Predicting the Collapse of Pain Medicine Using the Economic Recession of 2008 as a Comparator: Lessons Remain Unlearned

Recent literature has suggested that there are foundational problems with the educational state of Pain Medicine due to inconsistencies amongst training programs. The knowledge and integrity of the emerging occupants of our field will define our generation. If our recent and upcoming graduates lack the clinical preparedness, research acumen, or political savvy required to carry our field into the next period of advancement, we may struggle to develop the next exciting era of Pain Medicine. It is the responsibility of current academic and society-based leadership to pave a path for their success by ensuring better, well-rounded fellowship education while instilling a passion for securing the autonomy of Pain Medicine.

Pain Medicine is one of the few sub-specialties in which “boarding” is not a requirement to practice in the specialty. For one to be “board certified” by the Accreditation Council for Graduate Medical Education (ACGME) in Pain Medicine, they must:

1. complete an ACGME (The Accreditation Council for Graduate Medical Education) accredited fellowship and
2. be a graduate of either an anesthesiology, physiatry, neurology, radiology, emergency, family, internal medicine, or psychiatry residency
3. pass an American Board of Anesthesiology (ABA) sponsored examination.

Some physicians graduate from non-ACGME accredited programs, some of which are strong though there is significant variability amongst them, as no certified accrediting body regulates education. Others forgo fellowship and work as an apprentice under a more experienced Pain Medicine physician. These physicians can claim non-ACGME certification by taking examinations which are administered by independent societies. However, even ACGME programs, believed to be much more rigorous and controlled than many non-ACGME programs, can be improved to promote consistency in training to meet the demands of a burgeoning field.¹ There are currently no procedural mandates for graduating an ACGME Pain Medicine fellowship despite a field that is booming with procedural innovation. These disparities may continue because of a lack of a universal Pain Medicine certification which does not force insurance agencies to discriminate based on type of training. The disparity of education has led to different practice philosophies and has led to a multitude of professional societies with variable missions.^2,3

Due to a lack of community governance, priority of payment, and righteous action, we attempt to elucidate the gravity of this dilemma by making a reasonable comparison of contemporary Pain Medicine to the 2008 economic crisis.

The 2008 economic crisis was a result of a confluence of numerous complex factors. First, creditors loaned money to untrustworthy borrowers. Second, banks bundled these loans and sold them as packages on the financial market. Third, large insurance firms backed these packages and misrepresented them as safe investments. Fourth, because of the ease of acquiring credit and a rapid real estate market, people were routinely purchasing several homes, intending to sell them for profit.⁴ These created landmines for the economy and, after they were triggered, sent markets into a downward spiral, causing employers to lose capital and lay off employees. Consumer spending decreased and most businesses suffered. All these events occurred due to a lack of responsibility and oversight in rapidly changing markets that were adversely affected by financial innovation schemes that outpaced the ability to regulate them.

We present an argument which replaces the names of the above-mentioned economic institutions with pain entities with similar functions to display a congruence of despair. In our analogy, we use education as our synonym for currency, and pain fellowships, the ACGME, pain societies, and industry as akin to banks that provide this commodity. First, pain fellowships, like creditors, are providing education to applicants of a quality different than that of the preceding ten years prior due to a recent drop in application volume⁵ (likely related to a surge in the need for general anesthesia physicians, and perhaps regulatory sanctions risked by opioid prescribing and increasing difficulty with third-party reimbursements). Second, pain fellowship graduates are being designated as adequately prepared for independent practice, so as to remain competitive with other fellowships.⁶ Third, the ACGME labeling is used to back these trainees as safe investments for their future employers. Fourth, industry has begun bundling training sessions for fellows and new graduates to perform procedures for which they may not have had sufficient or even any exposure during fellowship; these physicians are bundled to produce a profit for the companies that are training them. The authors argue that all these factors, in conjunction, create landmines for the pain medicine community. Education, which ideally includes careful and ethical utilization of all diagnostic and treatment modalities, is not transparently certified, and thus destabilizes the integrity (currency) of our field. Furthermore, we believe that this may lead to suboptimal patient care, providing an excuse to third-party payors to decrease reimbursements for pain treatments or eliminate them altogether. In fact, there is evidence that the downstream effect of fellowship educational debility has already begun.¹ Similar to the rapidity of change seen during the events leading up to the 2008 economic collapse, the innovations in the field of Pain Medicine have outpaced our ability to properly validate, teach and regulate them. The similarities are eerie, although will hopefully provoke thoughtful change.

The damage and its repercussions have already begun, yet it may not be too late for repair. The authors of this analysis suggest that a plan to remodel pain medicine education and training is necessary and making it an absolute requirement for one to practice within the subspecialty should be imperative. However, failure to act expeditiously in implementing these revisions to training will result in Pain Medicine becoming irreversibly damaged, with adverse implications for patients and providers alike. We also call for more agnostic education in society meetings, as this represents change that can be implemented in real time. In addition, we call for industry-related educational programs to be designed with the help of pain medicine program directors who understand the landscape of trainee education, allowing us to better pair training and continuing medical education as a means of filling the glaring gaps in non-industry-based learning activities. However, the most powerful way to redirect our course may be the collaborative development of a unified society to inform pain-related legislation and regulation. Currently, a fractionalized societal architecture dilutes society-based influence on all medical governing bodies, such as the ACGME and AMA (American Medical Association). Although our problem may have started with education and resulted in treatment coverage determination hardship, it is perhaps through the reparation of service reimbursement through a unified, society-driven process that may lead to the quickest preferred outcome.

Returning to the 2008 financial crisis, the government inserted itself once large corporations and banks filed for bankruptcy and gradually repaired the problem over the subsequent decade. However, Pain Medicine lacks a single entity that can correct a collapse, should such occur. Therefore, we must take preventative measures by rebuilding education while concomitantly seeking reparative measures through tactical collaboration between all relevant parties, as the field and the well-being of our patients will not fare well in the event of a tragic disintegration of Pain Medicine.

The 2008 recession was one of the most financially devastating events in modern American economics, although it did not come without warning. Whilst in the midst of events that caused financial despair, most of those responsible were unaware of circumstances brewing the inevitable collapse, as they were enjoying the riches that the deteriorating system delivered. Our mistake as a society was our comfort with the spike in artificial wealth in the early 2000s, which was produced without contemplating sustainability of its foundation. History has demonstrated that an activity based on reckless investments, poor faith loans, and short-sighted plans will fail. Pain Medicine is robust with excellent minds with philanthropic missions who are equipped to navigate our field towards the righteous and collaborative direction to grow. We hope that the Pain Medicine community remedies our educational ills before it is too late.