Publications
APS Bulletin • Volume 16, Number 1, Winter 2006
Past Presidents’ Perspectives
John L. Reeves II, PhD ABPP, Department Editor
An Interview with Russell K. Portenoy, MD, APS President, 1998–1999
How did you get into the field of pain, and who or what has influenced you the most?
In school I was interested in psychiatry and neurology. As I learned more about these fields, I thought that I probably would specialize in behavioral neurology. I began my neurology residency at the Albert Einstein College of Medicine and was fortunate to meet Ronald Kanner, MD, who had recently completed his fellowship with Kathleen Foley, MD. When Dr. Kanner told me that he specialized in pain, I initially thought that he was joking. I let him know that he couldn’t specialize in pain because everyone knew that it was a symptom and neither an organ system nor a disease. He challenged me to do some reading and observe in his clinic. Within months I decided to pursue a career in pain management. After my residency, I completed a fellowship with Dr. Foley at Memorial Sloan-Kettering Cancer Center and then returned to become Dr. Kanner’s associate. In 1987, I was invited back to Memorial Sloan-Kettering Cancer Center and spent the next decade there, first as director of analgesic studies and then as co-chief of the pain and palliative-care service. The strongest influences on me were the wonderful people who taught me clinical pain management and pain research during my residency and fellowship and the early years afterward, including Drs. Kanner and Foley, Drs. Raymond Houde and Charles Inturissi, and Stan Wallenstein and Ada Rogers.
What are you doing now?
In 1997, I was recruited by Beth Israel Medical Center in New York City to develop and chair the country’s first department of pain medicine and palliative care in an academic institution. I remain there today. The department now has an interdisciplinary full-time faculty of 13 physicians (eight pain physicians—two neurologists, three physiatrists, and three anesthesiologists—and five palliative care physicians, four of whom are hospice medical directors). Other members of our treatment teams include advanced practice nurses, a psychologist, a social worker, and a chaplain. The clinical programs are organized through a pain and palliative care division, and our academic programs are managed through a research division and our institute for education and research in pain and palliative care. We have a strong clinical research group and vibrant programs in professional and public education (see www.StopPain.org). Among other activities, we have two physician fellowship programs (one in pain management and one in palliative medicine), a nurse fellowship, and a social worker fellowship. The department of pain medicine and palliative care is closely aligned to Continuum Hospice Care, the largest hospice in New York City. More than a year ago, I also assumed the responsibilities of chief medical officer of the hospice and have enjoyed a new challenge in implementing a cutting-edge approach to hospice known as Open Access. In short, my time is taken in administrative responsibilities to the department and hospice, research, and a small clinical practice.
What do you think the most significant contribution to the field of pain has been?
There have been an extraordinary number of individual contributions, and I could not begin to identify the most significant. From the broadest perspective, perhaps the most important paradigmatic contribution does not actually belong to any one individual. This is the understanding of chronic pain as an illness in its own right. So many of the major advances in basic science and clinical research, and in the day-to-day practice of pain medicine, have been given a more profound and larger meaning because the field as a whole has come to realize that chronic pain in all its forms is best understood as complex illness, in which persistent changes in the nervous system interact dynamically with psychological and sociocultural factors.
How do you view current U.S. pain research and treatment?
Extraordinary advances in both pain research and therapy seem to accelerate every year, and it is a never-ending thrill to see them unfold. Yet, it also is a time of concern. The U.S. healthcare system is in a period of confusion and struggle, and problems of quality, equity, and cost vie for attention and creative solutions. Pain research and management cannot escape this context. Can some of the concerns be described without negating all the good that is happening?
In the clinical world distortions in healthcare financing are creating a very worrisome set of outcomes. Although primary care providers increasingly recognize the need to address chronic pain, the system provides too little support for the professional time required to manage complex, chronically ill patients. In a brief office visit, the primary care provider cannot organize and triage care, counsel the patient, support the family, and adjust analgesic therapies. Only 5% of those with significant chronic pain ever see a pain specialist, and those who do now encounter a discipline in which the financial realities have led clinicians to de-emphasize interdisciplinary conservative care in lieu of intervention-based pain medicine. Whether in primary care or specialist care, the system has disparities in access based on insurance coverage, socioeconomic status, race and ethnicity, and other factors. Change is needed through enlightened healthcare policy, but progress seems very slow. The development of leadership within our own field may be compromised by the economic struggles of academic medical centers, where future educators, researchers, and policymakers may find their paths stymied by financial realities that limit pursuit of academic involvement.
Progress depends in part on the science, and it is a continuing concern that government support for pain research is so meager. Industry research is robust, but the legitimate need for return on investment may skew the direction of this work. Large randomized controlled trials, the major source of the evidence that defines clinical practice, are mainly funded by industry and may be subject to criticism on this basis.
These problems should not be minimized. There are clearly daunting challenges ahead, mastery of which will be determined by many factors outside of the control of our discipline. Nonetheless, there is certainly reassuring news in the science, which will inevitably drive advances, and a growing acceptance of pain as illness. As long as there are researchers fascinated by pain and clinicians who seek the best for their patients, there will be progress.
Russell K. Portenoy, MD, is with the Beth Israel Medical Center Department of Pain Medicine and Palliative Care in New York.
Please direct your comments or suggestions about this article or department to John L. Reeves II, Department Editor, at reeves@ucla.edu.