Editor’s note: The third North American Pain School (NAPS) took place June 24-28, 2018, in Montebello, Quebec, Canada. An educational initiative of the International Association for the Study of Pain (IASP) and Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), and presented by the Quebec Pain Research Network (QPRN), NAPS brings together leading experts in pain research and management to provide 30 trainees with scientific education, professional development, and networking experiences. This year’s theme was “To Boldly Go…: The Future of Pain Treatment.” Six of the trainees were also selected to serve as PRF-NAPS Correspondents, who provided firsthand reporting from the event, including interviews with NAPS’ six visiting faculty members and summaries of scientific sessions, along with coverage on social media. This is the fifth installment of interviews from the Correspondents, whose work is featured on PRF and RELIEF, PRF’s companion site for the public. (See previous interviews with Ian Gilron here, Allan Basbaum here, Stefan Friedrichsdorf here, Michael Salter here, and Irene Tracey here.)
Judy Watt-Watson, RN, MSc, PhD, is a professor emeritus at the University of Toronto (U of T) Lawrence S. Bloomberg Faculty of Nursing; a senior fellow at U of T’s Massey College; and a scientific associate at Sinai Health System, Toronto, Canada. At U of T Nursing, Watt-Watson was the inaugural executive director of the Centre for Professional Development (formerly named the Centre for Advanced Studies in Professional Practice). She was the inaugural chair of the U of T Centre for the Study of Pain’s Interfaculty Pain Curriculum, which involves seven health-science faculties. She is also a former president of the Canadian Pain Society and a member of the executive committee of the U of T Centre for the Study of Pain. She was a member of the Education Initiatives Working Group of the International Association for the Study of Pain, as well as chair of its subgroup on interprofessional pain education. She is currently on the 2018 IASP Global Year for Excellence in Pain Education task force.
Watt-Watson’s research has focused on establishing pain prevalence and related risk factors, particularly for cardiac surgical patients, and pain education interventions involving health professionals and patients. She sat down with PRF-NAPS Correspondent Katelynn Boerner, PhD, a postdoctoral fellow at BC Children's Hospital, University of British Columbia, Vancouver, Canada, to discuss pain education, the leadership positions she has held, and much more. Below is an edited transcript of their conversation.
How did you get your start in pain research and education?
I worked as a nurse in a variety of settings. I remember caring for a patient with gastric cancer when I was a student; she was dying and her pain was excruciating. I asked for pain medication, and was told we could not give it to her because it had not been exactly four hours since her last dose. Health professionals were caring for the patient and her treatment needs to a point, but they were not addressing the pain. I also worked for a couple of years at the Smyth Pain Clinic at Toronto General Hospital. People gave up work and drove in with their families from all over Ontario for help with their chronic pain. Some of them had some good pain strategies, but they needed more help. Also, when I taught students clinically, I could see when they were knowledgeable and really listened to the person with pain, and that this response was effective. That really got me into the area.
It was during my doctorate that I started to look at pain with surgical cardiac patients. Several clinicians told me that it would be a waste of time because these patients did not have much pain and it would pass. I knew that, clinically, this was not true, and felt I had to document what was happening. At that time, there was minimal research about pain after major surgery, and my data showed that a significant percentage of patients had postoperative pain that interfered with everyday activities and recovery.
From there, I talked with Dr. Manon Choinière, a psychologist from Montreal, and we decided we needed to step back and look at prevalence and risk factors across the transition from acute to persistent pain problems. We followed 1,200 people in four cardiac centers and found that at two years post-surgery, about 10 percent of people continued to have pain related to surgery, and for 5 percent it interfered with everyday activities. A key predictor was inadequate pain management and interference with function in the first week after surgery—we can do something to manage that better. The other risk predictor was preadmission anxiety, which should be addressed during pre-surgery education for patients. The education they receive before surgery tends to be about the operation itself, but patients also need to know, How do I communicate pain and what happens when I go home?
In addition to your clinical work and research, you have held leadership positions with pain education groups at U of T and IASP, and as president of the Canadian Pain Society. What did you learn from those roles?
I believe that in your professional and interprofessional relationships, it is important to respect the other person and other groups, and to listen. I learned a lot from working with interprofessional curriculum development teams, both in Toronto and with the IASP Working Group. I always thought clinicians used the same language, but found we needed time to listen to each other and ask for clarification: “But isn’t that what I said?” And we found that we are not as similar in language as we sometimes think.
I was fortunate to be elected to the board of directors of the Canadian Pain Society and to also serve as president. They are a terrific group and very keen to advance pain education and pain research, including both basic and clinical science. When I first started in research, I didn’t have any nursing colleagues in Canada except for Dr. Mary Ellen Jeans at McGill. I very much appreciated the support of my American colleagues. But now, of course, I have so many outstanding colleagues in Canada, including in the pediatric pain community, which is amazing. I feel very lucky in Toronto to be connected with these groups; they are phenomenal.
The interprofessional piece is also important for your pain education work.
It is. If we can’t understand each other’s contribution, how are we ever going to move forward? Pain is too complex for one discipline or one profession. This generation of students is incredible in that they are confident and educated, and it’s critical that they are clear about their roles and that they understand the roles of others.
