Career: Pain relief

CHRONIC pain poses a major burden not only for individual sufferers but for UK society in general. Last year an estimated 10 million working days were lost to back pain alone, according to the UK Statistics Authority. This is equal to £1billion in lost earnings. Workers aged 50-64 were most affected with around 4.2 million working days lost.

People with chronic pain live not only with the physical pain itself but frequently suffer from depression, anxiety, physical dysfunction and social isolation which can make managing this condition even more complex. It is estimated that approximately one in five of all consultations with GPs are pain-related.

Persistent pain may originate from injury, disease or iatrogenically. It is often believed that its presence relates to ongoing pathology. In certain situations this may be the case (e.g. inflammatory disease), however mostly it is due to maladaptation within the sensory nervous system. Mixed pain states may be a combination of these.

In recent years there have been significant efforts to improve the way the NHS manages pain. A 2013 document co-authored by the Royal College of General Practitioners (RCGP) called for a more integrated and targeted approach to commissioning primary and secondary care pain management services – the aims being to improve quality of life and access to appropriate care, to optimise analgesics and to reduce reliance upon healthcare services.

Practitioners with a special interest (PwSIs) in pain management are an important element in this approach, with the move to bring more complex care out of hospitals and into appropriately skilled community settings. The RCGP and Royal Pharmaceutical Society (RPS) of Great Britain have published guidance and competencies for PwSI in pain management.

The job

There is no one-size-fits-all description of the role of PwSI in pain management. Commissioners in each CCG or health board identify the specific service requirements, and the competencies required by practitioners can then be agreed. PwSIs may have a broad or narrow competency depending upon what’s needed. There is no specific accreditation process for a PwSI in pain management; competency is underpinned by robust governance frameworks, involving mentorship from specialists as appropriate.

Most GPs working in pain clinics offer management of chronic pain, along with an understanding of the underlying neurophysiological mechanisms and the confidence to explain these to patients. PwSIs will usually work in a multidisciplinary team, ideally including psychologists, specialist nurses, physiotherapists, occupational therapists and other pain physicians.

PwSIs may also be in a position to lead local implementation of national frameworks and guidelines in pain management (e.g. British Pain Society recommendations for the use of opioids in the management of chronic non-cancer pain). This can include sharing best practice locally between clinicians, patients and carers.

Competencies and training

The RCGP/RPS guidance calls for all PwSIs to first demonstrate that they are competent generalists. For GPs this can be assessed in a number of ways including: meeting the competencies set out in the RCGP curriculum together with a holistic understanding of primary care practice; obtaining a pass in the examination of the Royal College of GPs or equivalent and being a member of good standing; evidence of critical appraisal skills and engaging in active clinical work.

Specific competencies for a PwSI in pain management include knowledge and experience in (not necessarily all):

• Comprehensive pain assessment
• Diagnosis and management of persistent pain
• Long-term condition management
• Rehabilitation and multi-disciplinary team working
• Management of drug therapy
• Management of delivery of pain services
• Mental health problems
• Complementary therapies
• Managing pain after trauma
• Welfare system and employment opportunities
• Support of research.

Necessary training for the role of a PwSI in pain management can be acquired in several ways depending upon the scope of the role. There are postgraduate courses available such as the MSc in Pain Management offered by Cardiff University Medical School. GPs can also work under the supervision of a specialist or consultant in pain management or as part of a specialist training programme. Training can also be pursued through self-directed learning, attendance at academic meetings, lectures or tutorials, participation in case conferences and in-depth case reviews.

The RCGP/RPS guidelines state that assessment of individual competencies for PwSIs in pain management can be undertaken by a combination of the following:

• Observed practice using modified mini clinical examination
• Case note review
• Reports from colleagues in the multidisciplinary team using 360-degree appraisal tools
• Demonstration of skills under direct observation by a specialist clinician (DOPS)
• Simulated role-play objective structured clinical examination (OSCE)
• Reflective practice and logbook/portfolio of achievement
• Observed communication skills, attitudes and professional conduct
• Demonstration of knowledge by personal study supported by appraisal (with or without knowledge-based assessment)
• Evidence of knowledge gained via attendance at accredited courses
• Conferences or from online or distance learning courses.

For more information on specialising in pain management contact your local CCG or health board.

Sources

• Guidance and competences for the provision of services using practitioners with special interests (PwSIs): Pain Management
• Pain Management Services: Planning for the Future – Guiding clinicians in their engagement with commissioners

What attracted you to pain management as a specialty?

At first I wanted to carry on with my anaesthetic skills I’d learned as a junior. The more pain I did, the more I realised interventional practice had a limited place, and good diagnostic skills and consultation technique were more relevant.

What do you enjoy most about the job?

I enjoy the endless variability in presentations, applying modern neurophysiology evidence to diagnostics, and having a bit more time than a standard GP consultation to be able to explain, explore and co-create management plans that are as meaningful as possible.

Are there any downsides?

Politics. Pain is “owned” by anaesthesia with little recognition for other clinicians who can often offer great expertise and unlimited motivation to collaborate meaningfully with those professionals who provide the bulk of care for this patient group. This is slowly changing but it needs to move quicker to keep up with modern commissioning.

What do you find most challenging?

Working with managers to identify and measure meaningful quality KPIs [key performance indicators]. Also changing long-established care pathways that promote dependence on clinicians and reduce patient confidence to self-manage. What about the role has surprised you most? How it cuts across most aspects of medicine. I don’t think there is a specialty that’s not represented in my clinic. Also how it’s really useful to have a deeper understanding of pain – especially in medically unexplained situations.

What is your most memorable experience so far?

The new patient consultation when I didn’t say anything for 27 minutes, and spent the final three being told how wonderful the management plan was!

What advice would you give to a trainee GP thinking about specialising in pain management?

Be open-minded. Consider the patient as an expert too.