Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage or is described in terms of such damage (1). The American Board of Pain Medicine (ABPM) defines pain medicine as the study of pain, the prevention of pain, and the evaluation, treatment, and rehabilitation of persons in pain (2). The pain physician is a consultant to other physicians but can be the principal treating physician. The pain physician may provide care at various levels, such as directly treating patients, prescribing medicines and rehabilitation services, performing pain-relieving procedures, counseling patients and their families, or directing a multidisciplinary team (2). The ABPM states that the practice of pain medicine requires advanced training, experience, and knowledge.
There is much confusion about what qualifies one to be a pain physician. The multidisciplinary approach to pain has led to many specialties claiming preeminence in the diagnosis and treatment of pain. There is no primary residency in pain medicine, although the ABPM has actively advocated for this concept. Informal pain fellowships existed for many years with no accreditation by the Accreditation Council for Graduate Medical Education (ACGME). As of 2002, there were 95 ACGME-accredited pain fellowships offered by anesthesiology departments in the United States (US) (3). According to data listed in Journal of the American Medical Association’s 2003 graduate medical education issue, 181 pain fellows were enrolled in the 264 slots available within anesthesiology pain fellowship programs when surveyed August 1, 2002 (3). In August 2002, no ACGME-approved pain fellowship was offered by any psychiatry or neurology department in the US (4), although the ACGME recognizes pain fellowships based in anesthesiology, physiatry, neurology, and psychiatry programs and uses the same fellowship training requirements for each of those four disciplines. Seven physiatry departments were offering ACGME-approved pain fellowships for the 2002–2003 year (4).
In 1993, the American Board of Anesthesiology (ABA) began offering the examination for the certificate of added qualification in pain management (5). In 1998, the ABA, the American Board of Physical Medicine and Rehabilitation (ABPMR), and the American Board of Psychiatry and Neurology (ABPN) pooled resources to create a multidisciplinary pain medicine examination with questions submitted from members of the three organizations. The certificate of added qualification in pain management was ultimately renamed the subspecialty certificate in pain medicine in 2002. The ABA administers the same examination on the same day to qualified applicants (i.e., the individual is already board-certified in his or her primary specialty) from the four primary specialties of anesthesiology, neurology, physiatry, and psychiatry. Each board may then award its own pain medicine subspecialty certification to those who qualify (the passing score is the same across the specialties). The American Board of Medical Specialties (ABMS) recognizes the ABA, ABPMR, and ABPN and their respective subspecialty certificates in pain medicine. The first subspecialty certificates in pain medicine for neurologists, physiatrists, and psychiatrists were awarded in 2000 (5).
Anesthesiologists have been required to complete an ACGME-approved fellowship in pain medicine since 1994 to obtain the ABMS-recognized pain medicine subspecialty certification. Anesthesiologists who had finished their residencies before 1994 were allowed to take the pain medicine subspecialty certification examination through 1999 by using their experience (grandfathering) in clinical pain medicine. A minimum of 24 mo of full-time pain practice in the prior 8 yr was required. The other specialties began offering the certification only in 2000 and allowed the same grandfathering exclusion through the 2004 examination for members who completed their original residencies before 1999. There is an additional exclusion through the 2006 examination for nonanesthesiologist physicians who completed their initial residencies by September 2004 plus an additional 12 mo of formal training in pain medicine, although not necessarily in an ACGME-accredited fellowship (6). After 2006, all pain medicine certification applicants from any specialty will have to complete an ACGME-approved pain medicine fellowship. Because the only current ACGME-accredited fellowships are offered through anesthesiology and physiatry departments, residents from neurology and psychiatry may obtain fellowship training through these fellowships.
The ABPM was established in 1991 (2) through the efforts of the preexisting American Academy of Pain Medicine. It offers pain medicine certification to physicians who can verify that they have received pain medicine training as part of their residency. Residencies that automatically qualify as including pain medicine in their curriculum are anesthesiology, neurology, neurosurgery, physical medicine, and psychiatry. Physicians from other specialties are allowed to apply, but they must prove training in pain within their residency. The candidate must have achieved board certification from an ABMS member board before being accepted for the ABPM certification process. The candidate must also have practiced pain medicine for at least 2 yr. A fellowship in pain medicine is not required but can be used as one of the two years required for the practice of pain medicine. The candidate must then pass the certification examination (7).
