Throughout the workshop, many participants emphasized the need to change health care practice to integrate nonpharmacological management of pain, with important implications for implementation and dissemination that need to be considered, said Kim Dunleavy, clinical associate professor and director of Professional Education and Community Engagement in the Department of Physical Therapy at the University of Florida. Every group that has looked at the problem of inadequate or inappropriate pain management has recognized that clinicians receive inadequate pre- and post-licensure training about pain and the treatment of pain (IOM, 2011b), said Scott Fishman, Fullerton Endowed Chair in Pain Medicine and professor of anesthesiology and psychiatry at the University of California, Davis. Adding to this problem are interprofessional and interdisciplinary silos and the fact that while each discipline includes pain in its curricula, pain is not the primary focus of any of them, he said. Benjamin Kligler concurred about the importance of interprofessional education and collaboration, noting that they are essential components of integrative medicine. Integrative medicine, he said, reaffirms the important
relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and uses all appropriate therapeutic lifestyle approaches and disciplines to achieve optimal health and healing.1
One of the biggest barriers to interprofessional education and health care is physicians who resist the idea of working collaboratively with other practitioners, said Kligler.
Belinda Anderson, founding director of the Institute for Health and Wellness at Monmouth University, added that immersion approaches might be far more effective than didactic approaches in bringing people from disparate professions together. Selling this idea to different professions may require different strategies, she said. In addition to informing practitioners from the various professions about how and why a particular complementary approach may be beneficial, she said it is equally important to let them know about the training and qualifications of the practitioners of that approach. Creative approaches are also needed to encourage CIH professionals to collaborate with mainstream practitioners,
she said. Educating patients about self-care and these different therapeutic interventions is also important, said Anderson.
With medical information increasing at such a rapid rate, data overload presents a significant challenge for providers. Thus, building complexity and changeability into interprofessional education curricula through the use of big data approaches, artificial intelligence, and telemedicine is essential, said Anderson. Learning health care systems that provide feedback to practitioners about successful and unsuccessful interventions may also help change behavior and practice, said David Shurtleff.
Fishman advocated a competency-based education model that employs competencies as goals. He led an interprofessional project that included physicians, nurses, pharmacists, acupuncturists, physical therapists, and other health care professionals to build consensus about core competencies for pain management. Based on the domains of the International Association for the Study of Pain Curricula, they developed and reached consensus about the competencies of the important goals for all students: Every student who graduates from a health professional program should know what pain is and how to recognize it and should understand how to safely and effectively treat pain within the scope of their practice. In addition, he said, they need to understand how the patient’s context affects their pain (Fishman et al., 2013). Fishman said the model has been embraced by many national and international professional organizations.
Fishman and colleagues were invited by the National Board of Medicine Examiners to review the U.S. Medical Licensing Exam to see how well it aligned with the core competencies they identified (Fishman et al., 2018). He and his team were surprised to find that 15 percent of the questions on the exam directly tested on pain. However, almost 90 percent of the questions that directly tested aspects of pain knowledge focused on recognition of pain. Fishman said that while recognizing pain is obviously important, without understanding pain or how to treat it safely and effectively, or the context in which it occurs, may create the conditions where clinicians reach for what is known and accessible, which typically means opioids and other pharmacological approaches. While he believes the National Board of Medicine Examiners will change the test as a result of this study, even more important is to convince accreditors of schools and li-
censing organizations to require that schools demonstrate they are educating students with clear competency-based goals for comprehensive pain education within their curricula.
Kligler and colleagues, with a grant from the Health Resources and Services Administration, established the National Center for Integrative Primary Healthcare (NCIPH)2 and developed a standardized curriculum in integrative primary health care. In developing this program, they looked at shared competencies across different professions, realizing right away that shared competencies exist because every one of those professions put the patient first. The 30-hour online course they developed, called Foundations in Integrative Health, identified a set of core competencies and developed educational materials in integrative health (Kligler et al., 2015). The Department of Veterans Affairs (VA) has developed a set of free educational materials for interdisciplinary pain teams and a course called Whole Health for Pain and Suffering.3 Beth Darnall, clinical professor in the department of anesthesiology, perioperative and pain medicine at Stanford University, added that the International Association for the Study of Pain also has free curriculum outlines available online.
