Pain management can’t be cloned


I’ve had occasion over the past few weeks to think about service delivery and teamwork and how to provide really good pain management programmes in a group context.

A problem with any interdisciplinary team is that the members of the team may change as staff leave, or are unwell, or even have annual leave(yes! we like to take a break too!). At the same time, programmes for people with pain need to be provided consistently and often enough to break even financially.

The economic viability of interdisciplinary group pain management has been established (see these papers by Gatchel & Okifuji (2006), Goossens, Rutten-Van Molken, Kole-Snijders, Vlaeyen, Van Breukelen, & Leidl (1998), Turk & Burwinkle (2005) for discussion), and we know the effectiveness of this approach on individuals from too many studies to list here. Often however these outcomes can be overlooked in the face of the need to resource a programme with professional staff members, facilities, administration, outcome measurement, and ongoing review and development. So managers sometimes think of ways to reduce the cost in the most expensive resource – the staff members and the time spent on reviewing and developing programme content.

The argument seems to be one of two:

  1. That once a programme has been developed, there is little need to review it, and a ‘cloning’ approach can be used (similar to a franchise strategy!)
  2. That once the programme has been developed, the professional involved in the programme can simply ‘teach’ the contents – and perhaps ‘any’ professional can do this…

Let’s take a look at the first argument – that programmes can remain essentially the same once they’ve been set up. I’d argue that because pain management is continuing to evolve and develop, it becomes foolhardy not to include the findings and ‘technology’ based on new research findings. For example, in the last 5 years the literature on the pain-related anxiety and avoidance model (Vlaeyen & Linton (2006) has rapidly established the place of behaviour change and exposure-based therapy for people who are fearful of movement or pain. Programmes ignore pain-related anxiety and activity avoidance at their peril. Review and update are necessary in all areas of health care – no less so in pain management.

The second reason, that therapists can be slotted in and out of programmes as required – provided that they can ‘teach’ the content, suggests that the technical needs of cognitive behavioural therapy have been misunderstood. CBT is not simply providing information to people – it is a process of reconceptualising concepts, developing and rehearsing new skills, and reviewing situations to problem-solve and develop strategies so that the next encounter can be successfully managed.

As I’ve written about before, interdisciplinary teams need certain things to be effective – these include

  • a common model that all members of the team are well-versed in
  • technical skills in providing cognitive behavioural therapy
  • group facilitation skills
  • knowledge and trust in each other as professionals
  • ability to work across professional boundaries as necessary so as to reinforce the common model

To achieve this state, I think these things are essential

  • really good induction
  • time together as a team
  • agreement to adhere to the programme process
  • systems and structures to support decision-making
  • opportunity to observe the team members and programme

It is simplistic to think that the best way to ensure an economically viable programme is to reduce costs in the areas in which the ‘technology’ resides – the therapists and their skill, and ongoing review and development of the programme.  Not to mention time and processes to develop teamwork.   Although it’s expensive up-front, this time and effort is recouped in the quality of the programme and the outcomes it achieves.

On a slight tangent – can a successful programme from one country be transplanted holus-bolus into another country across the other side of the globe?

Some things concern me about this – the ‘franchise’ approach which prizes adherence to a manualised approach and can prevent ongoing development; the belief that professionals in one country have the same background and training as in another country (especially with respect to occupational therapy training!); the thought that patients can be cloned and ‘one size fits all’; and finally the suggestion that the active ingredients in the programme will ‘fit’ with the social, economic and political climate in another country.  I don’t know that this is achievable in chronic pain management…and wait to see with a good deal of interest whether it can happen here in New Zealand.

Let me know what you think about this post – agree? disagree? want to point out arguments for and against? Bring those comments on!!

Gatchel, R. J., & Okifuji, A. (2006). Evidence-based scientific data documenting the treatment and cost-effectiveness of comprehensive pain programs for chronic nonmalignant pain.[see comment]. Journal of Pain, 7(11), 779-793.

Goossens, M. E., Rutten-Van Molken, M. P., Kole-Snijders, A. M., Vlaeyen, J. W., Van Breukelen, G., & Leidl, R. (1998). Health economic assessment of behavioural rehabilitation in chronic low back pain: a randomised clinical trial. Health Economics., 7(1), 39-51.

Turk, D. C., & Burwinkle, T. M. (2005). Clinical Outcomes, Cost-Effectiveness, and the Role of Psychology in Treatments for Chronic Pain Sufferers. Professional Psychology: Research and Practice, 36(6), 602-610.

 

Vlaeyen, J. W., & Linton, S. J. (2006). Are we “fear-avoidant?” Pain Vol 124(3) Oct 2006, 240-241.

 

4 comments

  1. I’ve seen few pain management services make it, and these are only inpatient. Most often finances is the reason outpatient ones don’t even get off the ground. It’s unfortunate.

    What’s second best is an informal network – colleagues who routinely work together with patients. Are you aware of a true outpatient model?

  2. Yes, I work in a centre where an outpatient interdisciplinary programme has been running for over 10 years. It’s at Burwood Hospital, Christchurch, and despite its faults, seems to work well. In NZ there are three very good centres that have been running for similar lengths of time. This is probably supported by our relatively small size, the funding streams which are also quite streamlined, and the comparatively high level of education about interdisciplinary pain management in the country. All three services are within public hospitals which probably also makes a difference.

    I agree that an informal network is the next best thing – and possibly works even better than a formal network because it allows for the possibility of a larger team and more . The challenge of ensuring consistency of approach and excellent communication is even more difficult than in a single-site model!

  3. I have limited knowledge of an outpatient IDT programme and think that the discrepancies in training and experience of staff are an unavoidable truth of working life.
    Does the flexible dynamic ideal you describe become impossible when trying to control too many variables? To assure the patients of some consistency when they attend, there needs to be standards and a model that can be picked up by new staff – whether that is a franchise or not I don’t know, but I imagine franchises operate in that manner to achieve similar goals ie control over the product.

    I agree that this isn’t the best fit for each group that passes through, but the dynamics, anxiety and entrenched beliefs of the members make this a real challenge and a potential drain on enthusiasm – and that is just the clinicians!

    It is unlike me to side with management (ever) but maybe a one-size-fits-most approach is a reality until there are enough hours in the day, and enough staff retention to assure a truly cohesive IDT.

  4. Could it be that a really good induction process could help? With the opportunity to observe a programme before being thrown in the deep end? A written description of the model, and some of the ‘key questions’ that people throw at clinicians, and regular meetings within the team might also help.
    What I know doesn’t work for retention is limited structure for decision-making, limited opportunity for orientation/induction, and limited time for good teambuilding!
    Thanks for your thoughtful comments – it’s great to have debate!

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