The American Academy of Pain Management (AAPM) is a pain management society that credentials health professionals in pain management. The AAPM’s diplomate status is awarded to individuals who have earned a doctorate degree (e.g., doctor of medicine (MD), doctor of osteopathy (DO), doctor of philosophy (PhD), doctor of chiropractic (DC), or doctor of dental surgery (DDS)) in a related health-care field and have a minimum of 2 yr of clinical experience treating pain patients. No formal training (residency or fellowship) is required. An examination is required. Board certification by an ABMS member board is not required (8).
The American Board of Medical Acupuncture (ABMA) first offered its certificate in 2000. It also grew out of a preexisting society, the American Academy of Medical Acupuncture. Many physician acupuncturists use acupuncture for pain management. For this reason, we decided to include the ABMA in this discussion. The ABMA requires an M.D. or D.O. degree, 300 h of continuing medical education training in acupuncture, and 2 yr of experience in using acupuncture clinically. No ABMS board certification or residency is required (9). Table 1 summarizes the comparative credentials required by these boards for certification.
As a major university pain center, we receive many referrals from the southern half of Ohio, as well as the adjacent states. Although most of the referrals were from nonpain physicians, some came from pain physicians of varying backgrounds. It was our impression that some areas of Ohio, such as rural southern Ohio, were lacking in pain physicians. We sought to determine the number of pain physicians in Ohio’s urban and rural areas and to ascertain their demographics and qualifications.
The Web site maintained by the State Medical Board of Ohio (SMBO) has a searchable database that allows one to search all the physicians with active, inactive, or temporary Ohio medical licenses. It also lists demographic data such as birthdate and place, medical school, medical practice address, any history of board action, and up to three self-designated medical specialties (10). A self-designated specialty is a field of medicine that the physician chooses as representative of his or her medical practice. For example, a pain physician with an anesthesia background might choose anesthesiology, pain medicine, and pain management. This voluntary designation is added at the time of initial licensing and can be updated at every renewal.
During the winter of 2002–2003, the names of all actively licensed physicians choosing to self-designate their practices as pain medicine or pain management were collected. Ohio physicians were searched in the SMBO and the American Medical Association databases by using pain medicine and pain management (10,11).
For the purposes of this article, the pain certificates offered by the ABA, ABPMR, and ABPN will be referred to jointly as the ABMS pain certificate. The ABMS is the umbrella organization to which these specialty organizations belong. The ABMS has not recognized pain medicine as an individual specialty but instead recognizes it as a subspecialty, and thus there is no ABMS-recognized primary board in pain medicine.
The print and Internet directories of the ABMS, ABPM, AAPM, and ABMA were studied for Ohio physicians who held a board certification from that same organization (5,2,7–9,12). A Web site called boardcertifieddocs.com was also searched for names of ABMS-certified pain physicians (13).
The names of pain physicians were collected from these various sources to create a master list of more than 400 names. These names were again cross-referenced with the SMBO Web site to confirm that these physicians were still actively licensed in Ohio and practicing in the state of Ohio. Physician names were deleted if they had active licenses but practiced outside Ohio, had an inactive license, or were deceased. Duplicates were removed.
A final list of 335 Ohio pain physicians was created. Demographic data, such as degree (MD or DO), primary specialty, medical school location (US or other), practice location, and sex, were added to these data. The primary specialty was obtained from the physician’s pain board listing, because the board credentialing the applicant would have verified this before certification. The sex was assessed as a best guess according to given names. Ten ambiguous names were classified as unknown. Practice location (city) was entered into the Web site Mapquest to find its location in the state (14). The location was designated as urban if it was within an area already designated as urban by the US Census Bureau. If the city was outside these limits, it was designated as rural (15). The data were entered into a spreadsheet of SigmaStat for Windows (Version 2.03; 1997), with which data analysis was performed by using the χ2 test with the Yates correction for ties.
In the winter of 2002–2003, there were 335 physicians actively licensed and practicing in Ohio who identified their practices as involving pain medicine. Of these Ohio pain physicians, 218 (65%) had at least 1 pain board certification, and 117 (35%) had none. Ninety-six of the boarded physicians were certified by a member board of the ABMS. The demographic characteristics of Ohio pain physicians are depicted in Tables 2 and 3. Forty-six (14%) pain physicians were women. A nearly equal percentage of boarded (64%) and nonboarded (68%) pain physicians were American medical graduates (AMGs). Most Ohio pain physicians have urban practices.
