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Postmodern pain education: “from being to becoming”

Carr, Daniel B.

doi: 10.1097/j.pain.0000000000001334
Biennial Review of Pain
Global Year 2018

Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, United States

Address: Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, Stearns 203C, Boston, MA 02111, United States. Tel.: 617-636-3895; fax: 617-636-0898. E-mail address: daniel.carr@tufts.edu (D.B. Carr).

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Received June 22, 2018

Accepted June 27, 2018

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1. Introduction: IASP's 2018 Global Year for Excellence in Pain Education

The perspective on pain education presented in this article is offered in the context of IASP's 2018 Global Year for Excellence in Pain Education,65 including a 2018 World Congress plenary talk reviewing the accomplishments of the Global Year Task Force. This Global Year's accomplishments build on decades of work by IASP members and officers to advance pain education nationally and globally,45,60,72 particularly the efforts of IASP's Special Interest Group (SIG) on Pain Education and now, its Global Year Task Force. A variety of supporting resources were already in hand thanks to pioneering efforts by these and related groups such as IASP's Education Initiatives Working Group, the Interprofessional Education Collaborative,66 the European Pain Federation's Diploma in Pain Medicine, the U.S. National Institutes of Health Pain Consortium Centers of Excellence in Pain Education,42,82 and the North American Interprofessional Competencies Consensus Group,44 among others. This wealth of information ranging from prelicensure course materials and accounts of applying them within medical, nursing, or other schools,1,12,13,15,23,42,75,77–79,99 through the evolution of interprofessional pain education24,47,52,55,59,71,75,87,97,98 and other innovations58,62,71,74,79,100 was updated by IASP's Global Year Task Force and distilled into 9 practical Fact Sheets. IASP's Global Year aims were consolidated in a novel matrix conveying 12 related elements. Each element addressed one or more gaps between knowledge and practice that affect patients, health care providers, governmental and nongovernmental organizations, and researchers. The messages of the Global Year were further conveyed through professional meetings around the world, IASP chapter meetings, publications in PAIN and PAIN:E-Monthly, press releases, and social media. Details of these comprehensive, global collaborations including their praiseworthy participants are provided at IASP's web site.

Four fundamental questions inform IASP's core interprofessional curriculum65 and its other curricular outlines64:

  • (1) What is pain?
  • (2) How is pain recognized?
  • (3) How is pain relieved, reduced, or prevented?
  • (4) How does context influence pain management?

These questions not only serve to inform IASP's curricula but also (unsurprisingly given the number of mutual participants) have been applied with nearly identical language as the 4 core competencies presented by the North American Interprofessional Competencies Consensus Group44 (Fig. 1). Curriculum-based education rewards learners' capacity to absorb and cite content; competency-based education focuses on learners' capacity to act effectively in complex, diverse, and variable situations.44,54

Figure 1

Figure 1

The purpose of this commentary is to present challenges facing pain education by pointing out that:

  • (1) the 4 questions' simplicity and elegance belie their complexity;
  • (2) controversy surrounding concepts behind each question (eg, how to learn from evidence57,93 or how to infer causal relationships38,84) renders them imperfectly answerable at the single-patient level and hinders their translation into clinical practice;
  • (3) pain education is shifting from conveying impersonal, objective evidence at the scale of nociceptors or subcellular processes towards greater inclusivity of multiple types of knowledge, attitudes, and experience including patient narratives7,33,41,46,69,76; skepticism towards the utility of objective evidence in the absence of context37; opposition to hierarchically organized social structures for care delivery and support for interprofessional team care; advocacy and other policy-directed actions; and the frequent need to act amidst incomplete, qualitative, or ambiguous information;
  • (4) finally, the above dilemmas facing pain research, education, policy, and patient care are not unique to this field nor even to biomedical science, but typify those faced throughout the arts and sciences in this uncertain and unsettled27,86 “postmodern” era. We close with a call to venture still farther afield to harvest and harness concepts developed with other purposes in mind in other branches of science, now to advance the goals of pain education.
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2. What is pain? Balancing “bottom-up” with “top-down”

