A “Pain Hospitalist”
Jerry Wesch, director of the pain program at Alexian Brothers Hospital Network in Arlington Heights, Ill., recently posted a job listing on the Internet seeking a pain management physician. He is looking for a doctor with an interest in comprehensive, interdisciplinary team management of chronic pain who is “able to function as a pain hospitalist.”
Although the details of this new position are still being finalized and a pain hospitalist would function with a different focus than a generalist hospitalist, Wesch suggests the role has important analogies with what hospitalists like Dr. Weston face in coordinating a virtual team of multidisciplinary pain resources.
Wesch is building an inpatient pain service comprising the pain physician, two nurse practitioners, and a part-time psychologist with full-time presence in two Alexian Brothers acute hospitals. This team would work closely with hospitalists, the palliative care service, and ancillary services such as physical therapy and chaplains.
“This should make us ideal collaborators with the hospitalists, who can just walk down the hall and initiate a pain consult,” he explains. “We’re all working toward the same goal, which is to improve efficiency, medical management, quality of care, and patient satisfaction. A good hospitalist is also my best ally in building a multidisciplinary pain service.”
In other settings, however, it will be the hospitalist’s responsibility to build the relationships that bring these pain resources together.
Deb Gordon, RN, MS, FAAN, senior clinical nurse specialist at the University of Wisconsin Medical Center in Madison, also sees herself functioning like a hospitalist in addressing pain issues. “I manage a clinical pain consultation service. I see patients every day,” she says. “I’m also in staff development, helping professionals in the hospital learn to manage pain better, and using quality improvement techniques to take what we know about pain management to support people like hospitalists at the bedside.”
Since 1990, an interdisciplinary quality improvement pain management group has been meeting at the UW medical center to improve the institution’s response to pain patients. Gordon believes pain is a natural target for hospital quality-improvement activities because it touches on the domains of quality identified by groups such as the Institute of Medicine in Washington, D.C., and the Institute for Healthcare Improvement in Cambridge, Mass.
Limits in the Hospital Setting
Even with a vast array of pain modalities, hospitalists face inherent limitations in addressing pain challenges within the hospital, starting with caseload pressures and short lengths of stay. Many of the approaches that might offer long-term solutions to the patient’s chronic pain syndrome belong in the outpatient setting, adds John Massey, MD, president and medical director of Nebraska Pain Consultants in Lincoln.
Dr. Massey sees chronic pain cases that have been refractory to treatment, both at his clinic and as a consultant in the hospital. Inevitably there is a psychological overlay to these cases, he says. That doesn’t mean the patient’s pain isn’t real, but if high doses of analgesics have failed to bring the pain under control, then a different approach is needed—one that includes behavioral techniques and involves the patient not as a passive recipient of treatment, but an active participant in his or her own pain management and coping strategies.
“There are ways to treat, for example, back pain that require finding a specific nerve in the spine responsible for the pain,” says Dr. Massey. “If I can locate that nerve, there are things that I can do, like radio frequency neuro-ablation. But this requires three separate visits to the pain clinic to make an accurate diagnosis. I’m often consulted by hospitalists and there are things I can do to put a finger in the dike. But I try to add another perspective to my discussion with the hospitalist, pointing out that many of the best pain management modalities are done on an outpatient basis.”