The distribution of boarded versus nonboarded pain physicians in Ohio was similar across specialties, although 84% of the nonboarded pain physicians were anesthesiologists, whereas 69% of the boarded physicians were anesthesiologists (Table 3). The specialties with the smallest percentages of AMGs practicing pain medicine were neurology (43%) and internal medicine (50%).
Further investigation into the 218 pain board-certified Ohio pain physicians is shown in Table 4. The most common board held by Ohio pain physicians was the ABMS certificate (44%), followed by the AAPM diplomate credential (37%) and then by the ABPM certificate (32%). The much newer ABMA had the smallest number of physicians (5%). When comparing MDs versus DOs for the rates of board certification, a pattern developed. A larger percentage of MDs than DOs had the ABMS certificate (49% versus 13%; P < 0.001; power = 94.9%) and the ABPM certificate (36% versus 7%; P = 0.003; power = 85.8%). A larger percentage of DOs than MDs held the AAPM certificate (77% versus 30%; P < 0.001; power = 99.9%). A significantly larger percentage of DOs were AMGs compared with MDs (100% versus 59%; P < 0.001; power = 99.4%), because osteopathic medicine is an American institution. Although there was a significant trend (67% versus 85%; P < 0.034) for fewer DOs than M.D.s to be in urban practice, our sample size was not large enough to generate sufficient statistical power (<80%) for this to be interpreted as more than a trend. Most board-certified Ohio pain physicians had an urban practice.
Further investigation into the medical specialties of the 218 board-certified Ohio pain physicians is given in Table 5. Anesthesiologists were the majority in all 4 boards and were 91% of ABMS pain-certified physicians. Several Ohio pain physicians were certified by more than one board. Anesthesiologists were the group most likely to have more than one pain certification. Thirty-one (21%) of 150 boarded anesthesiologists had more than 1 pain board. Of these, three anesthesiologists had three of the pain boards, and one had all four. By contrast, only one physical medicine and rehabilitation physician and one osteopathic medicine physician had an additional pain board. All other nonanesthesiologists had only one pain board. There were no statistically significant pattern differences between rural and urban practitioners. Most in all four boards practiced in urban settings.
Physicians may practice pain medicine without any pain board certification. With fellowships and subspecialty certification now available, this is likely becoming less frequent. The multidisciplinary pain boards (ABPM, AAPM, and ABMA) include orthopedists, neurosurgeons, family practitioners, general practice physicians, emergency medicine doctors, and general surgeons among their diplomates. Board certification in any field of medicine does not necessarily guarantee any measure of quality of care. The level of training and competency assessment requirements are quite different among the three ABMS boards and among the non-ABMS pain certification processes. Patients and hospital administrators may be unaware of the significance of one board certification versus another.
The accuracy of the data from our various sources must be explored. The data for the pain board-certified physicians from all four pain boards would be expected to be accurate and up to date, because this information was taken either from the most current published directory or from their Internet Web sites, which were supposedly up to date. It is unlikely that a physician boarded by any of these pain boards and licensed and practicing in Ohio was missed, because we cross-referenced with the SMBO. These data were also cross-referenced with a fifth Web site, boardcertifieddocs.com. We deleted deceased and out-of-state physicians according to data obtained from the SMBO. The only possibility for missed physicians would be those practicing pain medicine who were not board-certified by any of the four pain boards we studied and who did not identify themselves as pain specialists with the SMBO. Certainly there may be some who are practicing pain medicine but did not designate themselves as pain physicians. We expect that most physicians practicing pain medicine full-time identify themselves as pain physicians to their state medical boards, hospitals, and insurance payors. We would not expect the number of nonboarded pain physicians to out-number the boarded physicians. It is difficult to assess how many of the board-certified physicians are actually practicing full-time. A mailed questionnaire might answer this question. A mailed questionnaire, however, would not be expected to yield a 100% capture rate of pain-boarded physicians as the analysis of the pain-board directories did in our study.
Currently, Medicare, Medicaid, and private insurers pay for evaluation and treatment by a pain physician. In the 1990s, several medical organizations lobbied the Federal government for attention to and action toward the undertreatment of pain (16–18). In 1999, The Joint Commission for the Accreditation of Healthcare Organizations published its guidelines requiring health-care facilities to assess pain in all patients and to document a method of tracking and responding to the patient in pain (19). This appears to have increased the demand for pain physician services.
