Pain Management Best Practices During the COVID-19 Pandemic: The Well-being Perspectives of Chronic Pain Fellows.

Dear Editor,

We read with great interest the article titled “Pain Management Best Practices from Multispecialty Organizations During the COVID-19 Pandemic and Public Health Crises” by Cohen et al. [1], in which mental health considerations for health care workers were discussed. Some of the approaches highlighted to limit the deleterious effect of quarantine on health care workers are summarized in Box 1 [1]. We write to communicate some additional perspectives from chronic pain fellows currently adapting to the COVID-19 pandemic.

As coronavirus disease 2019 (COVID-19) continues to spread across communities, states, nations, and continents across the world, efforts to institute social distancing and build health care capacity have been the primary approach to mitigate spread and mortality from COVID-19. The quest to build a more robust health care workforce has resulted in deployment of health care providers, including chronic pain fellows, with skill sets in anesthesia and critical care medicine to manage COVID-19 patients in various settings. As a result, anxiety secondary to multiple factors unique to health care providers during the COVID-19 pandemic is on the rise [2, 3].

Despite some of the mental health considerations and approaches recommended by Cohen et al. [1], we would like to communicate some additional sources of stressors faced by current chronic pain fellows. These viewpoints are based on personal experiences and direct remarks of 16 chronic pain fellows distributed across the Northeast, Southern, Western, and Midwestern regions of the United States. Similar to a recent short survey conducted by Shanafelt et al. [4], we called 16 chronic pain fellows over the phone and asked about three areas of concerns during the COVID-19 pandemic: 1) What are you concerned about? 2) What message and behavior do you want to hear from the leaders? 3) What tangible resources of support will be the most helpful?

The major concerns expressed by chronic pain fellows centered on the following: 1) working in settings of reduced supply of personal protective equipment, 2) reduced fellowship training, 3) uncertainty with the job market, 4) deployment to intensive care units and field hospitals without adequate support and preparation, 5) inability to sit for primary oral board certification in respective specialties, 6) uncertainty with time frame for pain board certification, 7) safety concerns with exposing loved ones after treating COVID patients, 8) mixed messages from leadership across various institutions, 9) feeling abandoned by the Accreditation Council for Graduate Medical Education (ACGME), 10) uncertainty regarding hospital facilities providing support for trainees and family members should anyone test positive, 11) lack of consistent guidelines about symptoms requiring testing, 12) reduced volume of advanced procedures during fellowship, 13) anxiety related to efficiently performing advanced procedures as a new pain provider, 14) concerns for delayed graduation, and 15) hiring freezes after signing job contracts.

Overall, most chronic pain fellows understand that the COVID-19 pandemic is dynamic, making it difficult to come up with concrete plans. However, fellows would like leaders such as division chiefs, department chairs, hospital executives, and the ACGME to consider tangible actions to address their concerns. First and foremost, fellows would like various entities to acknowledge their concerns. One way of accomplishing this would be including fellow representatives as part of pandemic response planning at the division and departmental levels. Second, pain fellows would like leaders to show an interest by asking about their individual needs during the COVID-19 pandemic. Third, pain fellows would like leaders to provide additional support to their family should they need to be quarantined. Some of the suggestions include lodging support, childcare, and additional paid time off. Fourth, pain fellows would like to hear from the ACGME about measures in place to protect residents and fellows on the front line who may be unfairly treated during the staffing and redeployment for COVID-19-related patient care. Due to geographic variation in the severity of COVID outbreaks as well as institutional policy differences, fellows across the country have had a wide variety of different experiences with respect to their training and redeployment during this crisis, leading to an unraveling of the generally standardized training paradigm. On a positive note, it is encouraging to note that the American Board of Anesthesiology has allowed pain fellows to take their subspecialty board exams before sitting for primary specialty oral boards, which have been affected due to the pandemic.

Maintain a daily schedule of activities during quarantine to reduce frustration and boredom

Exercise

Online or social media contact with family, friends, and colleagues

Pursue hobbies or other meaningful leisure activities

Develop proactive approaches to continue working from home when possible

Identify clear and transparent sources of information about the pandemic

Avoid exposure to sensationalized news content

Schedule daily periods of time to consume relevant information

Limit the daily amount of media exposure

Secure consistent means for acquiring household supplies during the period of quarantine

Attempt to limit the duration of quarantine in accordance with health authority recommendations

Ensure access to available online resources

May include cognitive behavioral therapy, coping skills, audiovisual group therapy

Early treatment is associated with better outcomes

Organizational and institutional support for quarantined workers

Mitigate concerns about causing extra work for colleagues

Reduce feelings of isolation

Ensure access to information about the need for quarantine

Emphasize that quarantine is helping keep others safe

Box 1. Approaches to limit the deleterious effects of quarantine on health care workers

Source: Cohen et al. [1]

Despite the challenges faced by pain fellows, there were some tangible aspects that were unanimously observed to be very beneficial. These include 1) the accelerated advent of telemedicine for chronic pain care and 2) participating in educational opportunities such as pain rounds and webinars; recent webinar series by the American Society of Pain and Neuroscience (ASPN) and Pacific Spine and Pain Society (PSPS) [5] were well received by some of the pain fellows; 3) adoption of video conferencing platforms for at-home lectures by certain institutions; 4) and video conferencing for emotional and social support.

Approaches suggested by Cohen et al. to mitigate the deleterious effects of quarantine on health care workers were very practical and insightful. Our short interview with pain fellows suggests that the sources of anxiety and individual coping mechanisms vary across training institutions. Compared with younger fellows, older trainees with additional professional experience before pain fellowship appeared to have more positive responses. Additional support measures addressing truncated training duration, future pain certification, employment after fellowship, and immediate resources for those caring for COVID-19 patients will go a long way in mitigating the deleterious impact of the COVID pandemic.