Evolution of the specialty and perspectives on training
The Board of FPM recognised that to play a leading role in the field, they had to act quickly, and forged ahead to develop a curriculum to support training in the field, and to accredit pain clinics throughout Australia and New Zealand. Despite some initial concerns about the inherent difficulties of combining specialists from five separate practices into one training structure, FPM was able to leave the door open for fellows of any of the specialties to undertake courses in pain management.
From 1995 onwards, FPM received applications from hospitals and health care centres that wished to be accredited as multidisciplinary pain clinics.
The criteria were strict, leading to several institutions being denied accreditation. Others though, such as the Flinders Medical Centre, the Auckland Regional Pain Services, and Sydney’s Royal North Shore Hospital, were approved to take on trainees, and began to implement the curriculum which was outlined in ANZCA document P25 (Guidelines for Trainees and Departments Seeking College Approval of Posts for the Certificate in Pain Management). At first, the Faculty offered a one-year Certificate in Pain Management, but this was quickly replaced in 1999 by a two-year Diploma. By August 1998, eight centres had been approved, and twelve training positions had been offered to applicants wanting to gain accreditation.
The curriculum set the tone for not only FPM and its trainees, but for how members of the public would have their pain considered and treated in Australia and New Zealand. The strength of its core curriculum has led to international recognition and seen similar overseas providers of training in pain medicine adopt parts of the curriculum. The FPM’s approach to training has always been active rather than reactionary, which has enabled them to stay at the forefront of pain medicine.
By 2000, 159 doctors from all five specialties had passed their examinations to be fully qualified in pain medicine.
To become a fellow of FPM, in addition to passing examinations, members registered and paid an annual FPM fee separate to the membership fees of their primary specialty college.
The curriculum was rigorous, and prepared staff in a multidisciplinary pain centre to assess and treat the physical, medical, psychosocial, vocational and social aspects of pain. In particular, the inclusion of psychiatrists, and significant efforts to understand the psychological bases of pain was forward thinking and represents part of FPM’s growing role in the evolution of the specialty.
The Faculty has grown significantly in scope since its early days. It now includes several working parties across all domains of training and professional affairs. FPM fellows have been involved in diverse areas of pain medicine, contributing to the findings and report production of the Pelvic Pain Steering Committee. The 2011 report included guidelines for the management and treatment of the pain associated with endometriosis. This type of work reflects FPM’s increasing role in representing subgroups within the field of pain medicine, and demonstrates its willingness to continually adapt to change and the interests of different parties. Regional and national committees have also been set up to allow for greater representation across Australia and New Zealand.
In the July 2012 edition of FPM’s newsletter for fellows and trainees entitled Synapse, pain medicine specialists Professors Stephan Schug and Rollin Gallagher noted an over-reliance on medication for pain, and the need for more education and training for non-drug therapies. They recognised a changing philosophical approach from biopsychosocial to a sociopsychobiomedical approach – one that recognised the importance of social factors associated with pain and helped some patients learn how to control their pain without medication. This shows FPM’s willingness to look at a variety of methods to develop the best approaches to pain management. As a faculty, it has always been outwards looking and been an instigator of change, rather than responsive or reactionary.
Challenges
It was not all smooth sailing during the early years of FPM. The decision to include members from the five specialist medical colleges created some friction concerning which disciplines would be represented in the Faculty and its courses, and how. Some anaesthetists found it difficult to imagine how a multi-disciplinary diploma might be organised, and there were also several concerns about the apparently diminishing role of anaesthetists in the management of pain. Many others queried the inclusion of those not trained as anaesthetists, as well as the feasibility of bringing all five specialties together under one umbrella.
Some already working within pain medicine were even a little insulted at the basic claim that pain medicine was grossly underrepresented in Australia and New Zealand. Clearly, many people thought it unrealistic to even expect that the creation of a multi-disciplinary faculty focused on pain medicine would work. If it did, it would be a tedious process of difficult negotiations between the colleges. Instead, they suggested that pain medicine retain a primary role in each separate specialty, rather than adopting a multidisciplinary approach.
Several anaesthetists in New Zealand voiced their concerns that the strict protocol for setting up a pain clinic were ‘too prescriptive, too ambitious’ and would ‘effectively eliminate all training opportunities within New Zealand’. Inter-college friction existed as well, with one comment declaring it ‘highly debatable’ that a psychiatrist, for instance, would want to take an examination run by a different college. Professor Michael Cousins stated that he was not at all surprised by the lack of unanimity, and that it reflected the wide variety of individuals in the field at the time.
Although in these early days, there was significant resistance to the idea of a Faculty that required all five specialties to work together, in time this grew to be one of its major assets. In effect, by insisting on a multidisciplinary approach, FPM helped to facilitate better continuing relationships among professional bodies, and to inspire a sense of collegiality among specialists in a diverse range of fields. FPM has used its multidisciplinary nature to explore areas and opportunities for collaboration, in a way that sets it apart from other specialties.
Wider recognition of Pain Medicine
In 2005, the Australian Medical Council recognised FPM and pain medicine as an independent medical specialty, and in 2012, the Medical Council of New Zealand followed suit, accrediting pain medicine as a distinct scope of practice. It also acknowledged and celebrated the valuable work of FPM in raising the status of pain medicine during the preceding decade.
These recognitions represent major milestones in the growing reputation of the Faculty, and also illustrate firm governmental acceptance of pain medicine as a necessary specialty.
In Australia all state health departments now view chronic pain as an independent chronic condition.
From initial conceptual talks about the development of a Faculty of Pain Medicine, through to the recent admission of its 465th fellow and 37th accredited pain clinic, FPM’s reputation has grown. It is now recognised not only for its valuable contribution to the field of pain medicine in Australia and New Zealand, but also for its internationally acclaimed curriculum. To stay ahead of changes in the field and continue to be a driving force, FPM began to redesign its diploma curriculum in 2013, and the new requirements came into effect in 2015.
In 2016, FPM was fittingly selected as the 2017 recipient of the American Academy of Pain Medicine’s Robert G. Addison Award, which is given to an ‘individual or organisation in recognition of outstanding efforts to foster international cooperation and collaboration on behalf of the specialty of pain medicine’. An array of awards and prizes offered by FPM also inspires the next generation of pain specialists to challenge themselves and continue to push for growth in the field.
Above image: Faculty of Pain Medicine Board, 2017-2018. Back row: Associate Professor Paul Gray, Dr Kieran Davis, Dr Michael Vagg, Professor David A Scott (ANZCA President), Dr Patrick Farrell (Council Representative), Professor Stephan Schug, Associate Professor Andrew Zacest, Ms Helen Morris (General Manager). Front row: Dr Melissa Viney, Associate Professor Raymond Garrick, Dr Chris Hayes (Dean), Dr Meredith Craigie (Vice-Dean), Dr Harold Eeman. Absent: Dr Newman Harris.