North, South, & West-
By Donald Schanz, D.O.
After finishing my pain management fellowship in 1995, I left the U-M to join a very busy private practice anesthesia and pain management group in Traverse City, Michigan. Traverse City is a very progressive and growing city on the northwest corner of the Lower Peninsula. This group practice is out of Munson Medical Center, which boasts an impressive list of specialists that represents and provides a wide range of medical specialties. There is a very strong U-M presence here.
Munson Medical Center services a very large geographical area with a widespread referral base from throughout northern Michigan and a large portion of the Upper Peninsula. Our practice services a very active cardiothoracic surgery group and we have two newly built cardiac obstetrical services for the community. We also have an acute pain service and a large cancer pain population. The hospital and community are committed to providing state-of-the-art health care for our patients.
In addition to being involved in all aspects of our group’s anesthetic responsibility, my major focus is pain management. I am part of an extremely busy multidisciplinary pain clinic headed by anesthesiologists. Munson is currently constructing a new facility that will house our pain clinic. Its planned completion is in the spring of 1997 and plans to include on-site physical and occupational therapy, psychological services, offices, examination rooms, and fluoroscopic procedure rooms.
Our focus here is a multidisciplinary approach to the management of chronic pain. Our staff includes anesthesiologists, pain psychologists, pharmacologists, physical and occupational therapists, and access to “addictionologists”, substance abuse counselors and nursing. Members of our team bring with them diverse viewpoints, talents and experience in all areas related to the practice of pain management. The cumulative product allows us to provide the highest quality of care.
My fellowship provided excellent training and experiences, however, I still find myself in the learning process. Working with other members of the pain clinic team exposes me to new ideas and allows me to share ideas and techniques with other team members. Pain is such a rapidly developing subspecialty that it requires vigilance and dedication to keep in touch with current and ongoing theory and technique.
Our clinic provides all aspects of current pain management, including a chronic pain support group, access to 24-hour crisis counseling intervention, 24-hour physician access, biofeedback, relaxation therapy, all currently acceptable nerve block procedures, cryoneurolytic techniques, implantable infusion pumps and spinal cord stimulators.
An important feature of our clinic is the availability of implantable devices for appropriate pain care. All patients considered for an implantable device, be it a spinal cord stimulator or implantable drug delivery system, must meet various criteria including psychological evaluation and clearance. The patient must have failed conservative treatment, there must be no evidence of ongoing drug or substance habituation, they must be judged not likely to benefit from further surgical intervention, and they must have had a successful trial treatment response. The most important factors to successful implantable intervention includes appropriate patient selection, proper surgical technique and implantation, and adequate postoperative management and support.
Implantable intrathecal infusion pumps are used for continuous drug infusion. They are used for chronic intractable pain, including malignant pain. Baclofen is also used in infusion pumps for spasticity of spinal cord origin in patients refractory to oral baclofen, or intolerant of its side effects.
Spinal cord stimulation is also used for intractable pain, stimulating electrodes are placed into the epidural space under fluoroscopic guidance. Spinal cord stimulation utilizes the pain control gate theory of pain modulation by stimulating large fibers in the dorsal column. In the dorsal column we create impulse modulation of small fiber ascending pathways. Spinal cord stimulation is commonly used for arachnoiditis, phantom limb and stump pain, ischemic limb pain, sympathetically maintained pain syndromes, and failed back syndromes that have not responded to other methods of treatment.
My practice provides an excellent balance and diversity between anesthesia and pain management. I believe there is a no more basic a goal to the practice of medicine than relieving pain and suffering. I find treating pain patients extremely rewarding and energy-consuming. They often bring with them complex psychosocial issues, as well as satisfaction in knowing that we improved the quality of their lives. They also tend to be very appreciative of successes that we might obtain and for all the effort that we put forth toward their care.
We will encounter patients in chronic pain management who will fail to improve. This can be very frustrating for the physician and one of the most difficult things I have found is being able to accept the fact that we will not be able to cure everyone. However, our efforts must be tempered with the wisdom of ‘do no harm’.
by Kimberly Greenwald, M.D.
After completing my fellowship in pain management in July of 1993, I left the U-M to pursue a private practice opportunity in Raleigh, NC I was the fifth pain fellowship-trained physician to join a group of 14 anesthesiologists. Our practice is unique in that most of my partners have fellowship training; four have done cardiac fellowships and three have critical care board certification. One of my partners is also a board-certified pediatrician. I was recruited, in part, to help start a growing pain practice.