IASP's 2018 Global Year for Excellence in Pain Education65 has addressed gaps between knowledge and practice by focusing on 4 key areas: public and government education; patient education; professional education; and pain education research. Education of governmental (eg, representatives, regulators, and policymakers) and nongovernmental organizations was absent from IASP core curricula for professional education in pain until recently.32 Apart from a few early leaders focused on ethical and human rights' dimensions of access to pain control,11,14,17,19,63 until the opioid crisis emerged in North America,53,80 it was uncommon to see efforts on behalf of patients with pain originating within public health departments.50,51 The increasing credence given to population level thinking about pain is reflected in recent statements by governmental (eg, U.S. National Academies of Science, Engineering, and Medicine)17,61,62,80 and nongovernmental (eg, World Health Organization11) organizations, declaring that pain is a public health issue and a major global health burden.11,89 Recognition that chronic pain has social determinants not only echoes the WHO model of social determinants of disease in general73,92 but also reinforces abundant evidence that the dysphoria of social rejection is integral to the experience of pain, particularly chronic pain.36,43,96 Traditional instruction about pain as a biopsychosocial process12 presents pain as a “bottom-up” phenomenon beginning with activation of nociceptive neurons (Fig. 2); some proponents have declared that “the fundamental unit of pain is the cell.”88 A complementary view is that pain is a “top-down” process shaped by culture, personality, past experience, expectations, and context or meaning.13,22,46,69,70 Calls to revise the IASP definition of pain to acknowledge its social dimension alongside its sensory and emotional ones continue to echo within the pages of PAIN.35,81,101,102 Thus, the very definition of pain cannot be said to have been finalized once and for all.

Figure 2

Figure 2

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3. How is pain recognized? Or should it not be?

Among the many negative consequences of the opioid crisis affecting North America and other places (eg, Australia) has been the reversal of decades of progress in pain assessment in both inpatients and outpatients. Improvement in pain assessment and treatment was encouraged by regulatory bodies such as the (U.S.) Joint Commission nearly 20 years ago as a response to well-documented, widespread underassessment and undertreatment of pain.5 Subsequently, government and private insurance payers began to offer “pay for performance” financial incentives to institutions scoring higher on surveys of inpatient satisfaction with the effectiveness and timeliness of pain control. For some years in the United States, a patient satisfaction survey has been required for all hospitals by the principal governmental payer, the Centers for Medicare and Medicaid Services (“CMS”). This survey is called the Hospital Consumer Assessment of Healthcare Providers and Systems (“HCAHPS”).

On April 2016, a Citizen Petition was sent to the CMS requesting that 3 questions be removed from the HCAHPS:

  • (1) During this hospital stay, did you need medicine for pain?
  • (2) During this hospital stay, how often was your pain well controlled?
  • (3) During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?

Although 2 of these questions do not mention medications and none ask about opioids, the petitioners stated: “Aggressive management of pain should not be equated with quality health care, as it can result in unhelpful and unsafe treatment, the end point of which is often the inappropriate provision of opioids.” The petition and directly related Congressional bills and inquiries argued that assessment-based pain control in hospitalized inpatients is responsible for initiating or perpetuating opioid addiction in the population at large. In 2017, the CMS announced that as of January 2018, all institutions' responses to these 3 questions would be delinked from quality-based payment adjustments. CMS's announcement about this change stated it was “not aware of any scientific studies that support an association between scores on the pain management dimension questions and opioid-prescribing practices, (but) we are finalizing the removal of the pain management dimension…in an abundance of caution.” Unintentionally ironic, the “abundance of caution” ignored hundreds of clinical studies showing benefits of optimal pain control on physiological and experiential outcomes as well as efficiency of care.

