Pain Medicine is a specialty area that incorporates a few skills from anesthesiology, more skills from physiatry and
neurology, a few skills from neurosurgery and rheumatology, a few skills from orthopedics, and some skills from family
medicine.
Pain Medicine is not simply a branch of anesthesiology. The goals, philosophies, skills, scientific advancement, and
fundamental clinical nature are radically different for treating chronic pain patients vs. the practice of anesthesiology.
Therefore, the transition to becoming a good pain physician is not as easy as one might surmise given the number of
fellowship training programs which are subsets of anesthesiology. Pain medicine is a long term approach to patient
care while anesthesiology produces the briefest of all specialty patient encounters. Pain medicine is complex decision-
making which requires skills of ordering and interpreting advanced radiographic techniques and sometimes obscure
laboratory tests, synthesizing the psychological, social, economic, and rehabilitative aspects of the patients lives,
advancing long term health maintenance and preservation policies and medical interventions in the areas of substance
abuse, obesity, smoking, sedentary lifestyle, etc. Only a small part of pain medicine involves skills of placing needles,
and when injections are part of the therapy, fluoroscopic and CT guided techniques are used. The exceptions to this
statement are the “block jocks” who spend the majority of their time needling patients. Whereas the block jocks are
perfectly acceptable in a “spine specialist” model in which the majority of their referrals are derived from
neurosurgerons/orthopedists (who may also represent their employers), the block jock approach of injections only
works in the acute or subacute model of pain. Chronic pain patients with their multiple psychological, economic,
social, and medical issues rarely derive any significant sustainable relief from the needle jockeys.
Pain medicine is more advanced and uses more imaging technologies than the highly variable and non-standardized
training derived from one year anesthesiology fellowship training programs. Most pain management physicians must
deal with the economics, ergonomics, and policies of running a clinic as a business with far more non-physician
employees than are used in anesthesiology practices. Anesthesiologists have little long term integration with their
patients, do not involve themselves with patient rehabilitation or lifestyle modification, have few business skills or
training in setting up or running a clinic, and use predominately blind needle placement for injections.
Physiatry has far more rehabilitative skills and clinic operational skills than anesthesiology, but suffers from
inadequate training in airway management and emergency venous access practice, inadequate training in advanced
fluoroscopic techniques.
Neurology has a better understanding of large fiber transmitted pain states, a much better grasp of clinic operations,
and a better basis for psychological analysis than many other, but lacks integration of nearly all other aspects of pain
medicine.
Therefore the transition to pain medicine from other fields is not simply deciding to stick needles into patient’s spines,
but in fact necessitates a commitment to a lifetime of learning, synthesizing other specialty area techniques into the
specialty of pain medicine. Such an integrated approach is not currently available in any single residency or any
fellowship program. The most difficult transition is from anesthesiology to pain medicine because the precepts of
nearly all prior modus operandi must be jettisoned and new skills acquired. Many of the skills used daily in
anesthesiology are only rarely used in pain medicine. Given there are few similarities between modern pain medicine
clinical practice and the practice of anesthesiology, it is somewhat surprising there are so many fellowship programs in
pain management attached to anesthesiology residencies.
Eventually, pain medicine will develop their own residency program with an integrated approach of cross training in
several specialty areas which overlap pain medicine’s sphere of influence. But we have not yet arrived at that eagerly
awaited moment, and therefore must acquire independently, the skills and training to become a comprehensive pain
physician.
The practice of Pain Medicine is an exciting, rapidly evolving, professionally rewarding area of medicine. The
patients are sometimes neurotic, psychotic, delightful, pathetic, and funny. Their struggles become your struggles
which engenders an immense outpouring of compassion. You will grow with your patients as technologies change,
and will often see the same patients for many years. By practicing pain medicine, we have a unique opportunity to see
life through a different pair of glasses by helping our patients live and easing their pain as they die.
But pain medicine is not for everyone. For those who are used to batting 1000 by giving one anesthetic after another
for years without any poor outcomes, pain medicine can be sobering. Your patience will be tested with querulous
patients who can never be satisfied and by patients who have unrealistic expectations of "being fixed". You will
receive absurd calls at nights and on weekends and will find yourself buried in an unfamiliar maze of disability and
other governmental forms. Your malpractice rates may be much higher.
Yet, given all the negatives, they only question I ask myself about entering pain medicine is why I did not make the
transition to full time pain from part time pain sooner than 1998. The positives for many outweigh the negatives,
especially when given the privilege to interact with and affect so many lives in a useful and satisfying manner.