It may seems that the answer is obvious: do high quality research and try to move your work towards the clinic if you are in a position to do so. This is the position that I have taken since I entered the pain neuroscience area back when I was wee PhD student. As of about three weeks ago, I’ve changed my mind.
First, let’s make a few things clear. I still think that ultimately the research has the potential to have the largest impact on patient care. There is a severe lack of efficacious treatment for large swaths of the chronic pain patient population. As we continue to learn more and more about what makes pain become chronic more and more opportunities for intervention arise. Many of these have the potential to be disease modifying, in other words, to reverse chronic pain by targeting its underlying pathophysiology. In the meantime, the more you get involved in patient issues, the more you realize that there are massive numbers of patients that need help right now. I suppose that all of us know this at some level but sometimes events and/or circumstances make it obvious that you need to take another approach.
Two recent events have caused me to undertake a major reevaluation of my overall approach.
1) Mrs Juniorprof is working on her advanced clinical degree. She is writing up her clinical research project. I have been shocked to find, through helping her edit her write-up, that despite thousands of basic research articles on pain sensitization there are very few studies out there which evaluate efficacy of available treatments for stopping the progression of pain disorders in susceptible patient populations. If you consider substance abuse patients the problem gets even worse. A consistent complaint is lack of physician education in the area. Education. Duly noted.
2) At a recent big pain meeting including basic researchers and clinicians I spent most of my time in the physician-type sessions. The disconnect between the basic science and the clinical areas was huge. A canyon in fact. While the basic scientists were discussing novel targets and basic mechanisms the physicians were arguing over opiate use policy and FDA regulations. In discussion periods after presentations several physicians explained that they felt that many patients were too far gone by the time they got to their pain speciality clinics. Again, education. No one is teaching physicians how to manage pain efficiently when it begins, no one is teaching how the basic science indicates that treating pain early is critical to avoid chronic pain and no one is effectively communicating that chronic pain is a disease in its own right. Apparently.
Now, those last statements are obviously a gross generalization. There are fantastic pain service physicians out there. Our hospital has one of the best. But one, quite literally. One pain specialist in a public hospital that serves millions. There are other physicians in the hospital that care deeply about treating pain, I know, I have interacted with many of them. But the fact of the matter is that they have other things to worry about when they see the patient come in on an ambulance after a car accident and more than likely they have never been properly educated in the critical nature of treating pain early to avoid later, lingering medical problems. Treating pain needs to be routine, something they can do without even thinking about it. Education. Its not the fault of any one physician. Its the fault of a training system that does not adequately incorporate what we know about pain into how we do it on a daily basis. Somewhere there is a gap, and we need to fill that gap.
So, eventually one realizes that you can get there from here in the lab but that route is filled with uncertainty and clinical development that is largely outside your control. The fastest way to get there may actually be in the classroom. It may not mean getting adequate treatment to those that are not helped by available therapeutics but it has strong potential to prevent the emergence of new patients by teaching the importance of adequate pain control early on and overcoming some of the myth and stigma that come with the territory anytime pain treatment comes up.
Well, this week one of the deans got together with a few of us pain people around these parts and we started to sketch out the beginnings of a “pain course” for medical students in clinical years. The course is going to focus on those issues that come up in the clinical treatment of pain in different settings and discuss the basic science behind the importance of treating pain early on. One fairly innovative part of the course is that it will begin as a small series of lectures, largely composed of clinical and basic findings (not a review of neuroanatomy/physiology — all new material), followed by explanations of current guidelines (WHO and International Association for the Study of Pain) and things to look for as students head out into clerkships. Then, in intersessions, we will reconvene in workshops to discuss clinical practice and observed shortcomings in pain treatment with an eye to how these can be better addressed and what the basic science tells us about what these shortcomings may mean for patients. This will be repeated throughout the clinical year. Hence, the course will comprise a number of lectures and workshops focusing on improving pain management skills in physicians that leave this medical institution. Since a large number of these clinicians either stay in state or return after residency, the overall goal is to begin the process of improving pain management skills in the next generation of clinicians for our area.
Obviously, this is going to take a good deal of work and I’m not sure I’m quite ready to take on co-directing another course but at the end of the day this is the area of science that I have chosen for my career. While I would like to think that the lab work has the greatest potential for immediate clinical improvement, this would be somewhat delusional. The fact is that medical student instruction can have a huge impact on clinical care and classes such as these, that address pain issues, are generally either given the short shrift or not given at all. That won’t be the case around here anymore.