The National Institutes of Health (NIH) Pain Consortium’s Centers of Excellence in Pain Education (CoEPEs)4 has also developed modules to promote prelicensure training on pain, according to the David Thomas, leader of the program and health scientist administrator in the Division of Epidemiology, Services, and Prevention Research at the National Institute on Drug Abuse (NIDA). One goal of these modules is to address misconceptions, such as the idea that pain is in your head, or that if you treat a disease the pain goes away. Through the presentation of case studies, the modules also hope to reduce the stigma around pain, including the common belief that patients who present with pain are drug seekers or simply complainers.
The case studies approach also provides opportunities to learn about how to manage specific types of pain, said Thomas. For example, at a sickle cell disease (SCD) meeting, Thomas heard the story of a woman coping with pain related to the disease. SCD, said Thomas, is a condition where racism and ignorance collide. The woman’s story led to the creation
3 For more information and to download a Whole Health for Pain and Suffering course brochure, see https://wholehealth.wisc.edu/courses-training/whole-health-for-pain-and-suffering (accessed February 6, 2019).
4 For more information about the CoEPEs, see https://painconsortium.nih.gov/Funding_Research/CoEPEs (accessed February 6, 2019).
of an interactive module on the collaborative management of pain associated with SCD. Thomas said he believes that the gap in pain education results from society’s lack of caring for people in pain. Although empathy for people in pain goes down in medical school, he said, empathy can be taught, and can pay dividends in terms of sustaining clinician’s interest in caring for people in pain (Chen et al., 2012; Hegazi and Wilson, 2013).
Addressing Gaps in Pain Education
To address the education gaps both in pre-licensure and post-licensure training, Fishman said we need to make some of the current NIH research funding available to study the impact of the education gap on the current opioid crisis as well as the impact of retaining our students and clinicians. Accreditors also need to be brought on board. Otherwise, he said, there will be generations of clinicians on the front line, particularly in primary care, who have not received adequate training in pain management. To fill this gap, he and his colleagues at the University of California, Davis, have developed a fellowship program using telementoring for retraining primary care clinicians; and to make this training more widely accessible have also instituted a “train the trainer” primary care fellowship.
Health professions with curricula that cover all these competency domains still face challenges in training students to synthesize this information into a comprehensive way to treat patients with chronic pain, said Nancy Baker, associate professor of occupational therapy at Tufts University. The best way to do this, she said, would be through internships; however, such internships are rare, in part because there are few sites that focus on the treatment of chronic pain. In addition, when an occupational therapist does gain this expertise, there are few jobs available. This “catch 22” is a problem for many other health professions, said Baker. To address this challenge, she suggested creating post-professional training programs to provide additional training for therapists with excellent skills but little specific training in pain. She and her colleagues at Tufts have created an online training course for working therapists to increase their understanding of chronic pain and how to treat it.
Moving from Classroom to Practice
In 2010, the Lancet Commission published a report on health professionals for a new century, emphasizing the importance of patient-centered, collaborative, team-based care, said Elizabeth Goldblatt (Frenk et al.,
2010). Shortly thereafter, she said, the IOM published a report on the future of nursing—the largest segment of the health care workforce—which emphasized the need for all health professionals to practice up to their full scope of training (IOM, 2011a). Those seminal reports led to the formation of the National Academies’ Global Forum on Innovation in Health Professional Education, while at the same time the Interprofessional Education Collaborative (IPEC)5 was getting starting with its 6 original members that has now expanded to 21, and includes the Association of Chiropractic Colleges, said Goldblatt.
