ANZCA Bulletin June 2012 - final.pdf - Australian and New Zealand ...

Dr David Jones’farewellAs ANZCA celebrates its 20th birthday, theFaculty of Pain Medicine reached its teens.I have been privileged to be there since itsconception and gestation via an ANZCA JointAdvisory Committee on Pain Management(JACPM, 1994-1998) then continue to serveon the Faculty Board as inaugural censor(subsequently assessor) since the Faculty’sbirth late in 1999 and through to being thesixth Dean. Now it is necessary for me to stepaside.I would like to acknowledge many finepeople who have also been dedicated to seeingthe Faculty grow from a good idea, thenevolve and thrive into the peak training andassessment organisation that it is today.In particular I pay tribute to AssociateProfessor Leigh Atkinson and Dr PennyBriscoe, both former deans who also nowleave the board having completed maximum12-year terms, and former dean AssociateProfessor Milton Cohen, who continues hisvaluable input as the Faculty’s first director ofprofessional affairs.From the founding dean, ProfessorMichael Cousins, together with all otherboard members, these people have made amajor contribution to this early genesis ofthe Faculty. In addition I acknowledge thestrengthening relationship with ANZCA asthe host College, which has made the venturepossible. I would not like to belittle in anyway all the other contributing specialists, butat the same time note that anaesthetists arepresent during the genesis of many long-termpain conditions, and have a very significantcontributory role in working towardsreduction of chronicity.A new board with five new members hasbeen empanelled led by Associate ProfessorBrendan Moore. This happens at an excitingtime – especially to continue developinga realigned curriculum flowing from theblueprinting project, and also the time ofsettling the strategy directions for the next fiveyears.The priority directions include maturing ofthe project for outcome data collection and itsevaluation, and development of future leadersand increased advocacy.Since pain traverses most areas of healthpractice, it is important to have all healthprofessionals better educated, as well as thepublic in general. To that end, the Facultyis continuing to build new relationships.Primary care and gynaecology are twomajor fields where much persistent pain isencountered, and through the efforts of aformer dean of Faculty, a new section on painwithin Royal Australasian College of Surgeonsconnects to another large source of clinicalcases.It is significant that the Faculty’s VisitingSpeaker, Professor Henrik Kehlet, a worldauthority on persistent post-surgical pain,delivered his plenary on the transition fromacute to chronic pain at the recent ANZCAASM. The Faculty is multidisciplinary, andthese examples illustrate the cross-specialtycollaboration that is necessary to get all on thesame page regarding persistent pain.In partnership with the pain societies andPainaustralia, the task of improving access toservices looms larger than most. Growing askilled workforce is inextricably linked to thisin that increased places for training arealso needed.There is growing unrest in Australiaand New Zealand over what is appropriateregarding opioid prescribing, with much ofwhat reaches the headlines lacking balance byonly highlighting what is bad. Rarely, if ever,is there a mention of positive outcomes, whichI can assert from experience do exist. Havingthe wisdom to know the difference comes tomind.Much of what has been presented atscientific meetings recently (for example, fMRIstudies, graded motor imagery, placebo andnocebo research) tell me that the organ of painis … the brain!If I had to select a single theme abouthelping pain sufferers to cope and improvetheir lot, I would choose the relationship wemust form with them as being paramount.We do not cure long-term pain, we frequentlycontrol some of it, but always we need to striveto provide comfort. That comfort requires ahuge range of tools, including active listening,believing and acknowledging the person hasa problem – although not an unsurmountableone – reducing the perceived threat from apain condition, reassurance, and providingrealistic expectations from health interactionsfor pain.Stressors, such as the effects of not beingbelieved, or uncertainty about the meaning ofa particular pain regarding the patient’s futureand even life expectancy, are consistent withrecent research on creating nocebo effects.Dealing with these factors usuallytakes more than one interaction (that is,a relationship), and I ask whether we asspecialists should be treating doctors (whodo it) or consultant doctors (who tell otherpeople what to do)? There may be someimportant style differences that alter outcomes– something for Faculty members to considerwhen it comes to evaluating outcomes data.None of those arts of medicine methodsexonerate us from having top-notchknowledge about all the scientific aspects ofour specialty. But the art of communicatingthat meaningfully to the patient needsmuch thought and practice. It should be nosurprise then that experienced practitionersare questioning within Faculty circles theduration we allocate for training. How muchis enough?Briefly I would like to mention somethingabout the environment in which we operate.It is increasingly more politically correct, anda normal expectation, to provide informationand gain informed consent. It certainlyfeels right to inform patients well – and iseven expected by the law. But each monthI encounter an example of another healthprofessional undermining some aspect ofwhat I thought was a job well done, usuallyan act by someone thinking they are doingtheir job well. For example, in a dispensinglocation reading to a patient each the sideand adverse effects of a medication fromthe drug catalogue, or printing it from thecomputer and giving it to the patient. On thesurface it may seem like the right thing to do,notwithstanding we (patient plus prescriber)might have discussed the most likely sideand adverse effects before they departed theconsultation. Patients return with reports like“it freaked me out”. It may increase their fearof taking anything.Research proves that active medicationsinclude placebo responses (a real response)contributing to their beneficial effects 1 .Similarly pairing of dire/negative messageswith effective agents undermines theirefficacy (nocebo effect). And that happensfor even the safest of medicines we use.What can you as readers contribute on howwe can remain ethical, comply with legalrequirements but also not undermine theefficacy of our tools? The science is therealready.I have learned innumerable lessons fromthose around me – practitioners of all types,patients and even a few politicians. I thankall those who have shared their wisdom,guidance, stories, secrets and tricks ofpractice, and those who entrusted me withstewardship of the Faculty and its board overmy time as dean.To conclude, as I wish the Faculty and itsFellows an even brighter future, I would like toleave you with a modified version of the plea(from Niebuhr): “Give us Grace to accept withserenity what we cannot change, Courageto change what must be changed, and theWisdom to distinguish between them”.Dr David JonesImmediate past Dean, FPMReference:Tracey I. Getting the pain you expect: mechanisms ofplacebo, nocebo and reappraisal effects in humans.Nature Medicine (2010): 16;1277-1283.81