Publications
APS Bulletin • Volume 14, Number 4, 2004
Past Presidents’ Perspectives
John L. Reeves II, PhD ABPP, Department Editor
An Interview with Hubert L. Rosomoff, MD, APS President, 1992-1993
How did you get into the field of pain and who has influenced you the most?
I entered the field of pain in 1953 when I started my residency in neurological surgery at the Neurological Institute at Columbia University in New York. My first assignment was in a cancer hospital where all the patients requesting neurosurgical consultation had pain of one description or another and were candidates for pain-relieving operations. The first operation was a hypophysectomy for pain from breast cancer. Although I was at the beginning of my residency, I had come to the training program with a significant previous experience in neurological surgery from an informal preceptorship, so I was allowed to perform the hypophysectomy, which went without difficulty and with excellent results. This and the other experiences during the rotation that followed came to be the very substance of my future interests. I went on to develop percutaneous cervical cordotomy and, beyond that, the University of Miami Comprehensive Pain and Rehabilitation Center, which was founded under my direction at the same time that John Bonica started his center in Seattle.
Within the field of neurological surgery and neuroscience, the man who influenced me the most was William Sweet, both from the aspect of my early research in hypothermia and then the work with pain. Clearly, John Bonica was also a major influence because of our longstanding relationship with the initiation of the multidisciplinary approach in 1973. We later dedicated the center to John.
Lastly, my career in research was launched and nurtured by Dr. Duncan Holaday, Research Director of Dr. Emanuel Papper’s Department of Anesthesiology at Columbia, to whom I am eternally grateful.
What are you doing now?
I still remain as the Medical Director of the Pain Center, which no longer carries the University of Miami name but has been renamed The Rosomoff Comprehensive Pain and Rehabilitation Center. My wife, Renee Steele Rosomoff, who is well-known to our pain field and who is an international authority in her own right, is our programs director with whom I share this responsibility. We continue to operate the Pain Center, which for the past 20 years has been at a community hospital, South Shore Hospital, in Miami Beach.
What do you think the most significant contribution to the field of pain has been?
I think it is difficult to identify one most significant contribution to the field of pain. There have been so many in the last three decades as to be mind-boggling for this neophytic discipline. Clearly, neuroscience and other basic science areas have made major contributions as well, as is true for the clinical arenas in which we have transitioned from the ablative procedures that we neurosurgeons pioneered to the non-interventional multidisciplinary approach that I think is still the hallmark for pain medicine. It is unfortunate that managed care and reimbursement issues have made pursuing this approach so difficult.
How do you view current U.S. pain research and treatment?
Pain research and treatment in the United States has moved along at a very rapid pace. However, both are still underfunded, as basic pain research has such intense competition from other areas of neuroscience. The move toward the genome approach is very exciting. As for treatment, it is unfortunate that the translation of research from the laboratory has not produced as great an impact for clinicians as one would have hoped. I am certain this day will come, but it has yet to arrive.
In your opinion what is the current state of pain management?
In order to answer this, I need to provide some background. Prior to the early 1970s, pain was a symptom that patients readily perceived, but about which little was known, except for some of the primary neural anatomical pathways. At that time, the major discipline dealing with pain management was neurological surgery, with the use of ablative techniques, of which, most prominent was percutaneous cordotomy. Anesthesiology had a few “gurus” performing nerve blocks, either diagnostic or “permanent” with neurolytic agents. The other recourse was analgesic agents, mostly being prescribed by primary physicians and a few specialists. The largest number of patients being treated had acute pain with chronic pain being underdiagnosed, underestimated, and undertreated. In the 1970s, pain began to be better appreciated and the distinction between acute and chronic was better formulated. The multidisciplinary approach, in both clinics and centers, began to evolve. This concept grew throughout the next two decades, along with basic science insights into mechanisms that, unfortunately, were not translated readily into the clinical arena.
However, pain societies, like the American Pain Society with its regional subdivisions, the American Academy of Pain Medicine, and the International Association for the Study of Pain, formed and became influential. Chronic pain became recognized as a disease, and its treatment was pursued through multidisciplinary enterprise with great sophistication. Pain specialists evolved, accreditation procedures became recognized, and medicine finally became cognizant and sensitive to the need of our patients. Forthcoming was the recognition of the Fifth Vital Sign and Joint Commission on Accreditation of Healthcare Organizations standards for the evaluation and treatment of pain and suffering. Unfortunately, the pendulum began to swing to the right, with the change from underutilization to overutilization of pain technology and the heavy use of narcotics.
Despite these advances, the management of pain has failed to realize the goals set by our discipline and pain remains, in the main, inadequately controlled. Patients have become more disabled, as function has decreased from the overprescription of analgesic agents and pain treatment techniques. Although pain training programs burgeoned, many are inadequate and do not cover the breadth of pain management approaches, particularly as applied to the use of multiple disciplines and team effort. This inadequacy has been complicated by economics, from the aspect of both overutilization and underutilization. Legitimate programs have closed because of their failure to provide outcome data that would substantiate the claims for successful management, resulting in poor reimbursement. Clinical outcome data with long-term follow-up have not been forthcoming, except for a few institutions.
The pain movement has been subverted by specialty ignorance and, cynically, pecuniary concerns. As a result, the faith of the public, the insurers, and the government, which “pay the bills,” has turned negative, and we are to blame for not having done our part to support our claims. Moreover, the abuse of narcotics for recreational use has created a wave of political reaction and potential legislation that will further incapacitate our ability to provide bona fide treatment programs and relief for pain sufferers. There is great concern for the future of our discipline. It will take heroic measures to reverse the current downslide in reimbursement for clinical management. Even though research funding is well ahead of yesteryears, it is still insufficient.
It is time for our societies to take a strong stand against the abuses that have befallen us. It is time to educate, re-create, and police our membership. It is time to return to the multidisciplinary, interdisciplinary approach and to subrogate our individual disciplinary perceptions into a holistic movement that will not only serve us as providers but also, most importantly, the sufferers of pain whose needs continue to go unmet and who sink further into oblivion with costs that are well beyond their means. Adverse socioeconomic environments may continue to evolve, which could doom our efforts to a historical note. Help!
Please direct your comments or suggestions about this article to John L. Reeves, Department Editor, at reeves@ucla.edu.