To create inclusive and collaborative team-based, patient-centered pain care, all mainstream/conventional health professionals are now required to receive training in interprofessional education and collaborative practice, according to Goldblatt. Practitioners of five CIH approaches—acupuncture/East-Asian medicine, chiropractic, naturopathic medicine, massage therapy, and direct-entry midwifery—are licensed and have accreditation bodies recognized by the Department of Education. Others such as yoga or Ayurveda medicine,6 while highly credible, are not yet licensed in the United States, said Goldblatt. Models are emerging to promote integrated health care using blended classrooms and collaborative clinics where health care professionals can gain deep knowledge about other professions and learn how to work together. Goldblatt mentioned there is a wealth of information on the National Center for Interprofessional Practice and Education (NEXUS) website, which provides evidence-based resources across the education-to-practice continuum.7
Practitioners in medical and allied health professions also need to learn self-care since many of these professionals (e.g., dental hygienists, physical therapists, and occupational therapists) suffer from chronic occupation-related pain, said Monika Gross with the Poise Project and Alexander Technique for Pain Management. She also suggested creating a new class of health care professionals for persons skilled in advocacy and translation.
6 Ayurveda medicine is the ancient Indian medical system that “relies on a natural and holistic approach to physical and mental health.” It “combines products (mainly derived from plants, but may also include animal, metal, and mineral), diet, exercise, and lifestyle.” For more information, see https://nccih.nih.gov/health/ayurveda/introduction.htm (accessed March 7, 2019).
Working as consultants to health systems, these individuals could help translate curricula from one institution to another.
Creating egalitarian collaborative teams to provide patient-centered care remains a challenge, said Goldblatt. Turf, ignorance, and economics (TIE) all present barriers, despite the benefits that collaborative, team-based care can provide for patients and often can reduce stress for providers. Evidence of the benefits gained from collaborative practice can help build bridges across disciplines, said Goldblatt, adding that successful teams require respect and trust for all practitioners on a team and a clear understanding of the strengths and limitations each one brings.
The importance of collaborative practice in the treatment of pain and addressing the opioid epidemic mirrors what became evident in the early years of the HIV/AIDS epidemic, said Margaret Chesney, professor of medicine at the University of California, San Francisco. Then, like now, there were dual epidemics—treating patients while at the same time stopping the spread of the disease—both of which demanded attention to a wide array of medical and social factors, said Chesney. Specialists in infectious disease, oncology, dermatology, pulmonology, and others were called in for their expertise; and psychologists were also needed to help patients manage the stress of coping with the disease. All providers became integral parts of the collaborative team, she said. Moreover, because adherence to the complex and individualized medication regimens was so important to prevent development of drug-resistant virus, patients were not only the center of the team, they led the team, said Chesney. It was “their adherence to care” that the team needed to encourage. Wanting to avoid adding new medications to deal with the side effects of their antiviral treatment, patients began educating her and other clinicians about side effect management, including acupuncture, massage, dietary interventions, supplements, and other nonpharmacological approaches they had sought out. The collaborative team also expanded to include communities, when it became clear that providing housing and other resources would also be necessary to stop the epidemic. Anderson added that including social scientists and psychologists on the team can be especially helpful in elucidating the importance of social determinants of health.
The Department of Defense’s (DoD’s) Pain Management Task Force, which was mentioned in Chapter 5, also recognized the importance of collaborative practice, said Chester (Trip) Buckenmaier III, Colonel, U.S. Army (retired) and program director and principal investigator for the Uniformed Services University of the Health Sciences Defense and Veterans Center for Integrative Pain Management (DVCIPM) under the Department of Military Emergency Medicine. The ultimate goal of collaborative practice, said Buckenmaier, is to enable an individualized process and team approach that bridges the different treatment silos. Keeping silos and connecting them with the patient at the center of the activity is important, he said, adding that, in the operating room, the silo of anesthesiology is essential.
