ASPN Newsletter Issue 11

Empathy – When the Doctor Becomes the Patient.

The need to be empathetic is something we have been taught since not only medical school, but for many of us, since we were children. I have always embraced that goal and I thought I had achieved it. I was wrong. Sure, I had been a patient before, after a high school or college football injury. That is American football for my ISPN friends. I had also been a patient after trail running trauma and crashing my triathlon bike.

Despite this, my early bounce back from those events gave me the false perception that being a patient was easy. The sequence was the following: have a feeling of being amazing and great, get injured, feel acutely bad, recover, and then feel amazing and great again, then back to the old grind. I saw little issues with being on the other side of the hospital gown. My yearly physicals went fantastically well, and my doctor always told me I was the picture of health.

In July of 23, that facade of invisibility was initially cracked. During the buildup to the Badwater 135-mile road race, I was injured, and then pushing through on race day, I had a full thickness hamstring rupture, rhabdo, and acute kidney and liver failure. Despite this, I was still somewhat invincible, refusing hospitalization and being treated as an outpatient. This led to a 4-month long recovery, which led me to the cusp of being back to normal.

In May of 24, I never saw it coming. Feeling better, I ran the Key West Ultra 50 miler, a race I had won overall in the men’s division in 2017 and one that seemed, if anything, too short. It was 110 degrees on the heat index, and the sun was baking. I calculated my water to sodium balance poorly, and by mile 40, I was getting into very bad shape. Cramping, falling, suffering, my mind was going into strange places, and I started to hallucinate. This is when my crew told me I was in first place in my age group. Snap out of it, Tim; you can do this, I told myself, and do it I did. I could and would suffer through anything to get top 20 ultra finish and an age group win. Winning my age group, 11th place overall and still something was wrong. I asked the race director, “Did I finish?” three times, and then it went black.

A few hours later, I was awakened by the placement of a Foley catheter (not a good experience) and a new IV stick. The doctor in the ER, Dr. Barry, told me that my sodium and potassium were critically low, and my myoglobin was critically high. He also told me if I wasn’t airlifted to Miami right away, I may die. I consented, and my first helicopter ride was underway. I must admit that was surreal, and seeing the Keys coastline was fantastic. Once in Miami, I woke up again in the Brain CT scanner. Apparently, my sodium had been elevated too quickly, and I was at risk for brain edema.

Later, the ICU monitors went off every 5 minutes because my baseline heart rate was 50, and the nurse told me I was bradycardic and may have done heart damage. The real answer was quite the opposite; my heart was strong, and the slow heart rate was great conditioning, but still I had repeat ECGs and a cardiac consult. My IV infiltrated, I had bloody urine after my catheter pull, and I was getting 2-hour checks of my electrolytes.

Thankfully, I recovered very quickly, and at 48 hours, I declared myself ready to be discharged from the ICU. The doctor initially disagreed, but after discussion, agreed to let me go home, although I am not sure this was the right medical decision—VIPs always get suspect care. I drove 9 hours to Northern Florida, flew back to West Virginia, and went back to work 3 days after the event. I was doing great.

Then after working on Friday, I noticed the area of IV filtration was inflamed, red, and swollen. This required drainage twice and broad-spectrum antibiotics. Being ill, at this point, I took a week of vacation. During that week, I noticed my hands and feet felt “on fire” and appeared sunburned despite no sun exposure. This is when I learned of sulfa-induced vasculitis. This condition required me to switch antibiotics and go on oral steroids. This switch led to peripheral edema. Does this everend?

I found some relief by taking the steroids and propping my feet up after work, which led to sciatic nerve compression and a fall on getting up from the couch. That fall led to a biceps hematoma, ligament strain in the thumb, and back injury. I am now suffering from a facet injury to the lumbar spine from the fall. I am getting exhausted living and telling the story, but I did learn some major points.

1. Being a patient gives one a feeling of helplessness and loss of control.
2. Being a patient is expensive. Copays and deductibles add up.
3. Being a patient can lead to new comorbidities and iatrogenic injuries.
4. Being a patient is not easy, and sometimes, despite good care, one thing leads to another.
5. Laying on the pain procedure table instead of standing over it leads to an all-new perspective. Anxiety washes over you, and you are not sure it is the right move, but when it is over, you are happy you had the block.
6. Having great doctors, APPs, and nurses is worth its weight in gold.
7. Prayer worked for me.

So, to summarize, I have been the physician for 34 years, and I have been the patient for three months. Having to choose, I will pick being a physician every single time. I don’t think I am tough enough to be a patient for much longer. Hopefully, all of you can find empathy without undergoing a similar experience.

Check out my Linkedln post about this experience.

