Changing the Culture of Pain Medicine
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Special Interest Group for Philosophy and Ethics Changing the culture of pain medicine Launde Abbey 10 – 13 June 2013 Contents Changing the culture of pain medicine Introduction .................................................................................................................. 4 Peter Wemyss-Gorman Can we change the culture of pain management? ...................................................... 5 John Loeser Compassion in Healthcare: Exploring and sustaining compassionate practice in healthcare .................................................................................................................. 15 Frances and Sarah Dixon Learning and teaching about pain: The evidence and the values ............................ 24 Ed Piele Changing the Culture of Pain Medicine: A desirable and achievable international goal? .......................................................................................................................... 32 Clare Roques Social media in medicine: Benign influence or spin? ................................................ 44 Trish Groves Summing up – The way forward ................................................................................ 52 John Loeser Do nurses care? ......................................................................................................... 55 Janet Holt ‘Know-what-I- mean?’ Do we hear what is said and know what is meant? .............. 67 Karin Cannons Getting the right hand to work with the left hand. Knitting together: A future for healthcare? ................................................................................................................ 75 Betsan Corkhill Tales, Stories and memories: A pain clinic compendium ......................................... 85 Beatrice Sofaer Bennett Allegories of change: The poetry of Ted Hughes and images of the natural world .. 90 Ian Stevens The early days in Seattle and the birth of the IASP: A history of the pain movement 96 John Loeser Editor’s note Preparation of this transcript has involved some paraphrase and rearrangement of material to enhance readability. The editor apologises for any misrepresentation this may have occasioned. In representing discussion, the words of the speaker are in normal type and contributions ‘from the floor’ in italics. Cover photo: Launde Abbey Courtesy of Ian Clarke 2 Contributors John D Loeser, Professor of Neurological Surgery and Anesthesiology at the University of Washington and former president of the International Association for the study of pain. Frances Dixon, Medical student (absent) Sarah Dixon, Yoga teacher working with cancer patients Ed Peile, Professor Emeritus of Medical Education at the University of Warwick Clare Roques, Consultant in Pain Medicine and Chair, BPS Developing Countries SIG Trish Groves, Deputy Editor of the BMJ Janet Holt, Senior Lecturer in the School of Healthcare at the University of Leeds Karin Cannons, Nurse Consultant, Pain Management, Frimley Park Betsan Corkhill, Activity and Wellness Advisor Beatrice Sofaer-Bennett, Hon. Fellow, Clinical Research Centre for Health Professions, University of Brighton Ian Stevens, Senior Physiotherapist, Forth Valley, with a special interest in the arts/science interface 3 Introduction Peter Wemyss-Gorman “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has." Margaret Mead “It is better to light a candle than curse the darkness” Ancient Chinese proverb At the 2012 meeting on Care Ethics, we acknowledged the reality that identification of the shortcomings of contemporary pain medicine was of little use if they continue to be regarded as inevitable. So we decided that the task of this year’s meeting would be not only to define a new culture of pain medicine but also to determine the best means of ‘evangelising’ the message of the need for change, not only to our colleagues in the speciality but to the medical and health professions as a whole. The realisation that we had set ourselves a formidable if not insurmountable task was if anything reinforced by our keynote speaker, John Loeser. His name was among those my generation of pain clinicians would have pronounced with hushed awe and he still stands among the giants of the pioneers of our profession. As one of the founders of the IASP and its president from 1993 to 1996, he is uniquely placed to command an overview of pain management throughout the world, and to have observed the trends and changes that have emerged during his long professional lifetime. The picture he painted of pain management in the USA now totally dominated by the business model and the power of insurance companies to dictate treatment, resulting in the virtual disappearance of multidisciplinary pain management, was dismaying. We can only hope that the increasing dominance of a profit-driven business model over the NHS will not drive us down the same road. But the success of the IASP under the leadership of Michael Bond in promoting pain education, and the establishment of new IASP chapters championed by John Loeser, around the developing world, was much more encouraging. And we were inspired by Clare Roques’ account of the relatively small but nevertheless vital contribution of the BPS Developing Countries SIG. Education is indeed a vital part of the process of changing the culture and Professor of Medical Education Ed Peile presented a reassuring account of progress in undergraduate teaching guided by values. But pressures to abandon these after graduation, and to attend to other priorities than the management of pain, are still difficult to resist. We must use all the means at our disposal to ‘spread the word’ and included among these is the social media, hitherto somewhat neglected, at least by my generation. Trish Groves of the BMJ was an enthusiastic advocate of Twitter. We hope we at least ‘lit a candle in the darkness’ at this meeting. Although it continues to flicker somewhat feebly we should be comforted (in the original sense) by the words of Margaret Mead quoted above in our determination both collectively and individually to bring about the changes we know are so necessary. 4 Can we change the culture of pain management? John Loeser “The control of medical practice by market economics does not serve the healthcare needs of patients optimally and is not compatible with an ethically based profession of medicine.” My remarks are based predominantly on what I know, which is the United States, and the USA and the UK have very different health are systems. So many of the issues that I will address may be more prominent and problematic in my country than in yours. But my travels have told me that the same issues come up in every country I have been in; it’s just the relative proportion of which issue is the big one that changes. Culture The standard definition in the Oxford English Dictionary is ‘The distinctive ideas, customs, social behaviour, products, or way of life of a particular nation, society, people, or period,’ and I will address what I see as the culture of pain management that surrounds me. The first problem we have to address is the question: is there a culture? Or are there several cultures? Or – more likely – is it just chaos with no culture behind it where everybody has their own viewpoint about how things should be done. An example of that is the list of the pain societies in the USA [numbering at least ten]. Every one of these organisations promulgates guidelines, has meetings in which their various products are presented; often threatens litigation against people who say or do things that aren’t in their particular best interests. Many of these organisations have state- or region-based chapters so you end up with multiple sub-groups. If you simply ask a pain specialist what organisation he belongs to you can tell exactly what they do for a living. For example, there is the International Spinal Injection Society which has a national chapter and you know very well what they do, without knowing what their training or background might be. I’m sure in the UK you have something similar. I am aware of the revolution you had in the Pain Society because of the President’s agreement to standards of care that did not meet the desires of many of its members, when Michael Bond was drafted in to solve the problem. If you look at a set of guidelines – and we are saddled with guidelines in our country – you can immediately tell who wrote them, because they reflect what people do for a living. Far too many patients get what the provider does irrespective of what the patient needs. There are pain clinics in the USA where 100 per cent of the patients get an injection without a history taken or a physical examination. There are people getting surgical procedures who have never had an appropriate evaluation. Part of the chaos and lack of a common culture in our country is that there is no standard of what should be done before surgery or treatment is implemented. And we have guideline wars with different organisations promulgating directly opposite guidelines and each provider (mainly private insurers) deciding what they are going to pay for – one may pay for three injections and another for one or none. Why the chaos? The first problem is that many people have wrong conceptual models. There are many physicians who are fixated on a biomedical model of disease and just cannot 5 conceive of the issue that something outside of a patient’s back may be responsible for their