Publications
APS Bulletin • Volume 17, Number 2, 2007
Training Issues and Advancement
Robert P. Yezierski, PhD, Department Editor
The Next Generation of Pain Scientists: The Need for Integrative and Translational Training in Pain Research
Robert P. Yezierski, PhD, Donna L. Hammond, PhD, and James C. Eisenach, MD
Department editor’s note: This is a new section on education and training in pain research and management. As we near the end of the Decade of Pain, it is time to look to the future and begin designing a strategy to overcome the obstacles that continue to challenge the research and clinical components of our field. With this in mind, it is a pleasure to introduce a new section in the Bulletin that will focus on education and training for the next generation of pain specialists. In the opening article I discuss what I believe are some major challenges facing our field, along with changes necessary to achieve a more effective outcome. I invite APS members to submit articles and commentaries related to this topic. The objectives of this section are two-fold: (a) to examine the pros and cons of existing education and training programs and (b) to begin the process of designing novel training strategies that will lead to continued progress in achieving research and clinical goals of the future.
There is no question that the condition of chronic pain has reached epidemic proportions in our country as well as around the world. Some of the more alarming statistics about the epidemiology of chronic pain were recently reviewed in the Bulletin by our past president Dennis Turk (Winter, 2006). Briefly, it is estimated that in the United States there are more than 60 million pain patients costing over $150 billion annually (numbers that have been on the rise for the past 20 years). With the U.S. population approaching 300 million and the number of people over the age of 65 estimated to be 70 million by the year 2030, it is inevitable that the number of people affected by chronic pain will continue to challenge every aspect of an already overburdened healthcare system. The fact that we have fallen short of meeting the needs of present-day pain patients is by itself disappointing. The fact that we face an even greater challenge in the future should provide impetus to develop new strategies to attract, educate, and guarantee that pain specialists of the future are equipped to meet the challenges of tomorrow.
To be clear, these challenges are not about research productivity, curriculums for pain education, or the development of new technology or animal models. On the contrary, this is about making sure we have a welltrained workforce of pain researchers and pain clinicians that continues to pursue and implement new strategies of effective pain management. If we consider that the number of board-certified pain specialists is less than 5% of the total physician population, combined with the fact that there are relatively few positions supported by federally funded training programs, we are virtually assured a future with inadequate clinical care and an equally inadequate research community for one of the most significant healthcare problems in our society. To effectively meet the future needs and challenges associated with the staggering epidemiological and economic trends surrounding the condition of pain, now is the time to look at how we plan to recruit and train the next generation of pain specialists.
Current Challenges and Future Needs
There is a growing recognition in the pain community that the future of pain research is in jeopardy largely because the pipeline of new trainees is not as plentiful as it was 10 years ago. Where will the next generation of pain scientists come from and how prepared will they be to ensure progress into the next decade?
Without question, the obstacles facing individuals contemplating careers in academic and clinical research are having a serious impact on the production of newly trained pain specialists. These include (a) diminishing ability of clinical departments to support research from patient-care revenues, (b) declining resources from funding agencies, (c) perceived advantages of industrial careers, (d) perceived disadvantages of clinical research applications in peer review, (e) overly burdensome regulatory requirements, (f) inadequate infrastructure in academic institutions for translational and clinical research, and (g) the lure of financial rewards in full-time clinical practice (Dickler et al., 2006).
To ensure continued progress in the advancement of research and pain management we need to recognize that the next chapter in knowledge about the pain system and future insights into the development of novel interventions resides solely in the minds of today’s students, those in medical, graduate, pharmacy, dental, and nursing schools, as well as postdoctoral and physician fellows. To guarantee the continued production of well-trained pain specialists it will be necessary to clearly define the goals and objectives of training programs that will produce the next generation of experts in pain research and pain management. Training programs in the next decade need to be prepared to teach the vision of the future and not dwell on past traditions.