Greeting, friends. Coming out of our 6th ASPN Annual Meeting this past July, I am energized by the unprecedented growth and energy we experienced. Led by our program chair, David Lee, MD, our Collaborative Summit taking place October 12th in Nashville, TN, will build on our momentum.

The ASPN Collaborative Summit was born out of the need to foster a multispecialty group to address the evolving fields of surgical and interventional spine. The conference offers three separate tracts:

1. Advanced Practice Provider
2. Fellows
3. Collaborative Council

Each tract offers salient and relevant topics geared toward the specific level of training. The conference concludes with an open forum discussion involving APPs, fellows, and physicians.

The Fellows Tract allows exposure to the most advanced and novel spine and pain therapies. Each session, the fellows will rotate through addressing different interventional techniques. The course is designed to evoke learning and in-depth conversations on how to incorporate these technologies into clinical practice.

The APP Tract provides the most fundamental clinical training. The didactics and lectures focus on comprehensive spine and neurologic physical examination, reading spine imaging, and advanced case management. This course is intended to emphasize the skills necessary for advanced patient care.

The Collaborative Council Tract will address high-yield topics within the field of spine with the aim of bringing surgical and interventional spine together to advance the science. The Collaborative Council will foster an intimate group of forward-thinking surgeons and interventional pain specialists to identify treatment algorithms and gaps in spine care, along with how interventional procedures and spine surgery may complement each other to improve patient outcomes.

We are looking forward to our Collaborative Summit in Nashville, and we hope to see you all there!

Safety and Efficacy of AXON Therapy (SEAT)

This abstract highlights the groundbreaking research on magnetic peripheral nerve stimulation (mPNS) and its significant impact on patient care. The study showed a remarkable 95% responder rate in patients with various types of neuropathic pain, as well as a 93% improvement in patient quality of life.

These results demonstrate the potential of mPNS to provide lasting results and effective, cost-efficient treatment options for patients suffering from chronic neuropathic pain.

This research not only contributes to the existing literature on neuromodulation techniques but also has the potential to revolutionize pain management practices in the future. Considerations should be made to introduce this therapy early in the treatment of neuropathic pain.

Overall, the findings presented in this abstract represent a major advancement in the field of pain management and have the potential to significantly benefit patients worldwide.

Congratulations to all three Top Abstract Award Winners: Dr. Kapural, Dr. Beall, and Dr. Levy. We look forward to reviewing the abstracts in future editions of the newsletter.

It has been a fast-paced and incredible start to this academic year. For me, starting a pain fellowship marks the onset of an exciting and transformative journey dedicated to professional and personal growth. The Miami meeting was the perfect way to launch the fellowship year. The ASPN conference provided exposure to cutting-edge research, innovative treatments, and invaluable networking opportunities with leaders in the field. The conference featured a range of sessions and workshops, showcasing the latest advancements in pain management and neuroscience. Engaging with experts and peers at ASPN reinforced the importance of staying current with emerging trends and technologies.

For me, this fellowship year is dedicated to growth, not only in clinical skills but also in professional development. The emphasis on creating lasting mentorship will pave the way for continued success long after the fellowship concludes, fostering a community of support and ongoing learning. I encourage all fellows to get involved in society; ASPN offers numerous opportunities. One of the standout programs is the ASPN Poster to Podium initiative, which I had the chance to participate in this year. It was pivotal in elevating my research knowledge and provided a platform to enhance my public speaking skills.

The ASPN conference set the tone for a year of learning, collaboration, and innovation. As we embark on this journey, the knowledge and connections gained at ASPN will undoubtedly contribute to a year of profound growth and accomplishment.

It is such an exciting time to be in pain medicine! As a community, we continue to embrace the value that diversity brings to a healthcare team. We are witnessing a historical time in our field, where pain medicine fellowship programs are embracing diversity and welcoming candidates from a variety of specialties to train as the next generation of pain physicians. Diversity in pain medicine is crucial for providing equitable and effective care to a diverse patient population.

We have seen a tremendous growth in diversity in gender, race, medical training, and specialty representation in our field. ASPN fosters an inclusive environment that promotes a sense of unity in our field, despite various interdisciplinary backgrounds and levels of training. ASPN fiercely advocates for promoting equitable opportunities for its members to become leaders in education, innovation, community, and research.

The recent Annual Meeting showcased a commendable increase in diversity and inclusion across various dimensions, including background, stage in career, gender, age, and specialty. Notably, this event featured members from all stages in careers—from seasoned physicians with extensive practice experience to fellows still in training, all sharing their valuable expertise in panels, breakout sessions, podium presentations, and Master’s cadaver lab.

A significant milestone was the inclusion of women representation in approximately half of the presentations during the meeting, highlighting a progressive shift toward gender equality in the field. Additionally, there was a marked increase in faculty from diverse backgrounds, including experts in practice management, private equity, law, industry, and advanced practice providers. This diverse representation underscores ASPN’s commitment to fostering an inclusive environment that values the contributions of professionals from various backgrounds and stages of their careers.

