Moving Toward Interdisciplinary Pain Management

Introduction

Multidisciplinary Approach

The current method of caring for a human patient with multiple issues and problems is a “multidisciplinary” approach. Within this paradigm, a variety of medical specialists are recruited to care for the individual. Each specialist works within his or her area of expertise. However, despite a concerted effort, the participants in the group are most often not communicating among themselves.

The disadvantages of a multidisciplinary approach in human medicine are many. First, the patient is put in the difficult position of having to advocate for himself/herself in order to process all the information that is delivered by the various specialists. Self-advocacy is difficult enough without the added burden of having to integrate information from multiple sources. Second, the possibility of adverse drug interactions rises dramatically when multiple care providers are each prescribing medications for the patient without communicating with each other. Signs and symptoms may go unrecognized or be overlooked if they are not relevant to the specialist at hand. Finally, a multidisciplinary approach without good communication among the participants creates the potential for adversarial relationships among providers and between individual providers and the patient.

In veterinary medicine, the approach to complex diseases still tends to reflect a multidisciplinary approach. The primary care provider uncovers a diagnosis of cancer, and the animal is referred to the oncologist. The client takes the pet to the specialist’s facility for treatment, and then, like a ping-pong ball, bounces back to the referring practice afterward. A similar scenario unfolds for most advanced orthopedic cases. For example, the ruptured cruciate ligament is diagnosed, the animal is referred to the surgeon’s practice for the repair, and then back the animal goes to the referring veterinarian. Most veterinary specialists are very conscientious about drafting referral letters containing all of the appropriate information about the animal and the care provided, allowing for appropriate follow-up by the referring veterinarian; but, in general, much of the communication comes after the fact and is not in the form of a dialog during the animal’s care.

Interdisciplinary Approach

Clearly an alternative is more desirable. That alternative is an “interdisciplinary” paradigm. In interdisciplinary care, the patient is at the center of the care-giving circle.⁶ Interdisciplinary care is predicated on professionals communicating with one another about a single patient and designing care that is in the overall best interest of the patient. Interdisciplinary care is also, by definition, very inclusive and allows professionals from different areas of expertise to work together. An interdisciplinary care paradigm can take many forms and can be applied to any number of medical scenarios.

In the case of a human with multiple illnesses, the primary care provider becomes the choreographer of the medical experience for the patient. When the gastroenterologist orders a colonoscopy, there is dialog among the specialist, the patient, and the primary care provider to ensure seamless care. Likewise, when the cardiologist must get involved with the aforementioned patient, the gastroenterologist, cardiologist, and primary care provider are all communicating with one another in order to maximize the patient’s outcome while minimizing the risks for complications.

The interdisciplinary paradigm in human pain management has been defined by the American Academy of Pain Management (AAPM) as an effort “to bring together the many professionals who work with individuals suffering from pain and to assist in the creation of quality services for those individuals. The intent is to be inclusionary and not restrictive to any specialty.”⁷ In this scenario, patients in pain receive the benefit of expertise from and dialog among many different types of pain practitioners. This may include care provided by (in addition to the primary physician) a pain specialist, a physical therapist, a psychologist, an acupuncturist, a massage therapist, and/or any other practitioner with a commitment to alleviating pain in human patients. One unique aspect of a truly interdisciplinary approach is that all qualified individuals, regardless of specialty, are welcome at the care-giving table to participate in advocacy for the patient in pain.

So, how can a truly integrated, interdisciplinary approach be applied to the animal in pain? One obvious example is to reinvent the relationship between the specialist and the referring veterinarian, with the primary care provider coordinating the client’s and animal’s experience with the specialist. Many primary care veterinarians are already doing this in order to maximize the positive outcomes for their cases. In addition, they may be advocating the participation of additional care providers, like a veterinary acupuncturist or individual providing canine rehabilitation services, in order to augment their own skills and techniques.

Pain management is an obvious example of an area of veterinary medicine where an interdisciplinary approach makes perfect sense. Additionally, animals in pain provide an excellent opportunity for an increased level of participation in case assessment and care on the part of the credentialed veterinary nurse, veterinary assistant, and other members of the veterinary health-care team. These animals need and deserve as much support and ongoing assessment as can be provided.

Out of this need in veterinary medicine and the recognition of the value of the interdisciplinary focus of the AAPM, the International Veterinary Academy of Pain Management (IVAPM) was founded at the 8th World Congress of Veterinary Anaesthesia in September of 2003.^a The purpose of the IVAPM is to be an interdisciplinary veterinary organization dedicated to improving the identification, prevention, and relief of pain in animals. The IVAPM brings together individuals from a wide variety of allied professions to exchange information relevant to animal pain. The IVAPM seeks to improve the standard of care for treating animals in pain by developing guidelines for care, providing continuing education, promoting humane and ethical research in animal pain, and establishing credentialing of veterinary specialists in the area of animal pain management.⁸ The IVAPM intends to serve the veterinary profession by articulating specific guidelines of care in the arena of animal pain management and taking a proactive role in coordinating and disseminating information and research results. Eventually, it may be appropriate for the IVAPM to take an active role in guiding new research in relevant areas.

Individuals dedicated to the process of acquiring and disseminating knowledge related to the biology and clinical treatment of pain in animals include a wide cross-section of the profession. The current membership of the IVAPM is a loose amalgam of veterinarians, veterinary nurses, and others from many different disciplines including, but not limited to, anesthesiology, surgery, veterinary practice management, laboratory animal medicine, and academic clinical practice.

The IVAPM is in the process of developing a credentialing pathway for interested members. The credentialing process will reflect the interdisciplinary commitment, in that all individuals interested in becoming credentialed pain practitioners (including veterinarians, veterinary nurses, researchers, academicians, etc.) will take the same examination. This interdisciplinary, inclusive approach to credentialing is unique in veterinary medicine. The IVAPM recognizes that members of the veterinary support team are actually far more likely to be on the “front line of pain” than the veterinarian in many circumstances. While it remains the veterinarian’s ultimate responsibility to prescribe medications for pain, members of the technical support team are typically the ones recovering surgical patients and monitoring pain in the postoperative period. These same trained and qualified individuals are the people most likely to deliver physical therapy, to communicate with clients regarding responses to long-term pain therapy, etc.

Conclusion

The time has come for developing methods of interdisciplinary pain management in animals. The IVAPM is an important vehicle for change in the veterinary profession. It is time for all members of the veterinary health-care team, especially the technical support team, to be involved in the day-to-day prevention, recognition, and treatment of pain in animals.