Images
Dedicated to E.B. and R.A.
With thanks to my patients and colleagues.As we meet reality, we must learn to embrace it as a profound set of contingencies in which we are embedded, and whose meaning is unknown.
Polly Young‐Eisendrath
The Present Heart
Preface
Fifteen years in the making, this book was first conceptualized as one of the potential outgrowths from the first‐year medical student course in pain at Johns Hopkins assembled by an interprofessional team of pain experts. In the ensuing years, tremendous changes have swept the globe impacting the practice of clinical care: The North American opioid crisis has raised awareness about the perils of medication‐based approaches, especially when drugs impacting the reward pathways are used; revisions in healthcare financing, delivery, and education have increased the representation of nurse practitioners and physician assistants in primary care roles; and the gathering of large interprofessional working groups and creation of interprofessional curricula have endeavored to meet to the above needs. This text is responsive to the guidance of the Interprofessional Education Collaborative which recommends that curricula are based on teamwork, shared values, professional roles, and communication, centered on the patient and family, and informed by community and population. The concepts in this book are firmly rooted in the work of the International Association for the Study of Pain but some adaptations are present. The primary target audience of this book is the primary care provider, or nonpain specialist, seeking quick guidance about pain, within the context of an integrated, whole‐person approach.
This book springs from my passion for teaching and my profound belief in visual learning. My goal is to change how you think, and feel, about pain – to illuminate the reasons behind pain experience, the events of peripheral nociception, the impacts of pain on the person, and the outlines of how manage pain in the most holistic manner possible, with compassion and concern for best long‐term outcomes. With Pain Medicine at a Glance, it is my intention to capture the imagination and attention of each person who happens upon the book, to provide a series of visual mental images that imprint “pain logic” on the mind and aid each reader to approach pain with enthusiasm and interest.
My guiding inspiration for this book was to employ visual learning to change how healthcare providers think about pain. As a young person, I spent many weekends with my grandparents, my grandfather was a naturalist, and my grandmother had grown up on the farm but moved to the city as a teenager to study nursing. They both loved the outdoors but approached it as an opportunity to learn as well as to wonder and enjoy. They had a small collection of guidebooks with exquisite illustrations – trees, mushrooms, wildflowers, seashells, and birds came to life in glorious detail. I loved to gaze at the pictures but was awestruck at how much my grandparents had learned about the world around them and the gentle respect for nature that suffused their approach to exploring that world. Pain Medicine at a Glance is my chance to share the special love and wonder I feel for the human body as a physician and pain scientist. In it, I seek to unlock some fundamental knowledge so that students and colleagues can better understand and respond to this physiological system that functions to protect us, but sometimes causes profound suffering. May this book be a useful guide on your journey to helping others.
Beth B. Hogans
Baltimore, Maryland
Foreword
No North American pain educator today is more highly esteemed than Beth Hogans. Her career has been informed not only by her medical and scientific training as a scientist and neurologist, but also by broad interests in literature and the humanities. Dr. Hogans' early work identified, in a series of landmark studies, deficits and gaps in the medical student curriculum related to pain. Together with colleagues, she inaugurated an innovative course at Johns Hopkins for entering medical students about pain. For over a decade, this course has served as a model for other pain educators. It spans not only conventional biomedical content but also the experiential and social dimensions of pain. As the course has evolved, so have the fields of pain research, education, and policy. Throughout this time, Beth led the charge to more broadly advance clinical competence in pain. Working collaboratively, she created a scholarly journal section dedicated to pain education. Through this, she guided her peers in the field, raising the level of scholarship in pain education and supporting the development of clinician‐educators, nationally and internationally, continually seeking to innovate and disseminate academic advances. Central among these advances has been the reaffirmation that pain is a clinically salient subjective experience heavily influenced by social processes such as isolation and stigma that add to suffering.
Advances in educational psychology have been applied by Dr. Hogans and colleagues to render pain education more effective and efficient. The techniques of role‐playing, narrative, re‐enactment of brief pain, such as BandAid removal, have been incorporated into the course. Beth has had a particular interest in harnessing the neurobiology of learning to optimize pain education, whether through ensuring that experiences are of relatively brief duration so as not to overload students' cognitive capacity, and providing copious illustrations to harness other means to convey packets of knowledge, e.g. text. The practical results of such a sophisticated approach are embodied in Pain Medicine at a Glance: focused one‐ to two‐page chapters that convey the essence of a topic or clinical situation in a way that all members of an interprofessional pain care team can quickly absorb and apply. The consistent delivery of linked pieces of knowledge by a single exemplary clinician‐educator‐scientist – with practical dicta such as watching out for their own safety, or displaying compassion and empathy – conveys what it must be like for a student or fellow to accompany Beth in the clinic or on bedside rounds.
I believe that the magic by which Dr. Hogans' presence and style suffuse this book derives from its being a single‐author volume. Those who know Beth or have heard her speak will recognize the prose of the present volume as conveying her voice. Single‐author volumes on complex topics (think Bonica, Beecher, Ballas on sickle cell pain, or Selye on stress) are becoming more and more uncommon as fewer and fewer scholars – particularly clinician‐scholars – have the breadth of knowledge to single‐handedly convey their oeuvre. Two thousand years ago, Horace, the Roman playwright, satirist, and father of literary criticism, in Ars Poetica urged writers to choose their subject judiciously, in harmony with their own interests and abilities. That done, “neither elegance of style nor clarity of expression shall desert the [writer] by whom the subject matter is chosen judiciously.” Devoting her career to becoming an exemplary clinician‐educator, Beth has indeed chosen her subject wisely. Her descriptions of problematic situations and how to manage them (e.g. tapering opioids in a patient reluctant to do so) speak with clinical credibility. This volume is a testament to her mastery of the field of pain, and her own personal approach to interdisciplinary pain education, that call to mind the historical mission statement of a leading Boston hospital: “where science and kindliness unite.”
Daniel B. Carr, MD, DABPM, FFPMANZCA (Hon.)
Professor Emeritus, Tufts University School of Medicine, Boston
Founding Director, Tufts Program on Pain Research, Education and Policy
Past President, American Academy of Pain Medicine
Honorary Member, International Association for the Study of Pain.
Acknowledgment
Many thanks to Anne Hunt, James Watson, Vincent Rajan, Samras Johnson, and Avinash Singh, my editors at Wiley. I appreciate their consistent encouragement and