Since joining the practice we have built a new pain clinic in the medical office building attached to the hospital. This is a multidisciplinary clinic including anesthesiologists, a neurosurgeon, psychologist, and a psychiatrist, as well as several physical therapists. We have five exam/procedure rooms with built-in oxygen and monitors. We also have one large procedure room with an x-ray machine. Use of this room allows us to perform some of the more complicated blocks without having to leave the clinic. This has been a great advantage in increasing productivity. In addition, we have a fully equipped recovery room so that our procedure rooms can be turned over quickly. We are now seeing 20-25 patients per day including new consults, procedures and follow-up appointments. We each spend one day per week in the clinic, which we feel is an ideal amount of time. The rest of my clinical time is spent practicing all other types of anesthesia (cardiac, neuro, OB, etc.).
Recently, we developed a new database software program to enable us to track our pain clinic population as well as our rate of success or failure. We hired several software engineers to design this system and tailor it to our needs. It will enable us to compare our results with large patient populations from other institutions, and is now up and running. We have designed the system to enable all the data from the original questionnaire, as well as subsequent visits, to be entered very quickly at the time each patient is seen. A computer is located in each treatment room to facilitate this data entry. We hope this system will demonstrate that we can deliver care for a multitude of diagnoses with excellent results and acceptable costs. In the increasingly competitive environment of managed care this information is critically important.
As part of my other responsibilities, I am working closely with our cancer center at Rex Hospital to develop a cancer pain management program. In particular, I have been placing implantable epidural ports as well as intrathecal narcotic pumps. We have had great success with this program and now follow a large number of cancer pain patients. This has been especially rewarding for me.
We also have a large population of patients in Raleigh who has had Steffe plates and fusions. We have had good success with spinal cord stimulation in this population. Placing the stimulators as well as the implanted cancer treatment devices has allowed me to use the basic surgical skills I learned as a resident in general surgery.
My husband and I are very happy living in North Carolina. The weather is wonderful and the people are very friendly. Andy has been busy starting his own business. We are now the proud ‘parents’ of a two-year-old English Mastiff, Max, and a three-month-old Rottweiller, Jesse. Sadly, our Golden Retriever died in August. We would welcome visitors anytime! E-mail: KIMBERLYMG@aol.com.
by Richard Harris, M.D.
It is hard to believe that my first full year of private practice has been completed. It seems an appropriate time to compare pain management practice in a university pain clinic to that of the world of private practice. I work for a very large group of anesthesiologists in a medium sized city. We cover three hospitals and four outpatient surgery centers. Our office is used for consultations only, procedures are not done in the office. At the present time, we do not have a ‘designated site’ for a pain clinic.
Because of scheduling concerns, pain patients are seen as outpatients in all of the hospitals and surgery centers. Insurance coverage often dictates where patients are seen. Since I do both pain management and work in the O.R., it is very common for me to move from site to site during the day. I have lost count of how many times that I have ‘hit for the cycle’, i.e. seen at least one patient at each hospital and surgicenter, and the office all in one day!
This makes continuity of care very difficult as records are often scattered around the city. This means that I have to keep most of the records in my head, which I don’t do particularly well; or I have my office fax the last note to me from the files.
Another significant problem is that each hospital and surgicenter has its own particular equipment to use. There are seven different epidural kits, seven different spinal kits, and a wide variety of block needles. Fluoroscopy is usually done with a C-arm in the O.R., and once again quality of the picture varies greatly.
There are many positive things about pain management in the private practice world. The patients do appreciate our efforts and often will make referrals to us with their colleagues and coworkers. The hospitals and surgicenter personnel are very anxious to help get cases done because they want the business. It has often been said that there is no such thing as an emergency epidural steroid injection. I say that is not true!
The U-M and its resources in the pain clinic are hard to reproduce in the private practice world. It has a multidisciplinary pain clinic in the truest sense—physicians, nurses, psychologists, physical therapists, and social workers. In the private practice world, I am multidisciplinary—physician, psychologist, etc.
The greatest advantage enjoyed by the U-M clinic is the ability to use the talents of the staff to solve complex problems patients present. I can’t count how many times I have thought I’d give anything if deRo, Vildan, Marge, or — (fill in the blank with your favorite pain clinic staff person) were here to help me. My respect and admiration for the U-M pain clinic staff has grown over this past year.
Obviously, the U-M pain clinic has a set location, established hours, and consistent equipment. It seems as though it is often difficult to figure out when a job is done well—the patients just keep on coming. Scheduling fluoroscopy time also can be a problem (at least it used to be). Even with these drawbacks, the pain clinic enjoys many advantages over private practice.
Our group is now embarking on the process of establishing a permanent pain clinic. I feel that without a full-time staff and location there is little more than can be done to advance the practice of pain management beyond its present state. The logistics of setting up a clinic are tremendous, but in the long run this is where pain management is heading.