This is the eleventh in a series of Forum interviews with PRF science advisors.
Joseph Martin, MD, PhD, is a neurologist and former dean at two medical schools. Currently the Edward R. and Anne G. Lefler Professor of Neurobiology at Harvard Medical School, Boston, US, Martin is known for establishing programs and strategies that cultivate collaboration among basic scientists and clinicians. At the University of California, San Francisco, US, where Martin served as Dean of the School of Medicine (1989-1993) and then Chancellor (1993-1997), he established the W. M. Keck Foundation Center for Integrative Neurosciences. From 1997 to 2007, he was Dean of the Faculty of Medicine at Harvard, where he co-founded the Harvard NeuroDiscovery Center. Martin remains involved in the governance of the Center, where he had an early hand in creating the Pain Research Forum. Martin met with Megan Talkington and discussed his view of pain education, and how to encourage collaborative patient care and research. The following is an edited transcript of their conversation.
An often-cited study (Watt-Watson et al., 2009) showed that in Canada, veterinarians in training receive more instruction about pain and its management than do medical students. What is the state of pain education in your experience?
I think we really undereducate medical students about pain. Here at Harvard, where we have a case-based educational format, the students have one pain case in the second year during the brain course. Then, when we get to the clinics in the third or fourth year, pain education is hit or miss. If students are educated about pain during the explorations they take in the clinical years, it’s accidental, not planned. I think that’s a very important point—that students do not gain continuing education about pain.
I tutor students in the brain course, and when I think about how much they have to learn about pain in a week—to analyze the system anatomically, physiologically, and so on—I think they do reasonably well. But it’s then bundled into the rest of what they learn about the brain in a seven-week course, and by the time they are a month past it all, I think they remember very little, and currently there is no way to supplement that in a systematic way. If you take into account that 40 percent of patients have pain, then we don’t do a very good job educating students about pain.
Why is exposure to pain education in the clinical years so arbitrary?
Pain occurs across fields, and as a result, it doesn’t receive particular emphasis. Students go through three months of medicine on the wards and see patients with pain all the time, but in most of those rotations, there isn’t a longitudinal discussion about how a new case of pain that you might see is different from the last one.
The anesthesiologists, of course, do a lot of the procedures to relieve pain, which often are the mainstay of pain treatment—that’s part of the problem, because unlike the internists or the neurologists, the anesthesiologists work in their clinics in isolation. Anesthesiologists do pain management, they inject, they do epidural blocks, they do peripheral nerve blocks—and there are never any students in that setting that I’ve ever seen.
Is this fragmented nature of patient care specific to the pain field?
Something similar has happened in the cardiovascular disease area, where efforts to bring medicine and surgery together have been largely unsuccessful as well. If you look at traditional academic medicine, the cardiologists see the patients and do the diagnostic procedures, and then they call in the cardiovascular surgeons, who do the surgical procedures. On the other hand, a few places really have followed what they call service lines of care: A patient comes in with a heart problem and on a single day is seen by a cardiologist, a surgeon, an electrophysiology expert, etc. The Cleveland Clinic has established an excellent model. In cancer, the MD Anderson Cancer Center follows a similar service line of care approach. More institutions are using these models to provide more efficient patient care. But in general, healthcare in the US remains very fragmented, and patients with complex complaints like chronic pain suffer from those inefficiencies.
It would be interesting to assess service-oriented approaches in a number of institutions—how do they deal with pain? And are there connections being made between those service-line models and student learning?
I’ve heard neurologists say that not enough in their specialty are interested in taking on patients with chronic pain. As a neurologist yourself, what do you think about that?
It’s not a lot of fun taking care of patients with pain, since our treatments are so inadequate—often because we know very little about pain pathophysiology. For instance, among patients who come in with painful small fiber peripheral neuropathy that starts in the feet and spreads to the hands, diabetes is the most common cause, but half of cases have no known cause. The patients come in with the symptoms and the signs, but no clear underlying disease, so the treatment of those conditions remains very unsatisfactory.
