Friday, January 28, 2011

The Impossibility of Being a Pain-Care Expert

Pain-PourriIn 1970, when Alvin Toffler popularized the phrase “information overload” in his book Future Shock, he was portending an explosion of medical and scientific information that lie ahead — and this was before the Internet. Indeed, the pain management field today is overwhelmed with information, as well as education, research, and news coming from many directions — making it virtually impossible to keep current, let alone become expert in the field. This may explain, at least in part, why millions of people are still being undertreated or mistreated for their pain conditions.

Writing in the December 2010 edition of the British Medical Journal, researchers from the UK note that there are now more than 25,000 journals in science, medicine, and technology, and their number is increasing each year by 3.5% [Fraser and Dunstan 2010]. Specifically in the pain-care field, the number of journals publishing some pain-related articles increased nearly 250% from 1977 (363 journals) to 2007 (972 journals), according to an analysis in the journal Pain Medicine [Robert et al. 2010].

During that 30-year period the number of published papers on pain topics grew nearly 6-fold, reaching 4,619 articles by 2007, and the trend was steadily rising. Additionally, the authors found there are currently at least 36 journals dedicated expressly and wholly to pain topics and research, almost all in English and the majority coming from the United States and United Kingdom.

Those are conservative numbers, since the U.S. National Library of Medicine catalogs 45 publications specifically dedicated to pain, plus there are numerous uncataloged magazines, news publications, and websites devoted to pain management and research topics. And, this is not including publications focusing on specialty subtopics, such as massage therapy, acupuncture, hypnotherapy, nutritional medicine, and other adjunctive modalities.

Some years ago, David Sackett, a founder of evidence-based medicine doctrines, claimed that to keep current in just one discipline — Internal Medicine in his example — it would be necessary to read 17 articles each day, every day of the year (6,205 total) [ref in Smith 2010]. The pain-care field would be no exception, so it might be estimated that to stay current in most aspects of pain management could require reading at least about 6,000 articles every year.

Certainly, this is impractical and the mere prospect of trying to keep pace with information overload can lead to frustration and avoidance. In one survey, a sampling of physicians were asked how much of what they should read to do their jobs better they actually do read. The vast majority, 80%, said they read less than half of what they should, and 10% said it was less than 1% [Smith 2010]. How did they feel about the futility of trying to keep up with the literature? Most used terms like “overwhelmed,” “impossible,” “despairing,” “depressing,” and the like.

Another study found that a select population of university medical faculty members were reading 322 medical papers a year on average, while nonacademic medical professionals read 232 papers [Tenopir et al. 2004]. Sackett had found that half of recent medical graduates spent no time at all reading the literature, while more senior medical specialists spent a median of 30 minutes each day; although, 40% read nothing on a daily basis [ref in Smith 2010].
Note: Spending even a half-hour daily could be impractical for busy healthcare providers. To critically read and assess a substantive medical paper could take at least 30 minutes, so the nonacademic practitioners or senior medical specialists in the examples above were spending the equivalent of nearly 3 to 5 work weeks, respectively, each year just reading. And, in the pain field, the 232 to 322 papers read each year would amount to merely scratching the surface — representing merely 4% to 5% of the 6,000 minimum that could be necessary just to keep current. Incidentally, a quick search of PubMed for all articles during the past year relating to humans and with pain in their titles revealed about 3,400 entries; although, as noted above, the NLM catalog is not all inclusive.
Even if the time is invested in studying the medical literature, critiques of research quality have been largely negative. Some have observed that less than 1% of studies in most medical journals achieve stringent scientific standards, while others have argued that most research findings are erroneous [refs in Smith 2010]. Medical publishing is a colossal, profitable, and growing enterprise in which keeping pages filled with articles, often of dubious quality or merit, has a high priority.

We have similarly discussed strong concerns about the veracity of a many research reports in the pain field [posting here and e-Briefing PDF here]. Therefore, a huge amount of time can be wasted reading articles that are methodologically flawed, biased, and/or of little clinical relevance — in short, they may be teaching the wrong lessons to begin with.

All of this means that healthcare providers face a daunting challenge if they attempt to keep current with the medical literature on pain care. Even the most motivated practitioners cannot read every article, every abstract, or even every title. Additionally, continuing medical education programs and courses have significant limitations, since these are only as good as the individual authors or presenters who, themselves, may not be keeping up with the literature.

As Fraser and Dunstan [2010] observe, “The gap between what we can learn and what is known is increasing all the time. We now know less and less about more and more, so being expert means knowing and publicly acknowledging the limits of your ignorance.” One great concern is that “colleagues in the same medical discipline may inhabit intellectual worlds with little overlap.”

For patient care this means that the success or failure of a pain treatment plan may hinge on whether or not the individual practitioner has attempted to keep current on the latest developments in the field, as well as what they have taken the time to learn about in depth. No one can be expert in all aspects of pain care, so the best practitioners can do is understand the limitations of their knowledge or skills and take these into account.

> Fraser AG, Dunstan FD. On the impossibility of being expert. BMJ. 2010(Dec 18);341:1281-1282 [
article here].
> Robert C, Wilson CS, Nonnadieu S, et al. Evolution of the Scientific Literature on Pain from 1976 to 2007. Pain Med. 2010;11(5):670-684 [
> Smith R. Strategies for coping with information overload [editorial]. BMJ. 2010(Dec 18);341:1314-1315 [
article here].
> Tenopir C, King DW, Bush A. Medical faculty's use of print and electronic journals: changes over time and in comparison with scientists. J Med Libr Assoc. 2004;92(2):233-41 [
article here].