Everybody Hurts: Medical Board explains new pain guidelines

The Medical Board of California has new guidelines for treating pain with drugs.

But guidelines are no good if they sit on a shelf unseen. To understand where the medical board hopes these guidelines take pain care in the state, I corresponded with Medical Board Member Barbara Yaroslavsky and Medical Board Executive Director Kimberly Kirchmeyer.

I asked them both about the single biggest hurdle for physicians trying to effectively manage their patients’ pain.

“The biggest hurdle in effectively managing pain is the subjective nature of pain,” Kirchmeyer told me. “It can be a challenge for a physician to distinguish between the patient with a legitimate pain condition from the patient who is seeking a prescription for an illegitimate purpose.”

Yaroslavsky expanded on this, saying that she was speaking as an educated observer and not on behalf of the board:

I think that the single biggest hurdle to doctors in effectively managing their patients’ pain, is the lack of regular, well-spaced-out face-to-face visits to monitor how the patient is responding to the treatment and the changes. So … there is a need for more often and more constant communication, that's done face to face between patients and their doctors. 

But what about those doctors who don’t make the effort to communicate well? I asked if there would be any penalties attached to failing to follow the guidelines. Kirchmeyer told me that the guidelines are just that. They are meant to encourage best practices, improve patient outcomes and prevent overdose deaths. She wrote:

They are not intended to prescribe the standard of care. The Board recognizes that deviations from these guidelines will occur depending upon the unique needs of individual patients.  Physicians who deviate from the guidelines are encouraged to document their rationale. If a physician is the object of a complaint, a physician expert reviewer determines if the physician deviated from the standard of care. If the expert identifies violations of the Medical Practice Act, disciplinary action will be pursued.

I followed up by noting that clinicians have a big challenge when it comes to pain care. They have to correctly identify the type of pain a patient has, and they also have to be vigilant for signs of addiction. This requires time, patience, and practice. Doctors often have little of the first and, if they are just starting out, little of the last.

Yaroslavsky questioned whether the current system of short visits and a lot of patients makes the most sense. She suggested a model where physicians had medically trained assistants to help them engage more with patients, allowing for more access to medical advice, and potentially leading to better conversations about pain and other health issues. She wrote:

So this might be a different work model: The doctor, the patient and then a third person, medically trained to listen, engage with, question, recognize, check up on, etc., that would both be able to provide support and or intercede as needed with the MD.

I asked Kirchmeyer what sort of trainings she would like to see incorporated into medical school, residency programs, or offered later in a physicians' career to help them better make those distinctions about pain. She responded:

The type of training needed is really one that captures what is identified in our new draft guidelines. Training that discusses patient evaluation and risk stratification, consultation, treatment plans and objectives, education to patients, ongoing patient assessment, compliance monitoring, and medical record keeping. I do think there is training out there regarding this issue. Our Board recently provided free CME training in Los Angeles (September 19). This training provided helpful information on these topics. In addition, our Board website has a page devoted to CME courses on pain management. 

I pressed a bit on the question of discipline. It seems to me that even though physicians will not be penalized for failing to adhere to these guidelines, they might at a minimum help guide medical board investigators and the state Department of Justice in pursuing cases against physicians. I asked whether that would be the case or whether the guidelines would essentially be off limits to them. Kirchmeyer demurred, saying:

The guidelines are going to be helpful for Board and DOJ staff to know and be aware of. However, as stated previously, if a physician is the object of a complaint, a physician expert reviewer determines if the physician deviated from the standard of care. The Board and DOJ relies on that expert’s review of the case.

The question now becomes whether these guidelines will eventually influence the standard of care. Over time, I expect they will. If the Board continues reinforcing them with trainings and continues to encourage best practices in pain management, we may start seeing a true change in the way pain is managed. This still doesn’t solve the lack of effective tools clinicians have for identifying and treating pain. But a start is a start.

Photo by sharyn morrow via Flickr.