Combating prejudice against what are considered alternative treatment approaches can interfere with development of collaborative teams, noted John Chae, vice president of research at MetroHealth. Using as an example the field of physical medicine and rehabilitation (PM&R), he suggested that prejudice could be overcome with science. PM&R evolved to what is now a more mainstream approach in part because of the emergence of the biopsychosocial model as well as an embrace of science, he said. However, Kligler noted a tension that exists between pushing for research using conventionally established methods of proof and the use of other types of research methodologies. Patient-Centered Outcomes Research Institute (PCORI), for example, has successfully promoted the use of alternative methodologies, he said.
Collaborative Practice Models
Several models of collaborative practice were presented at the workshop. Some of these use case studies to discuss various aspects of pain management and treatment of opioid use disorder. Eric Schoomaker suggested that to explore management of opioid use disorder, a case involving traumatic amputation would be appropriate since wounded warriors are the most grievously wounded and do not want to be further disabled by opioids. Other models immerse patients in a well-functioning social group to leverage the importance of social, cohort, and kinship functions in managing chronic pain. Daniel Carr, past president of the American Academy of Pain Medicine and professor of public health and community medicine at Tufts University, suggested that these programs might inadvertently be providing something akin to family therapy.
University of Toronto Interfaculty Pain Curriculum
Judy Watt-Watson, professor emeritus at the University of Toronto, described an interfaculty prelicensure pain curriculum8 at the University of Toronto that has been mandatory for students in six training programs since 2002: dentistry, medicine, nursing, pharmacy, occupational therapy, and physical therapy (Hunter et al., 2008; Watt-Watson et al., 2004). Physician assistants were also recently added, she said.
The 20-hour program is completed over 3 days through a combination of online modules, large and small multiprofessional sessions, and concurrent clinically focused sessions that the students choose. Students are assigned to an interprofessional group of 30 people that is further divided into 10-person interprofessional teams to discuss several patient cases and develop appropriate patient-focused pain management plans. A facilitator on each team guides the team to ensure respect for the role of the different professions in patient care as well as the need for collaboration and future referrals to colleagues outside of their own profession, said Watt-Watson. Meanwhile, students learn about the relationship between pain and the social determinants of health.
Watt-Watson noted that an outcome of the curriculum is that many of the health science departments are now including more pain content in their curricula. As a result, students’ baseline knowledge is greater and overall scores for pain knowledge and beliefs between pre-test and post-test assessments increased by only 7 percent in 2018 as compared to 17 percent in 2002. Recently, they have conducted curriculum mappings to identify overlaps and gaps, which along with the many other evaluations, allow them to adapt the program in an iterative fashion. They also have published a pain interprofessional curriculum decision model to share with other institutions what they have learned through the development and evolution of this program, said Watt-Watson (Watt-Watson et al., 2017).
At the Biomedicine Campus in Phoenix, Arizona, the student-led clinic Student Outreach for Wellness (SHOW) has partnered with Crossroads, the largest substance abuse recovery residential center in the Southwest, to provide community-based interprofessional direct care and health
8 For more information, see http://sites.utoronto.ca/pain/research/interfaculty-curriculum.html (accessed March 11, 2019).
promotion services,9 said S. Liz Harrell, chief medical officer of integrated care at Crossroads and Doctor of Nursing Practice Faculty at the Arizona State University College of Nursing and Health Innovation.
SHOW provides a learning laboratory that uses an interprofessional team-based approach to deliver care to vulnerable populations, said Harrell. The program is run by students and guided by interprofessional faculty from 12 different professional programs. Crossroads has been operating since 1960, originally as a halfway house before transitioning to become a residential substance use treatment program. Their recognition of the need for additional primary care services led to the partnership with SHOW, said Harrell. The SHOW/Crossroads clinic is expected to open in 2019 and will use an interdisciplinary team approach that focuses on holistic restoration.
