Evolution of Multidisciplinary Services for Chronic Pain - by Dr Bianca Kuehler, Consultant Pain Management

The doctor's role

Multi-disciplinary pain clinics are nothing new. The founding-father of pain management Dr John Bonica who devoted his career to the study of pain, believed in a team approach, incorporating various specialties to treat acute and chronic pain. Therefore the first pain multi-disciplinary clinics were already established in the 1950s.

In July 2020 the International Association for the Study of Pain published a revised definition of pain. The definition is: ‘An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage,” This definition and the original one from 1964 make it clear why it is so important to address the management of chronic and even acute pain from a multidisciplinary approach, taking into consideration the underlying medical condition and the complexity of each patient’s emotional condition, cultural background, previous treatments and genetic components.

Unfortunately, even in today’s multidisciplinary pain clinics, the biological/medical model delivered by medical doctors often comes first and when all the medical interventions and treatments are not successful a referral to the psychologist and physiotherapists is made. This linear model, with the patient being handed down the line, starting with the doctor and ending with therapies, does not always benefit the patients maximally. Ideally, the patient meets or gets input from the entire treatment team (doctor, physiotherapist psychologist and nurses) right from the start and a treatment plan should be formulated together.

Sometimes the best developments happen during the most difficult times and due to the COVID-19 situation we found ourselves with a huge back-log of patients. Two thirds of the doctors were deployed elsewhere. Despite these difficulties we tried to keep our service running and called most scheduled patients independent of our usual speciality. Afterwards all the patients and pathways were discussed with the team and a treatment plan was developed. We found that this actually improved patient care and now we do continue with this model.

Currently we call about ten to twelve patients in such a remote assessment MDT clinic between four clinicians (nurse, doctor, physiotherapist and psychologist) and afterwards we discuss each plan and pathway. We will need to audit this clinic but so far the patients have a quicker access to pain management programmes, injections or mediation reviews. Some patients get followed up (this usually will be face to face, but this is really not required for every patient), others can be discharged back to their GP’s with advice and a third group will enter a pain management programme, plus doctor’s advice where needed. We don’t know for sure how the future will look like, but we find these assessment clinics are an ideal solution for these difficult times.

As a doctor, I feel that I have been learning a whole lot and we all benefit from each other’s expertise. This new model of working also increases feedback later on in the treatment of patients, when they usually would not have another appointment with us. I feel we have gone from a linear model to a completely rounded one.

Content provided by Dr Bianca Kuehler,
Consultant Pain Management
Specialist Doctor in Pain at Chelsea and Westminster Hospital