This turn of events, albeit in a single country, is problematic for pain educators striving to advance clinical pain control. In the absence of financial support to sustain pain control within the broader system of institutional quality and safety, educators may find that students' competencies in pain assessment may atrophy once they enter a workplace in which assessment of pain has been deprioritized.

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4. How is pain relieved, reduced, or prevented?

This and the next question represent the “nuts and bolts” of practical pain control. We are fortunate to have the benefit of thousands of clinical trials of nondrug and drug therapies to guide our therapeutic decisions, often involving multimodal strategies. During my career, I have participated in the application of systematic reviews and meta-analyses of clinical trials to inform the preparation of national clinical practice guidelines and practice parameters.16,17 Disappointingly, rather than eliminating uncertainty as to what is the best treatment for each patient in each case, syntheses of the randomized controlled trial (RCT) literature often fail to yield clear answers for clinicians as to which individual patients should be treated with which interventions, at what cost and benefit, and which outcomes are likely to result.18 Other “inconvenient truths”18 about evidence-based medicine include its failure to streamline or simplify everyday clinical decision-making. To the contrary, complexification26,28 has occurred at each stage of the multistage process of evidence identification, collection, and synthesis. Although pharmacogenetic information may reduce uncertainty in predicting how an individual will respond to a given drug, it does not eliminate it and in real-world practice is confounded by concurrent medications and comorbidities.57 Furthermore, widely used methods of evidence-based health care, such as cumulative meta-analysis, emphasize group statistics and in fact were devised to minimize the impact of individual outliers on policymakers' allocation of resources across an entire population.34 The shortcomings of RCTs (and by extension, meta-analyses) were recognized decades ago by Louis Lasagna. Among other accomplishments, Lasagna co-authored seminal studies of placebo responsivity and contributed to the modern regulatory framework for analgesic drug marketing approval as a phased progression of placebo-controlled trials. Lasagna pointed out that the conditions under which new medications are evaluated for marketing approval involve artificially uniform subject cohorts, clinical settings, and outcomes; he saw these as weaknesses and called for drug evaluation in the “naturalistic” setting of everyday practice.70 Accepting that RCTs are “valuable but easily misused tools,”68 leading clinicians and researchers now have gone well beyond RCTs in assessing clinical evidence48 to include other types of data such as from electronic health records, registries, social media, narrative, and so on. Thus, the presupposition that educators know the answer to this third key question cannot be taken for granted.

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5. How does context influence pain management?

Like the previous question, detailed knowledge of patient factors such as age or developmental status, as well as the application of the other above competencies has benefited from a research literature to help guide practice. Yet to continue in the spirit of pointing out the uncertainties underlying yet another apparently simple question, we must note 3 additional problems undermining our efforts to assemble a knowledge or competency base to address it. All 3 are related to complexity.26,28,57,85,93,94

The first problem originates with the increasing amount, types, and sources of evidence to screen for causality (eg, benefit of a therapy or the lack thereof). Researchers now commonly rely on machine learning algorithms to uncover causal relationships among data sets. As a result, the likelihood of misattributing causal relationships and failing to discern hidden variables both rise.84 Causality is relatively easy to establish when there are few variables to study, the variables align with our common sense, their putative interaction may be described in easily understood terms, and the conventions for inference are based on a limited duration of observation.

An example might be the ease with which a team is able to put a basketball through the hoop: the team that does this most consistently with the greatest frequency will win the game. But as more factors are introduced into the model of predicting which team will win, such as historical superiority in rebounding or stealing the ball, or forcing fouls, the predictability of the outcome need not be increased. Add still more factors, such as the number of spectators, the distribution of players' heights, whether the match is at home or away, the quantity and alcoholic content of refreshments sold, the ambient noise level, the color of the uniforms, and so on, and it is possible that spurious causal relationships will be identified by a machine learning algorithm. In other contexts as well, as more and more data including that drawn from novel sources (eg, activity monitors and online food orders) are subject to automated analyses, causal relationships between the variables may become harder to discern and interpret. Hence, there is growing interest in the philosophy of causation, particularly in population health epidemiology.38