A New Training Strategy: Partnerships Between Basic and Clinical Scientists
Many reports have documented the continuing crisis in clinical research, with fewer physician scientists and clinical investigators pursuing or maintaining research careers. Today’s physician is described as being forced to choose between research and practicing medicine. The unfortunate reality, however, is that to accomplish the NIH Roadmap objective of developing translational research initiatives it is important to strengthen the interface between practicing physicians and basic or applied scientists. We don’t need physicians to abandon their clinical responsibilities; instead we need to encourage them to develop interactive relationships with members of the research community. Researchers, on the other hand, must be trained to recognize the benefit of incorporating clinical expertise into their research strategies. There is little doubt that the research community would benefit significantly from clinicians providing relevant input to the design of preclinical research (Hansson, 2003).
Unfortunately, there are significant pressures that hinder the training of clinician-scientists. For clinical groups, including those in academic institutions, reimbursement for clinical services is decreasing and leading to pressures to further increase “clinical productivity” to maintain income. This can lead to a retreat from the strong history of collaboration between basic scientists and clinical care physicians. Frequently this is driven by “democratic” decisions within clinical departments that cannot afford to subsidize such efforts. In these circumstances clinician investigators are either not given a choice or are asked to reduce their salary, sometimes drastically, if they want to continue the pursuit of research.
For basic scientists, particularly junior faculty, these are extremely challenging times. The NIH funding situation has led to a common loss of funding during the competing renewal process, with few applications being funded on the first attempt and up to 2 years being needed to competitively renew a funded effort. This disrupts productivity because the researcher is spending time writing grants and generating preliminary data rather than focusing on research per se. Within the discipline of anesthesiology, the number of academic departments with active research programs has shrunk to less than half what it was 10 years ago, and may well shrink further to a dozen or so programs at large research universities with a strong endowment base. The clinical arena is polarizing into separate camps—clinical training and clinical training plus research—and the future of translational research may need to focus on a very small number of institutions.
Preparing for the Future: Addressing the Challenges of a Complex Problem
Recognizing the necessity for change and the need to develop innovative strategies of training will be an essential component of preparing for the future. Meanwhile, how do we deal with the challenges that exist?
Evaluating statistics and economic reports provides a compelling argument that a change is needed. Realizing the shortage of significant advances in new strategies of pain management provides additional support for stepping back and critically evaluating the changes necessary for achieving a more productive outcome.
There is no question that our basic knowledge and understanding of pain mechanisms is beyond what we imagined 20 years ago, but unfortunately there remains a disconnect between research productivity and bedside application. This simple fact underscores the need to develop a new approach to training pain specialists of the future, including those responsible for pain management and those who will pioneer the discovery of novel therapeutic strategies. To accomplish this goal it will be essential to recruit experts in nontraditional pain disciplines such as endocrinology, immunology, molecular and cellular biology, genetics, psychology, and anthropology.
No longer can we rely solely on traditional disciplines of anatomy, physiology, and pharmacology. Because pain impinges on nearly every clinical discipline, we should aggressively recruit participation and support the development of working relationships between basic researchers and clinicians throughout the medical community. It is important that we appreciate the fact that the complex nature of chronic pain eliminates the possibility of reducing it to manageable components that can be individually targeted by pharmacological, psychological, or physical interventions (Loeser & Melzack, 1999).
The American Pain Society and its parent organization, the International Association for the Study of Pain, need to take the lead by continuing to promote training opportunities for young scientists. The future of these organizations is in the hands of young investigators and therefore innovative sessions at meetings designed to help prepare future leaders should be a top priority. One example of how training can extend beyond local training programs is the “translational forum” where senior clinical and basic scientists meet with young investigators to discuss important questions and “hot topics” related to future challenges and potential solutions in the field of pain. Cooperative exchange programs between academic and industrial research institutions is another way to enhance the training experience for future pain specialists. Bringing industry into the loop is challenging, but clearly advantageous considering that industry is a major shareholder in the future of pain management.
Another strategy is to develop integrative and translational training programs in pain research. Such programs fall in line with the NIH Roadmap, which states “the scale and complexity of today’s biomedical research problems increasingly demands that scientists move beyond the confines of their own discipline and explore new organizational models for team science.” This vision suggests that interdisciplinary training will be the most effective mechanism for providing future pain scientists with the tools to establish innovative collaborative research programs to provide clinically relevant advances for the next generation of pain patients.
