I am not a pain specialist and I do not want to be. I am a family doctor and I try to care for my patients in as comprehensive a fashion as possible. While I certainly value and make use of specialists, I believe that in many cases a patient’s medical needs are most effectively satisfied within the boundaries of a comprehensive medical home. Furthermore, my patients are uninsured and underinsured. I am fortunate to have the support of a hospital which facilitates my patients’ access to medical supplies and services, but this access is limited. Finally, by education and inclination, if not training, I am as much a humanist as a scientist. Rather than focusing on specific diseases or injuries, my job is to try to understand my patients’ medical reality within the context of their lives and promote their well-being.

One of my partners recently observed that I have a particular interest in pain management. It is true that I have made an effort to familiarize myself with orthopedic and rheumatologic disease processes, that I perform a fair number of injections - both for my own and some of my partners’ patients - and that I am somewhat more comfortable and willing to prescribe pain medications, whether narcotic, non-narcotic, disease-modifying, or adjuvant, than some other physicians. My interest in the treatment of pain stems from my belief that I am obligated to address to the best of my ability those processes that threaten my patients’ well-being. To deny these obligations would be no different than ignoring their heart disease or diabetes.

Just as socioeconomic and demographic factors lead to an extremely high rate of endocrine and cardiovascular disease among my patients, these same patients suffer from a high incidence of pain. Furthermore, my patients have a great deal of medical, psychiatric, and addictive comorbidity. Even when my patients gain access to an orthopedist, rheumatologist, or pain specialist, these consultants are limited in what interventions they can offer, and are sometimes hesitant to do so for economic, social, medico-legal and logistical reasons. My practice setting demands that I treat medical disease to a level at which patients elsewhere would have been referred to specialists. While I believe that my partners and I usually rise to the occasion and meet this demand, I fear that this is not often enough the case when it comes to chronic pain. This is detrimental to our patients’ health and well-being.

I, like most of my peers, learned little about the management of chronic pain in medical school or residency training. I have been actively trying to increase my knowledge in this area through face to face, online, and print resources, as well as interacting with specialists, but I have much yet to learn. I have also recently had the opportunity to join a regional collaborative focusing on the safe treatment of chronic pain in a primary care setting, but this program focusses on systems and processes more than therapeutic strategies. I hope that through resources like PainEDU and attending PAINWeek I can increase my skills, knowledge base, and strategies. I am especially interested in increasing my comfort with treating pain in patients with medical, psychiatric, and addictive comorbidities, and in learning how to collaborate with specialists to accomplish these goals. I am also working on ways to make the treatment of these patients in the primary care setting more palatable to primary care practitioners.

Rudolph Virchow - a pioneer in social medicine as well as pathology - observed that “medicine is politics and politics is medicine on a grand scale.” This is nowhere so true as in the intersection of socio-economic need, medical illness, and chronic pain. I am neither a pain specialist nor a pain advocate; I am a family doctor and a patient advocate. I have become involved in the treatment of chronic pain because it is something my patients need and will not get elsewhere. While I wish none of my patients had pain, it is a fact of their - and truly all of our - lives, and managing it is not only an ethical duty, but involves many of the social and existential issues that attract many of us to primary care medicine. I do the best I can, but it is difficult, and I am trying to improve my skills in this area. I need all of the help I can get.