A second problem related to the magnitude and complexity of data gathered during clinical investigations (both prospective trials and retrospective mining of large data sets) stems from the somewhat arbitrary historical convention that findings judged with a 5% or lower likelihood of having occurred by chance are deemed statistically significant. This relatively permissive and accommodating threshold for further investigation and potentially, marketing approval, increases the likelihood that a marginal finding may appear significant in one trial and insignificant in another. Of course, it is already the case that clinicians and regulators appraise the clinical significance of a clinical trial finding as well as its statistical significance, but for many biomedical statisticians this does not go far enough. A growing number of statisticians are calling for a change in the convention for identifying a significant finding from the present P < 0.05 to P < 0.005, to discourage the fruitless pursuit of findings that are in fact marginal.67

The third problem is that as systems become more complex, it becomes harder to make clear, unequivocal statements about the nature of the interactions between their elements.38,84,93 Since Kurt Godel's early work identifying the limits of mathematical logic,29 as extended by Gregory Chaitin into computational logic, it has been recognized that even when all the postulates, operators, and variables of a finite logical system are specified, there is a limitless number of statements whose complexity exceeds the ability of that logical system to pigeonhole them as true or false. As Chaitin has expressed it, “(When young) I learned that math is more real than the world of everyday appearances…(however) it is not the case that simple clear questions have simple clear answers, not even in the world of pure ideas, and much less so in the messy real world of everyday life.”30 Thus, quantitative attempts to describe and predict reality face intrinsic limits of indeterminacy, even when confounding clinical factors such as variations in diagnosis, genotype, phenotype, heterogeneity of assessment methods, and incompleteness of data capture are not present.

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6. “From being to becoming”: lessons from the physical sciences

The phrase quoted in the title of this commentary is the title of a monograph85 published in 1980 by the Nobel laureate Ilya Prigogine, who devoted his scientific career to understanding (as described in his 2003 New York Times obituary) “how life could arise in apparent defiance of the classical laws of physics.”31 Building on earlier work by 20th century mathematicians and philosophers such as Henri Bergson, he described how it is possible that in closed, isolated physical systems, order inexorably dissolves into disorder yet in the world around us; physical and biological systems continually evolve to become more differentiated and complex. His answer was that the world we occupy is not closed but has energy flowing through it. Extraction of a portion of this energy fuels an increase in complexity as time progresses. In contrast to the idealized, static, and timeless world of Euclid,3 Aristotle, Galileo, and Newton56 (“being”), the fundamental characteristics of our real world are change, unpredictability and complexification (“becoming”). Prigogine was well aware of the philosophical antecedents and implications of his work.86

“The antagonism between 2 vaguely conceived entities, colloquially labeled ‘science’ and ‘postmodernism,’ seems to have become part of public life…Pages filled with entertaining invective have sprung up both on the Internet and in print…exchanges falling under the heading ‘science wars’.”95 Broadly speaking, postmodernism rejects the logic of classical science and emphasizes knowledge as having a social role to perpetuate hierarchical power structures. To define postmodernism—that explicitly rejects the conventional content of scientific definitions and embraces deconstructing such definitions to reveal the social role and purpose behind them—is oxymoronic. The online Britannica definition of postmodernism is “a late 20th century movement characterized by broad skepticism, subjectivism, or relativism; a general suspicion of reason; and an acute sensitivity to the role of ideology in asserting and maintaining political and economic power.” Wikipedia points out that it is a “broad movement…across philosophy, the arts, architecture, and criticism, (and that) common targets of postmodern critique include…objective reality, morality, truth, human nature, reason, language, and social progress.”