The old way was to have a nurse go into a medical classroom and, in an hour, tell the students about their roles. What we do in the pain curriculum at the University of Toronto is a mandatory 20 hours, where 50 percent of that is spent in small, interprofessional groups working on patient cases. It’s about the patient’s priorities and how, together, we work with them on a plan. To me, that’s the only way for change; we have to work together. We each bring some commonalities, but we also bring different strengths—and we need it all.
It sounds like bringing people together around a common goal is what fosters teamwork.
It’s the patient that should be the focus. We should not be fighting over who’s going to do what—nobody owns the patient. I have wonderful colleagues in medicine and other disciplines, including basic science, and we contribute together. Yes, they’re looking at a cell, but it’s a person’s cell.
How does pain education fit in with the theme of NAPS this year, which is “To Boldly Go…: The Future of Pain Treatment”?
Young investigators need education about the pain culture and the need to educate others about the importance of their work. Unless everybody knows what the issues are—the gaps in pain care, research, and education—then we don’t have enough data to make a case for pain treatment. Institutions need data, including cost-benefit, to support more pain research, pain fellowships, and/or great access to pain care. We need to use data from a variety of sources to make the case, no matter what type of pain research we are doing.
I am glad that NAPS included two patients in the curriculum this year, because education has to involve the patient experience, and the only way we’re going to know that is to ask, listen to, and hear them.
Patient engagement is gaining a lot of traction in the research world. How can the patient experience inform our work?
The person with pain needs to be a part of the whole process. It’s not tokenism because patients have valuable knowledge: They know what will work in terms of recruitment, what types of assessment measures are relevant, and they can help to interpret findings. Research needs to be relevant—connected with the actual patient—or it will end up sitting on a shelf. The problem sometimes with just having one patient representative is that the pain experience may vary from person to person. With representatives from advocacy groups speaking on behalf of a group of patients, you get a broader sense of what the reality is, more so than by including just one individual.
Including the patient perspective can also influence methodology. Randomized controlled trials have strict criteria for who gets included and how the trials are run, and this may not reflect what happens in the real world clinically. There is a movement towards comparative clinical trials (versus placebo-controlled trials), and rigorous qualitative methodologies, as well as the use of videography and patient narratives. I always had open-ended questions in my research, which helped to explain my quantitative data.
Patients are also part of the public. Members of the public are the taxpayers, and they also probably know somebody with pain, and so they’re interested in hearing the latest research. It’s about stretching the target audience; I’m trying to help people understand that education of all your stakeholders is critical. It’s not just the patient and family—you also have to educate the government to get funding, and you have to educate the hospitals and the universities to get the needed accreditation and regulation. Otherwise, things are never going to change.
What’s the best way to advocate for pain research?
You need to have the data about the gaps, because pain is the most common reason that people go to the emergency department or a clinic. It is very costly to society through healthcare costs and lost productivity—more costly than the five most common chronic diseases combined. With governments and hospitals, you have to talk about money as well as prevalence.
There’s another issue: Pain is considered normal. There’s an old culture of expecting people to put up with it and to think that it’s not a serious problem. But we know that persistent pain can change the nervous system, and we have to educate people about that, and about how costly pain is both socially and economically. We need research to find alternative, better ways to treat pain, particularly in light of the misuse of opioids.
What you’re highlighting is that data goes beyond what is collected in the research lab—that it can include administrative information from the hospital and economic data.
We use whatever we can, depending on who your target is. If it’s the government, there are lots of good economic data. If it’s the hospitals, then you can collect data on emergency department visits and the number of people being readmitted. It can be something as simple as doing chart reviews. I always recommend that clinicians document what’s happening in their context, and that’s where I started—I had to prove that some cardiac patients did have significant pain in the first week that kept them from deep breathing and coughing, which would lead to pneumonia.
We also had to do that to advocate for pain content in the health professional training curriculum at the U of T. We did a survey of all the faculties, and the word “pain” came up tens of thousands of times in their curricula, but it came up in the old traditional model where pain is considered a diagnostic indicator of diseases and not as an entity on its own. We also surveyed health science faculties across Canada and were shocked that veterinary colleges taught, overall, three times more pain content than we did—and five times more than medicine.
It requires a culture shift to view pain in this new way, as an entity on its own. To me, education is the way to do it, and the challenge is trying to figure out how to "sell it." You need to use all the data you can and make a case for what is relevant for your target group. Fortunately, now we have some good patient advocacy groups in Canada who can help, such as Pain BC.
There has been a lot of discussion recently, including here at NAPS, about gender equality and representation of women in science. Have you seen a shift in thinking over the course of your career?
I’m a nurse and I’m female, and historically nurses were not thought to be equally educated, nor was nursing respected. Generally nurses are well educated and a lot more respected today; they are active on committees and as leaders of pain societies. However, there are some colleagues internationally who have been surprised, for example, to learn that I was chair of the IASP subgroup developing the interprofessional pain curriculum because I’m “only a nurse.” I do occasionally run into that, but not that much anymore. I see the growth in my female students—they are very diplomatic but they’re negotiating for the patients, they are smart and confident, and they are going to be the leaders.
