Careers

C1MJA 196 (6) · 2 April 2012

Career overview

Persistent pain is a complex and multidimensional condition, so the solution should also be

multidimensional, say doctors who specialise in pain medicine.

Pain medicine was only recognised as a specialty in 2005, and like all young disciplines, it strives to embrace new approaches. For pain specialists, that involves strongly endorsing the “whole person” medical movement.

The term may have New Age overtones, but for pain medicine specialists, it means looking not just at somatic or “body-based” causes of pain, but also exploring the social and psychological aspects that are contributing to the pain.

“Western medicine teaches physicians to avoid those things, so pain medicine is not everyone’s cup of tea”, says

Associate Professor Milton Cohen, who is based at St Vincent’s Clinic in Sydney.

However it’s because pain has not been well managed in traditional medical settings that there is a need for a dedicated specialty, he says.

Usually, when people suffer from severe and persistent pain, it is not enough to just address an underlying medical problem. Other conditions often accompany the pain, which can magnify the problem and hamper recovery.

For instance, prolonged periods of inactivity and emotional disorders such as depression often accompany chronic pain.

“Pain is such an underdiscussed issue in the medical field”, says Professor Cohen. “Conventionally most medical specialties have a very biomedical focus. In chronic pain, there is a large

CareersMJA

Editor: Sophie McNamara • smcnamara@mja.com.au • (02) 9562 6666

continued on page C2

psychological dimension”, he adds.“There is also a misconception

that chronic pain can be easily cured, and that it’s just a matter of finding and ‘fixing’ the broken part. Another misconception is that a drug or procedure will cure it, and that’s not the case either.”

Professor Cohen says it was this complexity that drew him to the specialty. “ It involves addressing a challenging problem that is highly prevalent in the community but not well understood and therefore not very well treated”, he says.

However, he says that because of the emphasis on psychosocial issues, he wouldn’t necessarily recommend the specialty to a junior doctor.

“You approach this after you’ve done other training, for the reason that it requires a fair bit of experience and maturity to appreciate why there is a need for specific expertise in pain

Pain medicine applies a whole-person approach to a localised problem

In this section

C1CAREER OVERVIEW

What’s it like to work as a specialist in pain management?

C2REGISTRAR Q+A

Dr Luke Murtagh

C5MEdICAl MEnTOR

Associate Professor Roger Goucke on his career in pain medicine

C6

MOnEY And PRACTICE

Workplace safety goes national

C8

ROAd lESS TRAVEllEd

A literary prescription

‘‘Pain is such an underdiscussed issue in the medical field

” Professor Milton Cohen

Outsmarting pain

Careers Careers

C2 C3MJA 196 (6) · 2 April 2012 MJA 196 (6) · 2 April 2012

medicine. I would recommend it to early mid-career doctors who have already chosen a path of practice and find pain an interesting area.”

The Faculty of Pain Medicine is a faculty of the Australian & New Zealand College of Anaesthetists (ANZCA) but attracts trainees from various other specialties (see training box, below).

Pain management strategies once focused on acute pain following trauma or an operation, as well as cancer pain. The pain medicine specialty, however, evolved out of the need to help the large number of patients suffering from severe, chronic pain who had nowhere to turn for treatment.

Over the past decade, dedicated pain clinics staffed with both pain medicine specialists and allied health practitioners such as physiotherapists, occupational therapists and psychologists have emerged.

These non-medical specialists play a crucial role in the treatment of pain, according to Professor Julia Fleming, the director of the Professor Tess Cramond Multidisciplinary Pain Centre at Royal Brisbane and Women’s Hospital.

“When pain becomes persistent, you not only have to deal with that pain, but also a number of other issues that may result in poor quality of life,

like disruption to your normal daily activities, the impact on your family and friends, your ability to work and your perception of yourself and your role in society. That often leads to anger, frustration and despair about the future”, she says.

Trainees learn about managing acute pain, cancer pain, chronic non-cancer pain, as well as trying to decrease the progression from acute pain to persistent pain.

Dr Geoffrey Speldewinde, who works in private practice in Canberra at Capital Rehabilitation and Pain Management Centre, says pain medicine specialists are trained to always look at the person’s complaint in the context of that person and their life story, an approach that could also be useful in other specialties.

“In pain management we comfortably address psychology and social factors in someone’s biological pain state as we do in addressing probable physical pathology. We have much to offer our colleagues who manage other chronic health conditions such as diabetes, heart failure or asthma who don’t so readily acquiesce to the significance of those [factors] in illness management”, he says.

