Today, I asked my staff to tell me how many patients are waiting in queue to see me for their chronic pain condition(s). Turns out, over 1300 Ontarians. I nearly fell over when I heard this.
In fact, in the last month, we had over 120 different physicians submitting NEW referrals to our chronic pain. Where is this heading? CONGESTION.
The congested waiting list of our pain clinic is no different than any other centre out there. Any respectable pain management centre that is NOT screening their referrals would quickly get congested in a matter of months. Pretty soon, you have wait-lists that are more than a year long. Ultimately, patients are the ones suffering in all this.
The lack of referral guidelines, non-existent shared responsibility from primary care providers, lack of family physicians accepting patients in chronic pain, and an overall lack of case management end-points/goals are leading to the development of stagnant clinics.
I spend far too many hours per day writing scripts to keep up with patients with no GPs. Unfortunately, I spend little time thinking about the person in front of me. Even worse, I feel myself side-stepping the “options” discussions with my patients. The remaining time is spent in providing pain-reducing procedures (injections, nerve blocks, Botox, cortisone injections, infusions, etc) which makes me a technician, rather than a thinker.
Below are just some basic ideas we are implementing at the Integrated Circle of Care, Inc to help our patients and perhaps,… set in motion some changes that could help patients and primary care providers manage pain better:
1) Pain care should start at the time of the referral:
Far too often, we see patients totally burned out and exhausted from their pain by the time they walk through our doors. Their primary care provider gave up months ago and has washed their hands of problem-solving the pain issues leaving the patient to cope alone. This is magnified further given that chronic pain worsens (as does mood, social relationships, finances, outlook,etc,etc) and becomes harder to treat the longer it goes untreated when still a new problem.
2) Pain management should involve a lot more education early on in the process:
We have been providing pain education classes to our patients as part of our management program. The sad thing is that many are improving on simple (common-sense) lifestyle changes they can do on their own. This has got to start well before a pain clinic referral is being written up.
3) Pain is a symptom – NOT a disease:
Far too many patients are coming in and when asked what their problems are, they say “PAIN”. Pain is an outcome. Pain is a single manifestation of something going on. It is an endpoint of a process of disease, wear and tear, nutritional depletion, etc. Many times, there aren’t any investigations done to determine if nerves are being irritated or joints wearing out. We need to take the word “Pain” and distance it from the basic diagnosis list. With a better vocabulary and understanding of the pain problem, we get better solutions.
4) Goals and end-points need to be considered prior to the referral being faxed:
Patients understandably lose faith in their primary care provider when he/she cannot help the pain issue. When a referral comes to us and we ask the patient their “goals”, they typically say “anything to make my pain go away”. Rarely does a patient come and tell me that their goal is to be able to garden or go for longer walks. We ALL (me included) need to reformulate our stated goals and then focus on them. Ultimately, achieving a few of these goals would result in a better quality of life. Sometimes, the pain doesn’t feel any better but patients lead better lives (i.e. less “suffering”)… this is success. At this point, they can be discharged back to their primary care provider to resume care for a while. Chasing rainbows can go on indefinitely IF there aren’t salient goals that let’s you know it is time for a “parting of ways”. At least, the patient can return in the future should things deteriorate.
5) Shared-Responsibility — Dead or Alive?:
Seems these days, perhaps due to the rampant addiction to narcotics and drug-trade in our communities, physicians are essentially branding ALL patients as guilty. A number of patients with no concerns from our end (and believe me, we put patients through the ringer in terms of monitoring for addiction, prescription abuse, drug use, chemical coping), return to their GP who writes/calls us and says,… “I don’t feel comfortable prescribing for this patient so I am refusing to prescribe their pain meds”. So we get the bounce-back client returning feeling more guilty and ashamed of their pain situation.
6) “Pain control is my human right”:
Without this statement being firmly asserted, many patients are passively deteriorating (silently) hoping for the system to change. A number of agencies such as the Canadian Pain Coalition have brought the awareness of pain to the forefront but with competing interests by so many other health agencies (stroke, diabetes, heart disease, cancer), the messages are perhaps getting diluted. Patient suffering in pain need to have a much more vocal presence with our political system and our health ministries. As a matter of example of the downplaying of chronic pain, there are no insurance reimbursement codes for a pain consultation by our provinical health insurance agency. This means, even after 2-3 hours a pain specialist and/or their team may spend reviewing a client’s case file, there is minimal compensation to a medical professionals caring for you (perhaps $60 for most generalists practicing pain management). My hair stylist gets more to cut, colour and style… and I’m out within an hour. What would you realistically pay for someone to sift through years of your health information, come up with a suitable treatment plan, and perhaps set you on the path towards less pain, increased activity, better sleep, and improvements in mood and energy???
Education is the key to these problems. With over 2.5 Million Ontarians in chronic pain and fewer pain docs to take care of them, this growing epidemic will undoubtedly and significantly unravel our healthcare budget if we don’t all play a more active role in sharing care for pain patients.
We for one are not waiting for Government to figure this all out. We are turning the whole process on it’s head and re-vamping the existing approach. In 2011, we hope to employ some new technologies (such as an interactive educational website, social networks, self-learning programs, non-physician led pain care options, some product options for people to invest in/for themselves, connection to social support agencies, etc). This new model is called PainCARE ™ (more to come on this later).
Most importantly though, we want to start forming a relationship with a newly referred client at the moment we learn about them… not only to teach them some coping skills or help them endure the long waiting-list, but too empower them and to give them some HOPE again.
Sounds hokey BUT anyone who finds themselves at the end of a long, frayed rope in pain knows what I am speaking about.
Ketan Patel BSc MD
President, Dr. Ketan Patel Medicine Professional Corp.
Staff Physician, Integrated Circle of Care Inc.
Research Director, Pain and Addiction Medicine Program
Mentor, MMAP (Medical Mentoring in Addiction and Pain)
Member, CSAM (Canadian Society of Addiction Medicine)
Member, CPS (Canadian Pain Society)
Director, Genomix Canada
Member, Personalized Medicine Coalition
Unit 5 – 1385 North Routledge Park, London, Ontario N6H 5N5
Phone (519) 472-8282 Fax (519) 472-8281
Suite B – 3955 Tecumseh Road East, Windsor, Ontario N8W 1J5
Phone (519) 948-0768 Fax (519) 948-2681