Pain management: Check your doctor’s qualifications carefully
Looking for board certification in the pain management specialization is not enough for a patient to ensure the doctor is qualified. Learn the questions you should ask your doctor.
In most states, a physician may be licensed to practice medicine by merely graduating from medical school, taking a basic licensing exam, and then applying for licensure. At that point, a doctor can “hang a shingle” and start practicing medicine. Hospitals have the responsibility for verifying the licensure status and competence of physicians they allow to practice in their facilities through a process called credentialing.
Hospitals credential doctors to practice in certain areas of medicine or to perform specific procedures or surgeries. When a doctor has an office-based practice, though, neither the state licensing board nor a hospital credentialing process limits the type of medicine the doctor is allowed the practice. This is true for many physicians who practice in the area of pain medicine, which is devoted to controlling or alleviating chronic (long-term) pain.
The specialty practice of pain management evolved relatively recently, since the 1970s and 1980s, largely through advances in post-operative pain control overseen by anesthesiologists. The role of anesthesiologists expanded from operative epidural catheters and other tools to pain control for women in labor, trauma patients, and other types of cases.
So how can a prospective pain management patient intelligently select a competent doctor? It is a bit more difficult for pain management than other specializations.
When most people are searching for a physician in a particular specialty, they look for board certification. In most areas of medicine, there is only one board from which a medical doctor can obtain certification, and such boards require graduation from medical school, state licensure, completion of an approved residency program in the area of certification, and passing a rigorous board certification examination. For example, the American College of Obstetrics and Gynecology (ACOG) oversees the board certification for all OB/GYN medical doctors. The field of pain management is different and a provider’s advertisement of the term “board certification” can mean a lot of different things.
The American Board of Medical Specialties (ABMS) recognizes most medical board certifications. In 1992, the American Board of Anesthesiology (ABA), a member of the ABMS, began administering a separate certification for pain medicine that was exclusively available for anesthesiologists. Through 1998, an anesthesiologist could take a test and be certified, whether or not he or she had any training in pain medicine. During the same time period, the anesthesiology fellowships (training) being offered were rather short (one year) and the standards were ill-defined.
Pain Management Board
Since around 1990, the American Board of Pain Medicine (ABPM), which is not recognized by ABMS, offered board certification for any physician (non-anesthesiologists and anesthesiologists).
Physiatry (Physical Medicine & Rehabilitation) Board
Around 2000, the American Board of Physical Medicine and Rehabilitation (ABPMR) established its own board certification, which is recognized by ABMS. The ABPMR offered grandfathering through 2006, which allowed doctors without any training in pain medicine to gain board certification by taking a paper exam.
Neurology/Psychiatry Board Subsequently, the American Board of Neurology and Psychiatry (ABNP) offered pain management board certification, open to all physicians except anesthesiologists and pain management/rehabilitation specialists. The ABNP board certification also had a grandfather period for physicians with no pain medicine training.
It didn’t stop there, though. The American Academy of Pain Management, which is not limited to medical practitioners and includes homeopathic doctors and nurses, has a board certification program. And even more recently, the American Board of Interventional Pain Medicine, which is not recognized by the ABMS, started new board certification and makes it available to physicians who have no formal fellowship training in pain medicine.
Why this is a problem
When it comes to pain management, all board certified doctors are not the same—and selecting the wrong physician can have dire consequences.
For example, one of my clients fell and had a thoracic back injury and sought the treatment of a board certified pain management doctor. This particular practitioner was certified by the American Board of Physical Medicine and Rehabilitation. Within two months of my client’s injury, the doctor proceeded with a very radical treatment without explaining any of the side effects or even trying to change the patient’s pain medications. The treatment he used was phenol injections into the epidural space near the patient’s spinal cord, which are typically reserved for terminal patients because it damages the spinal cord’s epineurium and causes permanent nerve injury (and return of heightened pain and sensitivity) , typically over weeks to months from the injection. After one round of the phenol injections, my client, who was in her 20s, developed severe sensitivity and pain, which did not resolve even years later.
A properly-trained pain management physician, like someone who was fellowship trained and board certified in pain management by the American Board of Anesthesiology, would have likely tried numerous more conservative measures before resorting to the last-ditch treatment of phenol. These alternative treatments would include things like changing the dosages or types of the patient’s pain medicines, in an attempt to find something that offered relief, and injecting medications into the epidural space. My client relied on the physician’s representations that he was a competent pain management doctor, when in reality he was not properly trained. As a result of that physician’s negligence, my client will likely endure life-long pain that could have been avoided.
How patients can pick a qualified pain management physician
Many clients have told me that this is all quite confusing. With all of these competing certificates and board certifications, how can a patient tell the difference? It takes lots of questions.
I recommend these steps for your research:
• Find out if the provider is a medical doctor (M.D. or D.O.).
• If the physician is board certified in pain management, you need to ask questions to learn what that actually means. Which board granted his or her certification?
• Ask about the doctor’s training after medical school. Did the doctor complete a residency? Was it in anesthesiology or some other field? A residency is clinical training that a physician completes in a hospital setting after medical school.
• Make sure the physician completed fellowship training in pain management. A fellowship is additional clinical training that a physician undertakes after completing a residency. Ask the physician to discuss the fellowship training he or she completed that is relevant to the treatment you may be seeking.
• Learn about the pain management continuing medical education the physician has taken that is relevant to the treatment you may require.
Finally, as in all medical care you are offered, make sure there is a detailed informed consent discussion with the physician before the treatment or procedure begins. Under Texas law, obtaining informed consent is a duty of the physician that cannot be delegated to a nurse, clerk or anyone else. Make sure that your doctor describes precisely what treatment is recommended and why, as well as all of the risks of the treatment. The physician should also educate you about the risks versus benefits of no treatment or alternative treatments.
Pain management negligence
If you have suffered an injury as a result of a pain management physician’s improper training or negligence, contact Painter Law Firm and we will discuss and review your case.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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A physician has to supervise the care and prescriptions of nurse practitioners and physician assistants under written, signed agreements
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine
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