Amanda Bryan

continued from page C1

Registrar Q+A

Dr Luke Murtagh recently completed pain medicine training at Royal Adelaide Hospital. He is now qualified in both pain medicine and anaesthesia

Why did you choose to train in pain medicine?As part of my anaesthetics training, I spent 5 weeks in our pain management unit at Royal Adelaide Hospital. What appealed to me was the in-depth patient contact, and the opportunity to build a longer lasting relationship and rapport with patients compared with anaesthesia. I also found it an interesting challenge, and thought it would complement my anaesthetics practice.

What do you like most about the specialty?

The extreme satisfaction you get when you’re able to successfully treat a patient who is highly distressed with inadequate pain management and a high level of dysfunction, and you see them transform as a person. Although we don’t always win and our work is challenging, when you have a success story, it’s incredibly rewarding.

I would consider pain medicine one of the most complete specialties. It also gives you a different perspective on medical management. It’s about focusing on the person and their standard of living and level of function, as opposed to focusing on a single pathology and treating it.

What did you like about the training program?As pain medicine is an add-on specialisation, it requires at least 1 extra year. It was nice not having to go through the rigours of another 5-year training program (like anaesthesia). I liked the variety of training which spanned procedural intervention, assessing patients with the pain unit psychiatrist, multidisciplinary assessments, and simple initial consultations. The training program was also focused on a clinic with normal business hours, so my lifestyle was more stable and reliable. I only had to work one in six weekends, with no on-call.

Is there anything you disliked? Managing patients with chronic pain, especially those with complex psychosocial issues, can be emotionally draining. This includes managing inappropriate opiate prescribing, or dependence. However, with experience, you learn how to keep your emotions in check. You appreciate that it is the patient who has the problem, and you become increasingly confident in what you can achieve with the skills and knowledge that you have. The assessment was rather stressful. It involves four exams over 3 days, and in many ways was more challenging than the anaesthetics exams.

What are your future plans?

I intend to continue to work mainly in anaesthesia, but plan to do at least 1 day a week in pain medicine over the longer term, and possibly move more towards the interventional side of pain medicine. I also have a strong interest in perioperative pain management.

Training as a pain medicine specialist

Pain medicine is an “add-on” specialist degree, which means trainees have to have completed, or be training toward, a specialist qualification in a participating specialty, such as anaesthesia, surgery, psychiatry or rehabilitation medicine.

Entry into training is also open to Fellows of the Royal Australian (or New Zealand) College of General Practitioners or another faculty or chapter of one of the colleges for the participating specialties mentioned above.

Training is overseen by the Faculty of Pain Medicine of the ANZCA, and involves 1–2 years of supervised training (dependent on experience) in an accredited multidisciplinary pain centre.

The faculty evolved out of collaboration of five participating bodies: ANZCA, the Royal Australasian College of Physicians, the Royal Australasian College of Surgeons, the Royal Australian and New Zealand College of Psychiatrists and the Australasian Faculty of Rehabilitation Medicine.

Careers Careers

C4 C5MJA 196 (6) · 2 April 2012 MJA 196 (6) · 2 April 2012

Medical mentor

Associate Professor Roger Goucke

reflects on his career in pain medicine

“As a specialty, pain medicine is relatively young. There was a big effort in the mid 1990s to make it a specialty in its own right and it was recognised as such in 2005. I was on the planning committee that made the submissions to the Australian Medical Council to create a faculty of pain medicine. I was also involved in designing the training program and helping set up the accreditation process for the larger hospitals where people can do advanced training in pain medicine. One of my career highlights has been visiting these new training centres. We’ve also had several trainees through Sir Charles Gairdner Hospital and the benefits have flowed both ways. I’ve made some great contacts and friends. I’ve also helped the Hong Kong College of Anaesthetists set up their faculty of pain medicine.

It was the “whole-person” side of pain medicine that appealed to me. I started out in general practice, and because GPs manage a lot of chronic pain they are an ideal group to specialise in pain medicine. The pain specialty evolved out of the anaesthetics area after World War II, so it’s more often associated with that specialty. From my own perspective, it helped having a background in both anaesthesia and general practice.

If I had any regrets, it would be that I didn’t do much psychiatry when I was younger. The psychosocial side of pain includes depression, anxiety and distress, so

in the clinic I see lots of patients with behaviour and mood disorders. If I was 21 and doing medical training again, I might come back as a psychiatrist! You’ve got to win people over to get them motivated to go forward, to stop or reduce drugs and become self-managers.

