Redefining the “Pain Specialist” of Today
What it takes to hold oneself out as a “pain specialist” is a question I began to ponder when I started working in pain management 20 years ago, with the larger question being, what exactly is a “pain specialist?” I thought the answer would be straightforward, but after two decades of clinical practice in the specialty, I still don’t have a clear answer. The reality is that it depends on how you phrase the question and whom you ask.
As healthcare practitioners take on new roles and responsibilities within aspects of “medicine,” perceived turf wars, semantics, and professional identity all play a part, making the ongoing integration of multidisciplinary care, to put it lightly, “delicate.”
Katie Duensing, JD, broached this subject in the July/August 2019 issue of PPM,1 and I’d like to dig into it more here from the perspective of advanced practice providers (APPs).
Is the intent to treat and the expected outcome or liability different if an APP prescribes a medication to manage pain rather than if a physician prescribes the same medication? As the specialty moves toward multidisciplinary care, would we not consider each member of the multidisciplinary team a “specialist in pain management?”
I used to tell my nursing students that “all nurses are pain management nurses.” Today, I tell my patients that pain management is a team sport and that all healthcare practitioners involved in patient care have a role to play.
Physicians are trained as generalists in medical school. They then specialize in residency and subspecialize in fellowship. However, this path is more blurred in pain medicine. (Image: iStock: digitalskillet)
Defining a “Specialist” in Any Field
Let’s take a step back and consider what it means to hold oneself out as a specialist in general. As an individual who enjoys cycling, I’ll start with a cycling analogy. Nienke Oostra is a competitive cyclist, and she has stated that in order to become an expert (specialist), “You need time, experience, and mileage.” She often refers to Gladwell’s 10,000-hour rule, which states that one must perform a task for 10,000 hours—that is 20 hours a week for 10 years—to be considered a specialist at that task.2
In a legal setting, there are shades of grey, and winning a case may come down to the skill of the attorney. According to Bartels, “Many professionals, like doctors, dentists, chiropractors, or lawyers, may want to promote themselves as a ‘specialist.’ However, referring to yourself as a ‘specialist’ could run afoul of restrictions imposed by state-run boards.”3
In medicine, the definition of a specialist is clear. Physicians are trained as generalists in medical school. They then specialize in residency and subspecialize in fellowship. However, this path is more blurred in pain medicine considering that, as Duensing points out, there are no independent residency training programs for the specialty of pain medicine or pain management.1 While practitioners can pursue board certification in pain medicine after a qualifying fellowship, their residencies are done in an entirely different specialty (read one trainee’s experience).
Essentially, Duensing’s take-home was that state requirements matter. She wrote: “If one practices in a state that has adopted laws or rules that govern pain management clinics, answers may be found within those policies.” However, “with no federal guidance on the matter, and with only a handful of states having adopted relevant policies, there is no clear answer as to who qualifies as a pain specialist throughout the majority of the country.”1
Even though there are no laws governing the necessity to complete a fellowship in a subspecialty, such as pain medicine, the need has evolved as an expectation. This case is particularly true if one practices in academia or in an area where there is competition for services or reimbursement. When clear regulations on the validation of competence in a subspecialty are lacking, many turn to professional national organizations or centers of higher learning for guidance.
What Do Professional Organizations Say?
The American Academy of Pain Medicine (AAPM), a leading professional association for pain-treating clinicians, approved in 2017 a position statement titled “Scope of Practice in Pain Medicine.”4
It reads: “…a Pain Medicine practitioner is a physician who, by academic medical degree and clinical post-graduate training, board certification, continuing medical education in Pain Medicine and a license to practice medicine, is uniquely qualified to provide a comprehensive array of professional services related to the medical specialty of Pain Medicine. … the medical specialty of Pain Medicine is currently recognized … as a subspecialty of anesthesiology, physical medicine and rehabilitation, neurology, and psychiatry.”
At first glance, this clause may be seen as an invalidation of non-physicians who collaboratively practice on multidisciplinary teams to achieve the best possible care of their patients. When viewed from a less antagonistic perspective, one may look at this statement as a direct reference to physician practice. APPs, pharmacists, physical therapists, and psychologists are not physicians and are not licensed to “practice medicine.” However, it is well understood and appreciated today that the best patient care in pain management is through the “biopsychosocial” model and not the “biomedical” model, thereby requiring all members of the multidisciplinary team working together.5,6
There are many pain organizations beyond AAPM, such as the International Association for Study of Pain (IASP), American Society of Regional Anesthesia (ASRA), and North American Neuromodulation Society (NANS), that support multidisciplinary practitioners through the acceptance of affiliate membership and the formation of special interest groups and continuing education. National professional practice organizations like the American Association of Nurse Practitioners (AANP) and American Academy of Physician Assistants (AAPA) have also used these avenues to embrace the ideals of specialty focus.
However, we continue to lack a universally accepted standard that recognizes APP specialists in pain management. There are no defined standards, required skills, hours of education, or demonstration of practice–all of which could lead to certification or credentialing.
Validation: What Is Currently Available?
So when it comes to APPs, what are our options for continuing education, credentialing, and certification as a pain management specialist?
Most advanced practice registered nurse (APRN) and physician assistant (PA) programs provide generalist education. For nurse practitioners (NPs), there are subspecialties that include training in pediatrics, acute care, anesthesia, and obstetrics. As noted, there are few, if any, residencies in pain management and no known nationally recognized fellowships in comprehensivepain management.
While there are rapidly expanding continuing education programs, the standardization is lacking. What APPs working in the field of pain management desperately need is input from our physician colleagues and congruency among our professional organizations as to the minimal requirements to “qualify” an APP as a specialist in pain management.
The practice of medicine is the role of a physician. However, in recent years, pain management, especially that of chronic pain, has shifted to a biopsychosocial treatment model and has been recognized as requiring a multidisciplinary team that includes many “non-physician” HCPs. Already, these other providers have devoted their careers to the specialty of pain management, treating patients with chronic pain and undertaking advanced training through various education modalities—myself included.
Just like any physician advanced training, non-physician providers are able to demonstrate knowledge and skill, and in many cases, years of practice in the specialty. At the end of the day, APPs want to be seen as “professionals” in the field—defined as exhibiting specialized knowledge, competency, accountability, integrity, and ethics.7
In the future, I would like to see a formalized post-terminal degree residency, fellowship, and training for APPs in the specialty of pain management, as we are seeing in the disciplines of pharmacy,8 psychology,9 and evolving in physical therapy.10 Until then, we will continue to expand and enhance the quality of educational opportunities available to us, seek out validation through the satisfaction of a job well done, work to improve patient outcomes, and partner with our physician colleagues.