In the realm of education, postmodern teachers emphasize social equality with and among students, respect for diversity including different cultural backgrounds, acceptance of the uniqueness of each student and hence, a range of subjective experiences and truths. The shift away from curriculum-based education,2 that focuses on factual knowledge that learners are expected to absorb, towards competency-based education, that emphasizes students' capacity to act effectively in complex, diverse, and variable situations,40,44 parallels the postmodern reframing of reality from an unchanging, idealized entity, to a turbulent and unpredictable one. This shift also parallels Einstein's view, asserted during an interview in Boston in 1921, that “The value of an education in a liberal arts college is not the learning of many facts but the training of the mind to think something that cannot be learned from textbooks.” Layer over this perspective, the goal of patient centeredness in health care9 and growing disaffection with applying results derived from population-based studies or artificially uniform groups enrolled in clinical trials, to real-world decision-making with the individual patient,20,70 and the relevance of Prigogine's phrase to the challenges facing pain educators becomes clear.

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7. Conclusion

The accomplishments of the Global Year for Excellence in Pain Education are a fitting capstone to decades of pioneering work on behalf of pain education by IASP's Pain Education SIG. This commentary salutes that work and suggests that in some broad sense, the development of pain education has been both informed and challenged by contemporary developments in art, humanities, and science. Scientific advances catalyzed by the prevailing Western culture have occurred before.83,90 References to postmodernity are not meant to advocate for it; instead, they are used as a thread to link broader cultural developments and the challenges facing pain educators going forward.

Constraints on space and time to pursue threads within this commentary precluded exploring additional relevant concepts developed by 20th century physicists striving to understand the real world, as well as dynamic fields within educational science such as neuropedagogy. Of the former, 2 concepts seem especially relevant to postmodern pain education. The first is that of “complementarity” as articulated by Bohr,10 meaning that an item may be analyzed as having several contradictory and apparently mutually exclusive properties (eg, light being a wave or particle). Although some may debate whether pain is a bottom-up or top-down phenomenon,21 or strive to perfect “the” definition of pain, there may be value in accepting pain as having a variety of definitions at the same time. Second and last, in seeking a holistic vision of pain to inform pain education, we can learn from the discovery that the properties of the universe at the subatomic scale are fundamentally and precisely in harmony with its properties at the largest scales.8,25 Thus, the “constants of nature” that dictate the properties of and interactions between particles are not random, but instead are the only values that in aggregate are compatible with the ongoing stability of the macro universe.39,49 Slight alterations in the values of these constants would immediately cause the universe to collapse or fly apart.6,91 Similarly, genes and their epigenetic modifications that regulate pain-related structures and processes from the subcellular scale upwards, must be those that favor and are hence selected by the ongoing adaptation and survival of their host populations. Far from evolving towards greater and greater disorder, these multilevel ecosystems16 evolve towards ever greater complexity with intermittent small regressions back towards disorder4 and infrequent but catastrophic collapses.94

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Conflict of interest statement

The author has no conflict of interest to declare.

Partial financial support for work that this manuscript draws on was provided by an internal Tufts “Innovations in Education” award to Dr Bradshaw and the author.

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Acknowledgments

The author thanks the leadership of IASP (particularly Professor Michael Cousins) and its Pain Education SIG (chaired by Paul Wilkinson and previously Eloise Carr) for their decades of work to advance pain education in all the health care professions as well as for the public. Shared projects, proximity, language, and chance events have led to the author's having greater benefit from some pain educators than others: Judy Watt-Watson, Scott Fishman, Debra Gordon, Beth Hogans, Eloise Carr (no relation), Christina Spellman, June Dahl, Harriet Wittink, and Antje M. Barreveld, among others. Ylisabyth (Libby) Bradshaw, the Academic Director of Tufts' program on pain, research, education, and policy has brought boundless energy, commitment to students, and academic rigor to this program, which has been nurtured by Deans Aviva Must, Maria Blanco and Harris Berman and sustained by its admirable faculty and students, whom the author thanks as a group. Finally, the author thanks his daughter Rebecca Carr of Trinity College Dublin for helpful discussions on postmodernism.

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