A large component of managing pain is psychological. This involves working on changing patients’ beliefs, attitudes and behaviour toward their pain and that is now at the forefront of what we do in pain clinics. A lot of people have the wrong view of what’s going on in their body. They may think their headache is a blood vessel bursting or a tumour growing. They watch too much TV! So you need to explain the correct mechanism causing the pain and you need to reset their thinking, attitudes and expectations about it. In some cases, this may be enough to get the patient feeling well enough to go back to work.

Drug management of pain has also changed dramatically. When people don’t respond to simple painkillers, it’s easy to prescribe stronger ones such as morphine which can become problematic over the longer term. Much of the work in pain clinics involves helping patients get off morphine-like drugs. These days newer drugs are available to better manage nerve damage pain. Surgery — cutting out the pain — is now hardly ever done, but in the past 10 years there has been increased

interest in neuromodulation, which is the application of electricity via tiny catheters on wires close to the spinal cord. This is not new technology as we used this idea to treat intractable angina and back pain in the 1980s. The evidence base is growing but it’s still very expensive.

My latest hobby has involved developing a pain education program for the developing world. It’s called Essential Pain Management and I’ve run it in Fiji, the Solomon Islands, Papua New Guinea, Rwanda and Tanzania, plus its just been translated into Vietnamese and Mongolian. This has given me a terrific opportunity to revisit countries I worked in 35 years ago. It teaches practitioners how to recognise, assess, measure and treat pain. We have also developed a 4-hour instructors’ course on running the program, and in some countries these are taking off very well. It seems we are meeting a need.

One of the strengths of pain medicine is that it’s not just a medical field. Many different types of practitioners such as physiotherapists, occupational therapists and nurses have contributed a huge amount. They are represented by the multidisciplinary Australian Pain Society which I have been very involved in. Being a pain physician, you also see such a wide spectrum of presentations: chronic renal stones, irritable bladder, gynaecological pelvic pain, thoracic pain following surgery, chronic abdominal pain, intractable headache and, of course, lots of back pain. Cynics say it’s the dumping ground for patients other doctors can’t fix – and that’s the challenge. What a great job if your colleagues are sending impossible patients to you and you can help them. That’s the exciting thing about pain medicine. “

Interview by Amanda Bryan

‘‘What a great job if your colleagues are sending impossible patients to you and you can help them

”

After completing his medical training in Sydney, Associate Professor Roger Goucke practised as a general practitioner in Papua New Guinea, South Korea, Vanuatu and the UK. He then returned to Western Australia to train in anaesthetics. During the 1990s, his focus became pain medicine, and he was a key player in having it classified as a specialty. He currently works in the department of pain management at Sir Charles Gairdner Hospital in Perth and is a clinical associate professor in the school of medicine and pharmacology at the University of Western Australia.

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Careers Careers

C6 C7MJA 196 (6) · 2 April 2012 MJA 196 (6) · 2 April 2012

I t can happen so easily. A staff member in a medical practice is asked to archive some old files in an

awkward back cupboard. As some of the files start to fall, she reaches out to stop them and hurts her back.

Health and safety regulations will then come into play — but these regulations have recently changed.

New work health and safety (WHS) laws were introduced in Australia at the beginning of this year, replacing various state-based schemes with a nationally consistent framework operating under the new federal Work Health and Safety Act 2010.

Most states have introduced transitional arrangements to give businesses time to move from the old state-based occupational health and safety acts to the new national WHS arrangements.

Dr Graeme Edwards, a senior occupational physician and specialist in occupational and environmental medicine, says under the new national laws, being a medico–employer/manager is more complex because

of changes to the wording of who is responsible for workplace health and safety.

The new rules state that persons “conducting a business or undertaking” have a primary duty of care, “so far as is reasonably practicable”, to ensure the health and safety of workers and others who may be affected by the carrying out of work.

Dr Edwards, who is the regional manager of Queensland specialist services workplace health with Medibank Health Solutions, says the critical issue for doctors is in the definition of an “officer, or person conducting a business or undertaking”, and how it applies to their business structure and operations.

“It is likely that many more doctors will be caught by the definitions than previously but it really depends on their business structure”, Dr Edwards says.

Due diligenceThe new national legislation states that officers must exercise due diligence to ensure that the person conducting

a business complies with their obligations.

This includes taking reasonable steps to keep up to date with WHS matters, being aware of the hazards and risks of the workplace, and ensuring that the person conducting the business eliminates or minimises risks.