I think neurologists are more likely to be interested in multiple sclerosis, stroke, or epilepsy—or even migraine headaches, where we understand enough of the pathophysiology such that there are now treatments that really make a difference. Chronic pain is just not managed; there is no good treatment for it. And that’s a research question, not a clinical question.
You have cared for patients with chronic pain. What is it like to realize that you can’t do very much to help a patient, and what do you do then?
It’s very discouraging for both the physician and the patient. You go for a long time just adjusting medications, and trying things that have modest effects, like tricyclic antidepressants that are used for chronic peripheral neuropathy pain in diabetes. But if you talk to patients with diabetic neuropathy and ask them whether their doctor has been able to help them, most of them will say no, not much.
But it is always true that how patients fare is directly proportional to the relationship between the doctor and the patient. Getting support from physicians is very helpful to patients—knowing that if something comes up, we’ll look into it. I think that patients really depend on that, even though the drugs we have don’t do a lot.
Again, that speaks to having the patience to see patients with chronic pain, in a way that gives that sort of support.
What can be done to encourage neurologists to become more involved in the care of patients with chronic pain?
It’s complicated. The payment structure is part of the problem. Seeing patients for pain, spending time with them in the way a good clinician needs to do, doesn’t provide a lot of reimbursement. It is the procedures that pay well. So the people who get paid are often not the doctors who are following the patient. We need a mechanism to allow that kind of care to accompany the procedures, which currently have a value. This is not something you can fix easily.
Traditionally, neurologists are very good at following patients and caring for them over the long term in the case of chronic conditions such as Parkinson’s disease or Alzheimer’s disease. But pain management has always been a difficult journey. The situation is improving at pain centers where pain is treated by collaboration among physicians, and where reimbursement is shared within the group.
You have a lot of experience in setting up structures to catalyze biomedical research. What do you think is the key ingredient for making real advances?
Collaboration. It’s getting people who think outside the box and bring new ideas to an area that they haven’t necessarily thought about before. When we did the Huntington’s work [discovering the location of the gene that causes Huntington’s disease (Gusella et al., 1983)], it was having geneticists hunker down and find a way to use genetic methods to match up with the pathology and the clinical findings that we had.
What is essential to foster collaboration?
Proximity. You have to be down the hall from each other. But starting collaborations is very hard, and you need to have a good idea. Students and postdocs are the best collaborators because they seek out the people they think might help them with their projects.
It seems like opening lines of communication between basic researchers and clinicians is an issue. How do you encourage that?
I think the translation of basic information into clinical significance has improved a lot in the last decade.
Why do you think that is?
MD/PhD training has helped. Again, I think students have been a driving force. Here at Harvard, I have taught in the Neurobiology of Disease course. The students who take it are mostly PhD students in neuroscience, but they are interested in seeing patients, hearing about disease, and in the clinical relevance of their work.
We also have another program here that is run by Connie Cepko, who is a PhD and a professor in the Department of Genetics. The program is named for the first chair of the Harvard Medical School Department of Genetics, Phil Leder. The program takes students and postdocs and gives them clinical exposure. I think those kinds of experiences that allow students to actually think about and see patients are really great, and there is a lot of that happening.
Thank you so much for sharing your perspective.
PRF Related Content:
Forum Discussion: Pain In Parkinson's Disease: Is Neurodegeneration in Peripheral Nerves to Blame? (6 Apr 2011)
View Joseph Martin’s profile on Pain Research Forum (requires member log in)
Martin JB. Alfalfa to Ivy: Memoir of a Harvard Medical School Dean. Edmonton, Alberta: University of Alberta Press; 2011.
Martin JB. Strive for authenticity, in work and in life. An interview with Joseph B. Martin, M.D., Ph.D. Ann Neurol. 2011 Oct;70(4):A10-2.
Moses H 3rd, Martin JB. Biomedical research and health advances. N Engl J Med. 2011 Feb 10;364(6):567-71.
Moses H 3rd, Martin JB. Moses H 3rd, Martin JB. What should be done to improve the productivity of neurological research? Ann Neurol. 2006 Dec;60(6):647-51.
Other Forum Interviews:
Pain and Its Control: A Conversation with Allan Basbaum (6 June 2012)