On the basis of Ohio’s population of 11.4 million and a prevalence of chronic pain estimated at 20% (20), Ohio would be expected to have 2.3 million patients with chronic pain. Only a portion of these would need a referral to a pain physician. With only 335 self-designated pain physicians and 96 ABMS board-certified pain physicians, Ohio might be under-supplied at a potential patient to ABMS board-certified pain physician ratio of 24,000 to 1. We are not aware of any assumptions relating to the maximum numbers of patients a pain physician can safely and adequately care for. Given the relatively small number of pain-boarded physicians, it is unrealistic to expect only pain physicians to provide continuing care to chronic pain patients. Instead, their services might best be focused on evaluating and treating new patients as they are referred and then referring them back to primary care physicians with occasional rereferrals to pain physicians as needed.
Ohio’s population demographics reasonably represent the nation as a whole. Most states more populous than Ohio have larger percentages of minorities than Ohio (15). Consequently, Ohio’s population is less diverse than that of the nation as a whole, but we are unaware of any data suggesting differences in the incidence of chronic pain problems among different ethnic or socioeconomic groups.
When assessed as the number of state residents per ABMS-certified pain physician, the number of pain physicians in Ohio initially appears similar to that of other states. By using only the raw data available from the ABMS (5,15) and not cross-referencing for current practice address or active state licensure, the number of ABMS-certified pain physicians in the 4 most populous states was 348 in California (population (pop.) 33 million), 252 in New York (pop. 18.3 million), 223 in Texas (pop. 20.3 million), and 214 in Florida (pop. 15.6 million). The range of state residents per pain physician would be 73,000–95,000 residents per pain physician. Our research showed that there were only 96 ABMS-certified pain physicians in Ohio by early 2003—not the 126 that the ABMS Web site quotes. This would result in 119,000 residents per pain physician. We cannot assess the possibility that the number of ABMS-certified pain physicians in the other populous states mentioned above might be similarly overestimated.
In January 2004, The US 9th Circuit Court of Appeals upheld a California law prohibiting physicians from advertising that they are board-certified in a medical specialty unless the certifying board meets state regulations. The AAPM was a defendant in the case and had argued that the rule violated free speech. The California regulation was enacted in 1994 and allows physicians to use “board-certified” in advertisements only if they are certified by an organization that is a member of the ABMS, has equivalent requirements accepted by the California state medical board, or has a postgraduate training program approved by the ACGME. In 1996, the California state medical board had cited, among other things, the AAPM’s lack of a requirement for formal training in pain medicine before certification as reason for denying the right of physicians to use the AAPM certificate to advertise as board-certified in pain medicine (21). The ABPM has, however, been granted an ABMS-equivalent status in CA by the state medical board (22). During the period of this study, the numbers of California physicians holding each of the pain boards or credentials were as follows: ABMS, n = 348 (5); AAPM, n = 224 (8); ABPM, n = 201 (2); and ABMA, n = 24 (12).
We conclude that anesthesiologists currently make up the majority of pain physicians in Ohio and hold a majority of all available pain boards and that a significant minority of self-declared pain physicians hold no pain-related board certification. Less than one-third of these self-declared pain physicians hold ABMS certification in pain medicine. Although board certification may not be a guarantee of quality medical care, we speculate that most patients do not understand the qualifications of their pain management physicians and that education of the public and of referring physicians about these qualifications may favorably affect patient care outcomes.
We thank Mary Lewis for proofreading this manuscript.
1. Merskey H, Bogduk N. Classification of chronic pain: descriptions of chronic pain syndromes and definitions of pain terms. 2nd ed. Seattle, WA: IASP Press, 1994.
2. American Board of Pain Medicine. The American Board of Pain Medicine directory of diplomates, 2002–2003. Glenview, IL: The American Board of Pain Medicine, 2002.
3. American Medical Association. Appendix II: graduate medical education. JAMA 2003;290:1234–48.
5. American Board of Medical Specialties. 2003 American Board of Medical Specialties annual report and reference handbook. American Board of Medical Specialties Web site. Available at: http://www.abms.org/statistics.asp
. Accessed October 12, 2003.
6. American Board of Physical Medicine and Rehabilitation. Subspecialty certification in pain medicine information booklet 2004. Rochester, NY: The American Board of Physical Medicine and Rehabilitation, 2004. Available at: http://www.abpmr.org/certification/subspecialty.html
. Accessed August 6, 2004.
12. American Academy of Medical Acupuncture 2002/2003 directory. Los Angeles: American Academy of Medical Acupuncture, 2002.
© 2005 International Anesthesia Research Society
20. Blyth FM, March LM, Brnabic AJ, et al. Chronic pain in Australia: a prevalence study. Pain 2001;89:127–34.