Participating as faculty at the recent ASPN conference was a transformative experience for me. It was incredibly rewarding to discuss my journey, exchange ideas, and learn from my peers as a panelist in the Young Innovators session. As a member of the Poster to Podium program, I had the opportunity to present my collaborative research project, which not only facilitated significant professional growth but also inspired me deeply. These unique opportunities continue to reinforce my commitment to advancing in our field.

We are so excited to learn, collaborate, and gain perspectives from international colleagues in pain medicine at the annual ISPN meeting in London. This will be an engaging opportunity for members to gain fresh perspectives on disease processes, novel therapies, and understanding ways to create more culturally sensitive treatment approaches for our patients.

ASPN is committed to making equitable inclusivity a priority, which will continue to advance our field for years to come.

Looking forward to seeing you all at the ASPN mid-year next meeting in Nashville!

ASPN advocacy is crucial in bridging our understanding and treatment of chronic pain to improve patients’ outcomes. We are uniquely equipped to champion evidence-based approaches to pain management and to bring forth more treatment options. We advocate for research funding to explore the mechanisms of pain, which can lead to innovative treatments and improved pain control for our patients.

ASPN’s continued efforts also focus on policy changes that prioritize pain management strategies. We play a key role in educating both the public and our peers about the latest treatments in pain management. With this, the advocacy helps ensure that patients receive comprehensive, compassionate, and cutting-edge care.

For example, in April 2024, through collaborative advocacy efforts, Humana changed their criteria for the coverage of Peripheral Nerve Stimulation in their Medicare Advantage plans. ASPN’s dedication to research and advancement in the field allows us to continue to help more patients with improving outcomes. We hope that you will join us in the mission!

ASPN Advocacy & Policy Committee continues to advocate for all its members and the subspeciality of interventional pain and neuroscience.

• DEA controlled substance delivery regulation update affecting intrathecal compounded medication:

DEA law and federal regulation require pharmacies to dispense controlled substances to the “ultimate user,” meaning directly to patients at their home address. However, the DEA has historically permitted pharmacies to implement the industry standard practice of shipping these medications to physician prescribers instead of directly to patients. There is an obvious health and safety risk associated with shipping highly concentrated opioids directly to patients at their homes.

DEA will issue guidance to explain the current law in the near future and allow continued delivery to clinics, one of the options is that both the patient and treating physician sign a Power of Attorney (“POA”) form to cover the risk. This form will only need to be signed once per patient. While we eagerly await the final guidance from DEA, ASPN will continue to advocate on behalf of its members. We encourage our members who procure their intrathecal medications from compounding pharmacies to reach their respective pharmacies for further guidance and instructions to comply with the law written in its current form.

• ASPN is working with CMS to reconsider coverage of SI Joint radiofrequency ablation.

ASPN is a part of the multispecialty initiative working closely with the Federation for Pain Care Access. We met with CMS leadership and their medical directors of respective MAC”s to discuss strategies for reconsideration of SI joint LCD. We were joined by numerous other state and national pain societies for this meeting. The reconsideration request will be submitted soon.

The energy and enthusiasm at our ASPN Annual Meeting in July were truly inspiring! Witnessing standing-room-only sessions filled me with immense pride in our community. Thank you to everyone who made the ASPN Annual Meeting in July such an outstanding success. As we look forward to next summer’s gathering, I invite each of you to share your brilliant ideas for sessions, panels, and new topics.

During my presidential message, I touched on the challenges we face as clinicians and the potential for burnout. While systemic issues can feel overwhelming, we possess the power to be catalysts for positive change. Let’s shift our focus from the weight of these challenges to the opportunities for growth and impact.

There are concrete ways we can do something as agents for ourselves, our teams, and our patients. First, stop spinning on all the issues. Next, filter down to a few key addressable areas. Find an issue that is most interesting for you personally to take on and that resonates with your talents. Develop a way that you can act that creates positive value. Then take a few steps to make it happen. Enlist some support: “Join me while I try this out.”

Our society has flourished thanks to members like you who dared to share your talents and ideas. Programs such as our Fellows Webinars, Young Innovators, Advocacy and Regulatory initiatives, Poster to Podium mentorship, and APP and Practice Building tracts are testaments to your collective brilliance. All of these were ideas of members who spoke up to see if their interests and talents could be amplified through ASPN to benefit our community. “Will you join me while I try this?”

I encourage you to embrace your potential and contribute to ASPN’s continued success. Together, we can create a brighter future for our patients and our profession. Let’s inspire and empower each other to reach new heights.

Join us in shaping the future of ASPN!