The physician’s challenge is to educate the patient and talk to them about how they can participate in their own care and pain management: “‘I as a provider will help you any way I can. But this will only work if you help yourself.’ So you have to get buy-in from the patient,” he says.
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Explore This IssueJune 2018
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If patients are not disposed to engage with these approaches in their own care, perhaps they need a referral to a pain psychologist with expertise in psychosocial pain management. “But if you don’t have access to resources such as that, you’re back to working with the patient yourself,” Dr. Fillingim says. An alternative: Another member of your rheumatology group, such as a physical therapist or nurse practitioner, could obtain additional training in psychosocial pain modalities and take on such cases.
Dr. Janke says it is helpful to recognize a range of resources exist that you can offer to patients, including referrals to disease- or pain-specific websites, online support groups or evidence-based workbooks to help patients manage their pain. Patients can also download mindfulness apps on their smartphones. “But this requires the rheumatology practice to cultivate a list of resources.”
Some patients, such as those who show signs of depression, may require more extensive interventions, such as referral to a behavioral medicine specialist, which could be a psychologist with a background in behavioral medicine and pain medicine. “One of the challenges, of course, is that there are far too few psychologists in this field,” Dr. Janke says. “Access is a problem, undeniably. In an ideal world, wouldn’t it be nice to have an expert right there in the practice who could be pulled in?”
Sean O’Mahony, MD, is a hospice and palliative medicine specialist at Rush Medical Center in Chicago whose practice includes treating pain in patients who present with underlying life-threatening conditions, often with concurrent mental health issues. “There are a limited number of clinicians with the required training to support psychosocial interventions. Here we work closely with psychologists and social workers, and we have an occupational therapist [who] provides detailed instruction to patients on how to do mindfulness meditation. I refer about a third of my pain patients to a social worker or psychologist,” he says.
Dr. O’Mahony recently found, in surveying house staff at Rush, that 80% could not recall receiving didactic training on safe pain management prescribing at the undergraduate level. Now all medical interns at Rush get a week of pain training, including psychological modalities. “We also reached out to the oncology community to provide education about palliative care and psychosocial pain care. I could see developing similar collaborations with rheumatologists, to raise their comfort level with these techniques.”