Let’s start off with what we have now. The primary care service lines up with doctors in general practice. They are the gatekeepers for the specialists in hospitals and clinics. Only the “real” cases get referred on so the best use is made of the specialists’ time. So, if you have a heart problem, you see a heart specialist, a urologist for bladder problems, and so on. All these specialists cluster together in departments and, once they have the patient, they control the treatment. A specialist from a rival department is only called in when the first team admits it cannot cope. This works well so long as the patient really does have a problem within the first department’s specialism. But if there are different problems or complications result from the treatment, the patients really should be referred on to new specialists to match the new circumstances. Except that would be a loss of face between rival departments, each one fighting for its own funding and anxious to maintain its status. This means patients come second in the need to maintain each department’s reputation and avoid liability for medical malpractice.
Pain management should be an interdisciplinary department which reviews each patient’s history to decide, first, exactly what’s physically wrong, i.e. it reviews the diagnosis and, if necessary, calls for new tests. If a patient is still in pain, it suggests either the original problem was not solved or a new problem has arisen. In this, the reputation of the first set of specialists should not matter. The key person is the patient who deserves the best treatment. This may be further treatment or a new intervention to deal with the underlying physical problem causing the pain. Only when all the options for a physical cure have been exhausted should the team switch its attention to possible psychological problems. If the patient has become depressed, this may be amplifying the response to the pain. This may indicate the need for antidepressants combined with counseling and cognitive behavioral therapy to swing the mood from negative positive.
Unfortunately, this multidisciplinary approach is actively resisted by the existing specialist empires. Hospitals have been run on this basis for decades. Specialists are protective of their status. More importantly, they have considerable control over the budgets and refuse to allow money to be diverted from their departments for the creation of new multidisciplinary pain management groups that might make them look bad. While all this political nonsense is playing out, you remain a second-rate citizen. If you complain of pain, the specialist gives you Tramadol. This is the reliable first response to anyone who complains of moderate to severe pain. If you continue to complain, the specialist will increase the dosage. More complaints? That must mean you want something stronger than Tramadol. Even though the side effects may be significantly worse, it may stop you from complaining. At present, unless you have some powerful friends, the existing specialist is unlikely to refer you on to someone else. There’s always that lurking fear the second opinion might find fault with the first specialist’s treatment. Safety first!
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