Report from the AAP
By Rae Brown, MD
Chair, Section on Anesthesiology and Pain Medicine the American Academy of Pediatrics
Pediatric Pain Medicine is maturing as a fundamental part of the overall clinical care of children. The Society for Pediatric Pain Medicine (SPPM) is working hand in hand with the Section on Anesthesiology and Pain Medicine of the American Academy of Pediatrics (AAP) to assure the continued growth of pain medicine as a clinical and an academic field of study. The close relationship between these two organizations confirms that the combined resources of both can be put toward expanding our knowledge about acute and chronic pain in children.
What is essential for this field at this time? Indeed, the continued growth of knowledge of the differences between acute and chronic pain, their assessment and treatment in children will always be critical to the health of the field. Now a cursory review of the pediatric literature relating to nearly any subtopic in pediatric pain reveals a dearth of specific research addressing this area of study. So, it is vital for those of us interested in seeing Pediatric Pain Medicine (PPM) continue to grow as a field of research to encourage those capable of providing the answers to salient scientific questions through providing them the necessary resources, financial and time.
What about the workforce? Are there sufficient numbers of clinicians trained to provide the sometimes-sophisticated treatment necessary? Will there be enough trained physicians available to provide this treatment in the future? Our current assessment, during conversations within and between both groups, is that there are not currently enough trained clinicians to care for the patients that we have. Also, few within or outside of the field have been able to suggest that there will be future increases in clinicians adequately trained to do the work under the present circumstances. Pain Medicine for children, especially chronic pain medicine, has become an amalgamation of multiple fields – pediatrics, physical medicine, physical therapy, psychology, pharmacology, and anesthesiology. Pediatric pain programs across the country continue to recruit candidates, mostly from the pediatric anesthesiology population, while at the same time, the first generation of those physicians that have developed pediatric pain medicine as an independent entity are rapidly reaching retirement age. This loss of experienced clinician/scientists will represent brain drain of the first order.
To assure the vitality of the specialty, and guarantee sufficient clinicians for the future, those with interest must begin the process of creating a pathway for board certification for Pediatric Pain Medicine. For this to occur, ACGME accredited pediatric pain medicine fellowship training programs need to be established. The PPM leadership must, as a community, define the scientific and clinical knowledge and skill sets that every pediatric pain medicine fellow must demonstrate to be considered a competent clinician. This process requires some agreement about a standard curriculum, requirements for minimum clinical exposure, and the experience required of faculty that will be involved. Agreement is sometimes the most challenging issue.
A minimum period, usually two cycles, of training must be completed before accreditation. Subsequently, a professional organization, such as the ABA or the ABP can begin the work of creating an appropriate board certification process. From the beginning of discussions for certification in pediatric anesthesia to the first exam took 13 years. We hope to be able to use our experience with that process to reduce the time slightly, though it would be reasonable to consider a decade a reasonable length of time.
There are still significant questions that must be answered before moving to the development of fellowships. Will this be within anesthesiology, or should we open the field to pediatricians that have an interest? The involvement of multiple specialties could require a separate pathway to assure that every clinician had similar overall training. Should PPM be administrated by the ABA or the ABP? How many clinicians are needed and what should our expectations be for the number of fellows that should be trained per year? Should training in PPM be primarily for the treatment of chronic pain, or should there be elements of acute pain, or palliative care considered?
The answers to these questions are elusive at present, but jointly the AAP and the SPPM, with the support of the leadership of SPA, the American Board of Pediatrics, and the American Board of Anesthesiology are aggressively pursuing the common ground. There is much work to do to assure that Pediatric Pain Medicine continues to grow and thrive. I will have much more to say about this topic and the need for the help of all interested parties in the next few months.