Interdisciplinary programs translate into improved training by providing trainees access to faculty with whom they would not otherwise interact. This greatly increases the breadth of experiences, depth of conceptual models, and the opportunity to explore research strategies outside the traditional silo of pain research. For these interdisciplinary training programs to be successful there needs to be a collective commitment from academic, industrial, and federal institutions.
Innovative Solutions for the Future
Following completion of the first 2 years of medical school, there are limited opportunities to participate in research—nor is there necessarily a strong need or motivation to do so. The aim of these years is to perfect skills and gain competence in clinical care. Often research opportunities presented by basic scientists to clinicians address the investigator’s interests in mechanisms. While certainly valid, investigations of mechanisms do not often have immediate application. Yet for physicians “application,” such as the ability to deliver better pain relief more often, more reliably, and in a more informed manner, is of preeminent interest. As we seek to increase the number of physicians conducting pain research, it may be time for basic scientists to reassess or rephrase questions they propose to physicians. Greater interest and participation in research by physicians may follow when the outcome of investigations and the research hypotheses have a direct application to or will immediately advance clinical care. Without critical input from the clinical arena there is also the possibility that what is learned in preclinical studies may have little relevance to the human condition.
Participants in traditional training programs rarely receive exposure to the challenges of clinical and basic research; most clinical training programs include little formal training in research techniques. Similarly, basic scientists are rarely exposed to the daily challenges facing clinicians or the logistical challenges of implementing clinical research.
The formula for achieving progress in the development of novel therapeutic interventions requires that basic and clinical scientists work collaboratively in relationships based on mutual understanding established during the early years of professional development. Participants in pain research training programs of the future need “side-by-side” training experiences to gain an appreciation for the value of developing partnerships between clinical and basic science research programs. Creating an interface between science and medicine will produce clinician-scientists as well as a new breed of scientist-clinicians. This latter category will include basic scientists who obtain knowledge in a clinical discipline, one that will have a far greater appreciation for the clinical characteristics of different pain conditions. If translation is to be the benchmark of the future, we need to recruit the pieces of the equation that will serve as the interface between the bench and the patient.
Barriers between the laboratory and clinic need to be eliminated and replaced with a more fluid and cooperative working relationship. There should also be a realization that the strategy or method of pain research needs to change and that no longer can individuals survive within a silo of special interest when the reality is that we live in a world of complex clinical conditions that require interdisciplinary research strategies.
Essential Components for Future Training Programs
Recognizing that pain is a complex condition requiring an understanding of multiple biological systems as well as social and psychological components, we need to develop a training model that will adequately provide the next generation of pain specialists with tools to ensure the best possible chance of success. The training environment should include experienced clinical/applied and basic science faculty along with an institutional commitment for research and training. One way to accomplish these goals is to create virtual centers that combine experience, resources, and expertise from different clinical and research segments of a university community. In this scenario it would be possible to create seamless programs where trainees are free to circulate among different disciplines. Creating exchange programs between academic institutions, where expertise and research methods from different programs are shared, is another way of exposing trainees to diverse research strategies.
Components of Training Programs in Pain ResearchInterdisciplinary training platform Required research rotations for clinical specialists and required clinical rotations for research specialists Integration of research and clinical curriculums Side-by-side training experiences for clinical and research trainees Virtual training programs including exchange opportunities between academic and industrial institutions Infrastructure and commitment to translational research |
Finally, there is a need to take advantage of Internet resources in pain education. Basic science trainees should be encouraged to explore Web sites related to clinical pain to gain an appreciation for the challenges of the chronic pain patient. This kind of exposure will instill an appreciation for the necessity of translational research and developing relationships between the clinical and research communities. The above examples are but a few innovations that need to be considered in the design of a future model of pain training programs.