“[There is now a] statutory imposed obligation to undertake ‘due diligence’ concerning the health and safety of the workplace. While this has always been generally implied, as it was not explicit it did not get the attention it deserves”, Dr Edwards says.

“For the first time the obligations have been made explicit, and with explicit penalties. As is always the case, ignorance of the law is not a defence.”

A doctor in a partnership found to have committed an offence of reckless conduct under the due diligence provisions faces fines of up to $600 000 or 5 years’ imprisonment, or both.

Assessing risksWhen assessing the risks or hazards in a practice, ideally the best person is the individual with the legal responsibility for the practice, which is typically the practice owner, says Dr Edwards.

“It is appropriate to delegate the task

‘‘What we don’t want is a work environment where someone could have an accident and where we don’t have adequate [workers’ compensation] cover for that ”

Money and practice

related to medical treatment would be covered by public liability insurance, it can also involve WHS legislation.

MJA Careers put a series of questions to Safe Work Australia about the new national regulations and the effect on medical practices for this article, but it did not respond.

Kath Ryan

to an appropriately skilled individual but under the legislation you cannot abdicate responsibility and there are personal liabilities if you are found derelict in meeting your duties, especially if you are deemed an ‘officer’ within the meaning of the Act.

“Having no time is not a defence”, Dr Edwards says.

As a rough guide, a formal risk assessment should be performed at least every 5 years, but to truly meet the imposed obligations, it is a continual process of monitoring, reflecting and acting on the issues relevant to your specific medical practice, he says.

“If there is a change in practice procedures or processes, or whenever an incident occurs, this should trigger a risk review.”

Special qualifications are not necessary to undertake a review but training and insight are vital. Various workplace health and safety bodies across the country have developed tools to assist businesses to conduct risk assessments.

“However, you need to know where to find this information and how to adapt it to make it relevant to your particular workplace. Insight and understanding are therefore vital. Even if you have done your best, if your best is deficient you could still be held liable.”

Some professional organisations run programs to provide guidance on WHS issues. Occupational physicians are also specialists in this area.

Dr Edwards says Medibank Health Solutions is now one of the largest employers of occupational physicians in Australia, and can provide professional advice to businesses.

“The onus of responsibility is clear

— medico–employers shouldn’t keep their heads in the sand when it comes to their health and safety obligations in this new world order”, he says.

“As many medicos are effectively small businesses, they, like all small businesses, don’t escape the impost of these legislated responsibilities.”

Managing workplace injuriesDr Edwards says the employer now plays a critical role in helping an injured worker return to work. The two primary determinants in successful return-to-work programs are the proactivity of the employer, and the proactivity of the initial treating practitioner.

“The insights and understanding of a medico–employer, who may have been the first attending medico, means you can deal more effectively with the rehabilitation needs of workers in straightforward cases”, he says.

On its website, Safe Work Australia says the most common causes of compensated injury and disease in the health and community services industry in 2009–10 were muscular stress (due to manual handling or repetitive movement), which accounted for 52% of claims; falls, trips and slips, which accounted for 18% of claims; and being hit by moving objects, which accounted for 11% of claims.

Dr Edwards says falls, trips and slips, which are more common in private practice, do not relate just to staff. These are also the main hazards for patients. “This is a common concern for all business premises when individuals from outside the organisation are not familiar with the building”, he says.

Although an injury to a patient not

Developing a “no blame” culture

WORK health and safety (WHS) should be seen as an extension of practice standards, according to Dr Mike Civil, the chair of the Royal Australian college of General Practitioners’ National Standing Committee — Standards for general practices.

Dr Civil, who is a general practitioner in Perth, says WHS issues are part of clinical governance, which dictates the systematic approach all practices need to take to maintain and improve the quality of patient care. By having good systems in place, issues related to WHS are also recognised.

He strongly supports a “no blame” mentality in the practice to ensure that staff feel free to report any issues and to

provide feedback on ways to develop a safer work environment.

“What we don’t want is a work environment where someone could have an accident and where we don’t have adequate [workers’ compensation] cover for that”, Dr Civil says.

He says his own practice recently underwent a major renovation where important issues related to safety switches were found not to have been in place before the work was done.

He advises doctors to maintain contact with their professional organisations, local chambers of commerce and industry, small business groups and government bodies to keep up to date with WHS issues.

Workplace safety goes nationalWhat do new national workplace safety rules mean for your practice?