Other Innovative Programs to Promote Interprofessional Care
Kligler described an exchange program between students from the Albert Einstein College of Medicine and the Pacific College of Oriental Medicine, which gives students the opportunity to learn about each other’s practices and how they can be used in a complementary fashion to improve patient care (Anderson et al., 2012). Kligler also mentioned an acupuncture fellowship at Beth Israel in New York that trained licensed acupuncturists to work in inpatient hospital settings. In interviews conducted with the acupuncturists, physicians, and nurses, Kligler said he and his colleagues found that when nurses and physicians saw the benefits to their patients, they recommended acupuncture even if they did not know how it worked. The acupuncturists, meanwhile, felt like outsiders in conventional health care settings, and had to learn more about how hospitals function, said Kligler.
The VA also has some excellent programs in complementary and integrative care, added Kligler. For example, the Empower Veterans Program10 brings together social work, chaplaincy, physical therapy, and teachers of mindfulness in a 10-week program for veterans with high impact chronic pain. Participation in the program has yielded improved pain outcomes, decreased opioid use, and decreased suicidal thinking, said Kligler.
10 To learn more about the Empower Veterans Program, see https://www.atlanta.va.gov/services/Empower_Veterans_Program.asp (accessed February 6, 2019).
Another innovative program called Central City Concern in Portland, Oregon, addresses the social determinants of physical and mental illnesses as well as addiction among the homeless through a comprehensive approach that provides naturopaths, acupuncturists, chiropractors, working with a variety of mainstream health care providers while also offering housing, job training, and job placement, said Goldblatt.
Models have also been developed for sustaining both education and care delivery programs after initial grant funding runs out, said Harrell. Given that there is no business model for care programs, she is in the process of building such a model that others can use to replicate. On the education side, Watt-Watson noted that sharing specific curriculum content can be challenging because of copyrights held by the universities where the curricula were developed.
Michele Maiers, executive director of research and innovation at Northwestern Health Sciences University, summed up the discussion by citing the need to customize models of interprofessional and transdisciplinary education to the specific needs of the communities served, including the learning communities. Moreover, she said, in planning for the future it will be important to consider the next generation of health care providers. Most of them are millennials who are recognized as being highly collaborative with extensive communication networks, said Maiers, adding that they also want to be part of creating new models from the ground up.
Leslie Davidson, chair of the department of clinical research and leadership at the George Washington University School of Medicine and Health Science and an occupational therapist who specializes in traumatic brain injury and neurology, added that pain is not a sensation, but a perception which can be described as a complex phenomenon attributed to the confluence of ever-shifting internal and external variables. Consequently, the treatment of pain is equally complex, with patients at the center requiring a collaborative approach from practitioners with a range of skills. Davidson said,
implementing collaborative practice requires practitioners to consider multiple aspects of a patient’s pain experience. For example, pain may be particularly debilitating for different reasons depending on the current circumstances and life stressors of the individual.
She cited a recent book titled Not for Long: The Life and Career of the NFL Athlete by Robert W. Turner II, an assistant professor in her depart-
ment, who described how the lives of professional football players are affected by years of playing the sport. The pain they experience every day and the functional limitations imposed by the pain, frequently lead to depression that may increase their sense of pain and hopelessness, said Davidson. Other important considerations include the roles, priorities, and the sense of purpose or meaningful activity of the person who experiences pain. It is critical for those who participate on their care team to understand how the person expresses their pain, how pain can be treated to increase their quality of life, and whether the pain is acute, sub-acute, or chronic, said Davidson. She added that it is essential that the care team understands and explores what situations or activities are most painful, and the patient’s level of readiness to participate in a treatment plan. Davidson said,
With this more complete understanding of the patient’s pain experience a treatment plan can be devised, that may include occupational therapy, physical therapy, sleep hygiene, cognitive behavioral therapy (CBT), yoga therapy, nutrition, maintaining and activity journal, intimacy counseling, meditation, and other approaches. Simplification of the pain experience is a surefire way to set up a recipe for treatment failure.