benefits most by gaining a strong understanding of anatomy before memorizing any singular treatment approach.
Perhaps the easiest example and the one that I typically give to medical students is the sacroiliac joint. Rather than memorizing an optimal degree of contralateral oblique and caudal tilt, it serves the trainee well to understand how maneuvering the C-arm in these ways works to open up the joint space and line up the anterior and posterior lines of the SI joint.
So Many Syndromes
The breadth of pain medicine itself is something that can be challenging for residents. From low back pain to cancer pain to headaches, understanding a large variety of pain syndromes and keeping a wide differential is essential for any person learning pain medicine.
Academic pain practices have attendings with different focuses, and while the trainee rotates through with different faculty, it is important to remember that it is okay to gravitate toward a certain area, while maintaining a wide exposure. This breadth allows for trainees to keep an open mind and practice in different areas of pain medicine – ultimately to find their own niche. But while in the residency, it is certainly better to be a “jack of all trades.”
In fact, modern pain medicine integrates the behavioral and psychological components of chronic pain. Personally, this was the most interesting thing I learned about pain management, its complexity both in origin and in treatment modalities. Programs that teach coping strategies, improve physical function, and provide patient education on coping strategies and behavioral techniques for managing pain are of vital use in treating a large portion of today's chronic pain patients. Therefore, a trainee must not only be exposed to these programs, but also engaged in implementing the biopsychosocial model of pain.
By understanding these factors and how they interact with one another, trainees will be better equipped to manage complicated cases and to work in a comprehensive pain clinic in the future. This includes training in procedures such as acupuncture and therapeutic massage, and techniques like biofeedback and mindfulness.
Final Thoughts
The challenges of pain medicine education may vary based on the individual and their background, as with any career trajectory. For me, interventional skills and an understanding of anatomy came easy, but I struggled initially with pharmacologic study. This challenge required me to do a lot more reading and significant repetition. Even with this learning curve and the current COVID-19 pandemic affecting fellowship programs across the nation, pain medicine continues to be attractive to me as it provides an opportunity to be at the forefront of clinical medicine while also making a lasting impact in the lives of my patients.
More on the evolution of pain care including a 20-year game changing timeline.