“State-of-the-art” today is far different from what it was 20 years ago, but unfortunately some segments of pain research have not changed significantly during this period. Fortunately what has changed is the “state-of-the-field.” This is due largely to the entry of investigators from new disciplines and the development of interdisciplinary strategies that have improved understanding of the biology of pain mechanisms along with the psychosocial aspects of pain. Just as our understanding of the pain experience has revealed more complexities, we need to appreciate that the system we use to train our students needs to be more diversified to address these complexities. “State-of-the-art” is a dynamic condition requiring creativity and flexibility. Some have said that pain science is “less modern” than other fields and uses “old fashioned” models and, because of this, we are basically plodding along with the hope of finding a central or peripheral target that will change the gold standard that we have relied on for more than 2,000 years (Thomas Bartfai, Keystone Symposium, 2006). If the system is holding us back or not allowing creativity, there needs to be a collective effort to change the system. If the goal is to merely understand pain, we have developed a system that has far exceeded our expectations. But if the goal is to impact pain treatment, we need a better model. A first step in developing a new model is to examine the present system of how we train those who will be the pioneers of tomorrow. Cross-fertilization has been an essential ingredient in the enormous progress in contemporary science, including the field of pain. To encourage new pathways of discovery, we need to appreciate that future progress will likely require an understanding of the pain system at the molecular, cellular, and systems level. Not to be ignored is the importance of making clinical specialists a critical component of the research environment. The new organizational model of pain research must have a strong clinical and research foundation, an appreciation for translational goals, and an emphasis on team science that will require contributions from multiple research and clinical disciplines to ensure continued progress and more beneficial outcomes.
Meeting Future Needs
To meet future needs in the field of pain it will be important to emphasize: (a) multidisciplinary and interdisciplinary research strategies, (b) translation of findings to the human condition, (c) interfacing bench and bedside specialists, (d) creation of a translational and clinical research infrastructure, and (e) development of partnerships and research teams involving academics and industry.
Training programs of the future will need to emphasize different objectives to advance our understanding and, most importantly, to encourage the application of research findings to improve the human condition. To accomplish this we need to be creative and examine the potential benefits of establishing exchange programs between academic institutions as well as academics and industry, commit to innovative funding for novel educational and training programs, and utilize professional associations and societies to promote extensions of the training experience. Although the contemporary view of translational research is from “bench-to-bedside,” another view is that translational pain research should be considered a two-way approach, one being from “bedside-to-bench” and the other from “bench-to-bedside” (Mao, 2002). This underscores not only the importance of designing meaningful clinical studies, but also of translating clinical pain to testable laboratory models.
Because of the incredible progress that has been made in understanding the biology of pain, the challenges that face the next generation of pain specialists are vastly different from those of 20 years ago. If we are to effectively prepare our successors to meet these challenges we need an integrative and translational model of training that will provide the skills and conceptual commitment to a new era of pain research. Although we are unlikely to see the benefits of this model for many years, we can’t wait to begin the change. In the resounding words of former APS President Turk in his final presidential message in the Bulletin—“the future is now” (Winter, 2006).
References
Dickler, H. B., Korn, D., & Gabbe, S. G. (2006). Promoting translational and clinical science: the critical role of medical schools and teaching hospitals. PLOS Medicine, 3, 1–4.
Loeser, J. D., & Melzack, R. (1999). Pain: An Overview. Lancet, 353, 1607–1609.
Mao, J. (2002). Translational pain research: bridging the gap between basic and clinical research. Pain, 97, 183–187.
Turk, D. C. (2006). Pain Hurts—Individuals, Significant Others, and Society! APS Bulletin, 16, 3, 5.
Robert P. Yezierski, PhD, is director of the Comprehensive Center for Pain Research, Professor of Orthodontics, Neuroscience and Anesthesiology, University of Florida, Gainsville, FL.
Contributors:
Robert P. Yezierski, PhD, Comprehensive Center for Pain Research, University of Florida, Gainesville, FL; Donna L. Hammond, PhD, Department of Anesthesia, University of Iowa, Iowa City, IA; James C. Eisenach, MD, Department
of Anesthesiology, Wake Forest University, Winston Salem, NC.