Dr Ewen Forrest opened the meeting, welcomed everyone to the new academic year and thanked the Committee and in particular, its Officers for all their support during his tenure as President. He then handed over to the new President, Dr Clare Howard. Dr Howard briefly gave her views about the future of the society and then introduced the speaker, Dr Barry Miller, Dean of the Faculty of Pain Medicine of the Royal College of Anaesthetists.
Dr Miller opened his talk by looking at how the specialist register had undergone a variety of name changes over the last 20 years. Currently the acquisition of a CCT is required but a CST is proposed by the Shape of Training review. He looked at education and training and asked to basic questions; who are we educating and what are we teaching? He then looked at the history of pain medicine and its evolution. He thought that the management of painful problems had always been a primary mover in the history of medicine. The analgesic effects of opium, cannabis and willow bark had been known for many years although their use had been patchy. The focus on medicine had been a desire to save lives and although successful treatments were limited, they were largely surgical in nature. The palliation of disease did not seem to be high on the priorities of doctors. In the 1920s and 30s, anaesthetists first became involved in the treatment of patients with intractable and usually cancer -related pain offering nerve blocks which could be made permanent until the end of life. Doctors were still wary about the use of opioids due to the risk of abuse which is still an issue today.
Dr Miller also thought there was a cultural issue because medicine was traditionally about investigation, diagnosis and treatment. However in the 1950s, pain clinics began to be established with Dr Sam Lipton establishing one in Liverpool. Research began to further the understanding of the complexity of pain pathways with the Gate theory being proposed by Melzak and Wall. Pain medicine generally stayed within the confines of anaesthesia and in the 1980s/90s, the newly established College of Anaesthetists developed an increasing recognition of this area of practice. The answer to Dr Miller’s first question was that anaesthetists tend to be the who.
Pain medicine was formally introduced into the anaesthetic curriculum by the RCoA in 2001, Regional Advisers in Pain Medicine in 2004 and the Faculty of Pain Medicine (FPM) was proposed in 2005. Once the Faculty was established, its primary aim was to improve, direct and regulate pain training and provide guidance on the standards of practice at all times. The training environment has greatly changed over the last 10 years with PMETB being established in 2005 and its subsequent merger with the GMC, five years later. They have taken a far more proactive approach to curricula and there has been a push towards credentialing which has effectively placed a moratorium on sub- specialist applications since 2008. Consequently there has not been a separate CCT in Pain Medicine.
The main focus of the FPM is the pre-CCT environment however education and training is lifelong. Dr Miller described how pain training fits into the current anaesthetic curriculum with an exam for those completing advanced training allowing Fellowship of the Faculty. He described the difficulties of writing a curriculum in pain medicine because the total length of training in anaesthesia is preset at seven years and fitting everything in against all the other requirements in anaesthesia was very difficult. The ultimate aim of the training programme is to produce an individual capable of independent consultant level activity.
Dr Miller addressed his second question of what are we teaching? He thought that this was a much more difficult question to answer than it would appear. In other specialties, the area of study surrounds one organ or group of similar organs however with pain, it is the study of everything that hurts that can’t be treated by the conventional model. Therefore pain medicine is less about investigation and diagnosis and more about the treatment of pain itself. This perhaps suits anaesthetists better than other groups of physicians because we are less well trained as diagnosticians.
As for the future, Dr Miller thought that the Faculty was a cornerstone to recognise an important facet of medicine and build upon it. It was therefore an evolving institution. Currently only anaesthetists are eligible to join the Faculty but there are clearly other professionals who practice in the same field. Therefore the first question was how could the Faculty reach out to these individuals? This is difficult because the Faculty is wholly within the RCoA and has no control over training schemes outside the anaesthetic curriculum. He wondered whether non-anaesthetic pain doctors actually wanted to be included within the Faculty? The second question was whether or not the Faculty wanted any remit beyond the CCT environment. Dr Miller thought that this would be important because patients should be treated by trained individuals. This is also a very difficult area to regulate because job plans can change throughout a career to include an aspect of Pain Medicine. There is however no mandate to ensure that individuals have further training if this occurs and they are beyond CCT. With revalidation, this is likely to change. The GMC has been working on the concept of credentialing since 2008 as an integral part of the Shape of Training review. Progress seems to have been slow although it is anticipated that this will be a significant component of specialist skill recognition post CCT.
In conclusion, Dr Miller thought that Pain Medicine was currently under considerable pressure within the NHS. However it offered a variety of unique services from simple injections to Pain Management Programmes. He thought that training needs will continue to evolve to mirror the general progress and scope of medical practice.
Dr Miller took some questions from the floor and the meeting finished at 20.30.
Dr Ewen Forrest