‘‘ For the first time due diligence obligations have been made explicit, and with explicit penalties

”

Further information about the new regulations

• Safe Work Australia: - http://safeworkaustralia.gov.au/LEGISLATION/MODELWHSACT/Pages/ModelWHSAct.aspx

• State government workers’ compensation departments, including the Workcover Authority of New South Wales: http://smallbusiness.workcover.nsw.gov.au/New-Legislation/Pages/default.aspx and Workplace Health and Safety Queensland: http://www.deir.qld.gov.au/workplace/law/whslaws/legislation/index.htm

• Australian Industry Group: http://www.aigroup.com.au/ohs/nationalohsreview/

Dr Graeme Edwards

Dr Mike Civil

Careers

C8 MJA 196 (6) · 2 April 2012

Road less travelled

There’s a great tradition of doctors who also write, says Dr Peter Goldsworthy, who

divides his time equally between general practice and writing.

“[Anton] Chekhov, one of the greatest short story writers of all time, was also a doctor”, says Dr Goldsworthy.

“And Somerset Maugham, who never practised, but graduated from medicine, said he thought a medical degree was the best training a writer could have.”

Dr Goldsworthy began writing science fiction stories when he was 11, and although he was an avid reader, says he wasn’t very good at English for most of his school years.

Instead, he liked science, and was good at it, so he decided to study medicine at the University of Adelaide.

He enjoyed his medical studies, and says his poem Morbid song (right), about a dissecting room experience, expresses “the fascination of it all and the weirdness of it all”.

While at medical school he also pursued his interest in writing. He sat in on English lectures, had poems published and wrote reviews for the university newspaper.

After graduation in 1974, he worked for about 5 years in alcohol and drug rehabilitation at the then Hillcrest Hospital, and began writing and publishing short stories.

He says the cross-section of patients he met through the alcohol clinic was invaluable for his writing.

“The stories that people would tell you — it was fascinating work for a writer”, he says.

Dr Goldsworthy has achieved considerable success as a writer,

receiving numerous awards including a Helpmann Award and Commonwealth Poetry Prize. His most recent short story collection, Gravel, was shortlisted for the 2011 Australian Literature Society Gold Medal. Several of his novels have been translated into various languages, or turned into films.

He says that success came “creeping, creeping” rather than through a big break moment. For instance, by the time his first novel Maestro was published in 1989, he had already published several books of poems and short stories.

Despite these achievements, he continues to practise at the same small Adelaide general practice he has worked in since 1980, and doesn’t plan to switch to full-time writing any time soon.

“I did it for 2 years, a long time ago, when I wrote probably my most medical novel, Honk if you are Jesus. But I actually found I wrote less when I had the time on my hands. I didn’t have the deadline of having to go to work in the afternoon. It was like living forever — why do anything if you can put it off till tomorrow?”

Dr Goldsworthy says working as a GP also provides endless inspiration for his writing and a counterbalance to the solitude of writing.

“You can’t write a novel unless you have constant human contact — talking to people, listening to what they say, and studying their character — medicine’s perfect for that.”

He says his patients aren’t shy about providing feedback on his writing, and acknowledges that they do sometimes crop up in his stories.

“Sometimes they are in my books, but you move them sideways. You try

to find an essence in a character, or an emotional objective or character flaw.”

He also continues to draw satisfaction from the medical work itself, particularly from the relationships he has built with patients over 20 or 30 years.

“We’re friends now, and I know their kids, and their kids’ kids now, for some of them. I like that. I like that continuity.”

More about Dr Peter Goldsworthy, including links to his e-books and free downloadable essays and short stories, is available at: www.petergoldsworthy.com

Sophie Mcnamara

A literary prescription

‘‘You can’t write a novel unless you have constant human contact . . . medicine’s perfect for that

”

Dr Peter Goldsworthy combines careers in medicine and writing

Morbid song (for Alex)

I learnt to love a body once,

dead a year, in pickling spirit.

It was my nearest friend.

Every other day I lifted back

the linen lid and unpacked

fitted things. The weird contents

had been worked inside

a ribbed and leathery case

as if by ancient Oriental

luggage arranging arts,

less anatomy than origami,

with economy. No compartment

went unused, or bit or piece

of space. It was an installation.

Or else the winner of an organ-

cram,

a record squeeze inside a Mini

or a Beetle exoskeleton.

The only rule: the parts

must pack in two by two,

paired, like matching luggage,

with a spare of everything,

except a heart.

(First published in The Australian’s

Review of Books)