This article reminds me of the last time I spent 2 years obstinately trying to prove a point! Why? Mainly because I just received, hot off the press, this very article in which our team in Perth describes what we consider to be a really great way of approaching modern health care! One might also argue that it is a bit of a slap in the face of old-school Western clinical approaches…..but that might be getting carried away. So with an elevated eyebrow, dear reader, read on as I try to explain all this in a fairly neutral way.
Clinicians at the Fremantle Hospital Pain Medicine Unit (in sunny Western Australia) were plagued by one fundamental problem: that patients were often not equipped with basic self management tools and thus would receive medical interventions without being given a real chance at getting themselves better. Worse still, the collective experience was that these self-management approaches are still sometimes seen as something to try only when all else fails. To challenge this philosophy, we developed the group-based STEPS (Self-Training Educative Pain Sessions) programme. The basic premise of the project was to provide adequate education and self-management tools for patients experiencing pain, ahead of and alongside interdisciplinary clinical appointments. By introducing STEPS, we were able to provide a basic but effective and efficient framework for comprehensive care by spending just 2 days explaining pain and management plans.
STEPS involves approximately 6 contact hours in total, learning from (and with) a clinical psychologist, occupational therapist, physiotherapist, and pain doctor. Participants are taught about pain mechanisms (anyone feel “explain pain” creeping up here?), as well as strategies for managing pain including psychological, physical, pharmacological, and surgical options. Most importantly, the team works with patients to try to create a management plan out of the otherwise seemingly disparate pieces of advice. This is all before the patient is even formally assessed! Sound strange?…well read on…
The “tried and tested” (read: “accepted but inadequate”) traditional approach to complex, ongoing pain problems is to frantically seek a biomedical diagnosis and jab, stab, or fry the supposed source of all woes. In most cases, we do not find one clear origin of pain; when we do, it is usually just a part of the bigger picture. Often, this process is a bit like trying to annihilate the most ravenous locust in a swarm; it’s not really all that effective! As clinicians, we are often astounded by the complexity of pain problems and either end up staring blankly into the distance like a deer into headlights (thankfully not too often) or we go ahead and do what seems most obvious at the time. Sometimes this approach works and sometimes it does not. Sometimes when it does work, it takes a few tries but, problematically, this all costs a lot of time and money and ties up the system; of course this is not a bad approach IF there is no better way of getting things done. So, STEPS was born because our interdisciplinary team, led by the inimitable Dr. Stephanie Davies, decided to strategise and implement a new approach to helping people with pain.
As clinicians, we know that there is strong research and clinical evidence that pain is a complex (and confusing) thing; the difficulty has always been in making sense of the evidence and then finding ways of applying it. There is also pretty good evidence suggesting that involving people in their own care is helpful. The only problem with being involved in your own care and providing informed consent is how do you do it when you just do not understand what is going on? Alas! We must never forget that the origins of the word “doctor” lie in the well established teaching tradition. Thus, in forming the STEPS programme, we decided to live up to the challenge of the true meaning of health care and really try to involve our patients by educating and rehabilitating before medicating. After all, we all recognise that living with pain is a challenge and needs addressing as much as the pain problem itself.
After 2 years of running this program we found that the patients did not hate us (they came back and were quite satisfied). Patients that saw us in individual clinics were overall better educated about their pain and better able to engage in treatment. This was one of the most immediate and palpable effects: patients and clinicians were actually able to “speak the same language” during clinic appointments. Finally, patients were seen sooner and surprisingly the whole thing was cheaper! While this does not prove that this approach is “the bee’s knees” (“a superlative approach” for those of you unfamiliar with this phrase) it does strongly justify the use and further testing of this model with an RCT (anyone interested?). It really is pretty powerful evidence that involving patients in their care can be made to work well in practice and is not just a pipe-dream. What was made clear to us, is that this approach solves one of the most critical problems in health-care: timely access to specialised services. By providing patients with more comprehensive, evidence-based treatment we paradoxically found that wait-lists decreased (from 2 years to 4 months) thus providing faster access to care. Not only were the patients and clinicians happy but the administrators gave us that rare thumbs up and decided to support a continuation of the project. What’s more, this approach served to complement the actual biomedical components of treatment.
Now the real question is, what would happen if we universally applied similar models of evidence-based, truly interdisciplinary, person-centred care?
Luke Parkitny is a PhD student at Neuroscience Research Australia. He is researching some of the factors that play a role in the development of complex regional pain syndrome (CRPS). Luke joins the Body in Mind team with a background of clinical practice and research in Western Australia. He has rapidly cultivated an interest in all things pain and has very successfully exploited every opportunity to share this knowledge with other health professionals and lay-persons.
Davies S, Quintner J, Parsons R, Parkitny L, Knight P, Forrester E, Roberts M, Graham C, Visser E, Antill T, Packer T, & Schug SA (2010). Preclinic Group Education Sessions Reduce Waiting Times and Costs at Public Pain Medicine Units. Pain medicine (Malden, Mass.) PMID: 21087401