Episode 13: Cervicogenic Headaches, Nerve Blocks and the Birth of Chronic Pain Medicine in Ontario Part 2

In the second part of the interview with Dr.Howard Jacobs, one of the fathers of pain management in Ontario, we discuss how the medical discipline of Chronic Pain developed in the last 20 years and the challenges facing it in the future.

Listen to Episode 10-Part 1 of this interview to discover how Dr. Howard Jacobs revolutionized chronic pain management in Ontario: https://www.buzzsprout.com/2329542/episodes/15984433

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Chapters

• 1:01 The Dark Side of Pain Management in Ontario: College of Physicians and Surgeons of Ontario (CPSO) Controversy and Billing Issues
• 9:28 The Development of the Ontario Medical Association (OMA) section of Chronic Pain
• 12:02 How the Canadian Academy of Pain Management (CAPM) Society Arose
• 14:36 The End of Change of Scope Programs and Thoughts On the Future of Regulations in Ontario
• 23:23 Dr. Karmy’s Concluding Thoughts

Transcript

Dr Howard Jacobs: 0:05

So when we started the section on chronic pain, there was a lot of opposition. I have to take credit for this development in the fields because I was the one that actually developed the section. Long story short after many battles to get it recognized, we were a probation section for a year, and then we pushed for, to get it a full section. When we pushed for a full section, again, this is the politics of medicine, which is our topic today, the policy of medicine was, the academics finally, after all these years, decided that, maybe chronic pain is something special.

Dr Karmy: 0:45

Hello, this is Dr. Karmy, and today we have Dr. Howard Jacobs to talk to us about the origin of pain management in Ontario. So let's go back then and what you were implying is that things were okay for a while and then College of Physicians and Surgeons of Ontario, CPSO, started to create problems. So what happened?

Dr Howard Jacobs: 1:19

This is actually the dark side of pain management in Ontario. When we started out and I was doing what I was doing, the controversy was whether, this occipital nerve block was actually something that we were billing correctly. A big part of the story of why there was so much controversy is because, like all things, when money became involved, and finances became involved, and cost became involved, That's when the authorities looked into it. I truly believe that if we had left everything as it was in the Rothbart clinic, with the six doctors doing it for myself, and Peter did not go away and allow other physicians to come and train with them, that this would be a non discussion, that it would have just been a pain clinic that does these nerve blocks. And that would have been the end of it. The only problem there is that many hundreds of thousands of patients over the years would not have been treated appropriately and lives saved if that had been the case. We didn't realize that there would eventually be a financial problem related to this. Because of nefarious behavior by some people involved in the field. And that's why the authorities got involved. Because there became a problem with the cost of, a couple of hundred doctors doing these nerve blocks. And the costs started to rise exponentially. Doctors and patients were seeking out this, so morally and ethically, that shouldn't have been our problem, but in, in hindsight, we look back and now we see that it was important, that the cost was, in the view of the government, a problem, so they got the college involved. And in those days, as you probably remember, the college was very aggressive in pursuing doctors. As, when it became to anything related to billing, because OHIP had to report to the college anytime there was an issue, and the college would then be the police and they would go after it. So the first person they went after was me. And they went after me very aggressively. An investigation was started. You remember, Semmelweis, the story about Semmelweis and his treatment for septicemia. Semmelweis was a professor and the patients were dying from septicemia after deliveries. And he realized that the only common thing was that the hands, people weren't washing their hands. So he suggested they wash their hands with chlorine. People thought he was crazy. And in the end they ostracized him, he was thrown out, and he ended up committing suicide in an asylum. That's the story of people who try to bring something new in that turned out to be life altering. And there are many stories like that in medicine. Thank God I didn't end up in an asylum and I'm still fighting. So that's the good thing here. So in those days though, it wasn't so easy. So , I was investigated. And I fought the battle, but we lost the war, because the college eventually told me that I gave a good explanation, but they didn't buy it. They didn't believe in cervicogenic headaches. And, you know, really tried to make my life misery, but I didn't shift from my view and I went back to do what they said I shouldn't be doing. But I just used a different billing code. It was the billing code that was their issue. That's a very important point. They didn't deny what I told them, but they didn't like that I was using a billing code they didn't like. Bottom line was we did continue to do what we were doing, and we billed it as they asked us to billed, but we didn't stop doing it. We didn't say, oh, we're not doing this anymore. In the end, OHIP was forced to change the billing code because they couldn't stop what we were doing. So that was the next step up where it was accepted, but all their experts couldn't beat me down. So they accepted what I was saying was probably true, but how I was billing it was false. That's the story of what happened at that time. And I saw how every specialty had developed over the years. Psychiatry, neurology, gastroenterology, they all started the same way. They did something, they tried something, and they realized that they needed to pursue this to make it something special so that it wouldn't be lost. So we did the same thing. We decided, Peter and I to approach the college to suggest to them that they're fighting a losing battle here. And that we should, work together. So I became an enemy of the state and then I became a friend of the state. So they liked my idea that I would do this. And we then began to start developing the standards and guidelines. That were, as you said, are important and we had to develop that from scratch. It all sounds very nice now looking back, but it was years and years of work and a lot of time and effort to get this accepted to where it is today. We also started the section of the Ontario Medical Association and realized that we would have to, bring this into a proper subspecialty or at least a scope of practice to make it respectable. And that's what we did.

Dr Karmy: 6:58

Just to, again, give a little bit of background, College created a lot of problems for a lot of pain physicians over the years. So what, do you think changed their mind and embrace you in some way?

Dr Howard Jacobs: 7:17

I'm a very nice guy. Why wouldn't they embrace me? I was very charming and I was able to convince them that the way they were going around this was going to be very problematic for them and for the patients. And there would be a lot of opposition to them stopping because at the end of the day, it's the patients that tell us they're the final arbiter. If something works, if something doesn't work, it doesn't last. So they, we had to lobby the college. We had to, do a lot of work, a lot of meetings to show them, in great detail what it was we were doing, why we were doing it. We had to show them the literature. And they realized, again, because I was able to convince them that this was something that we could regulate. And they agreed that if we could regulate it, they formed committees. And, I was on the committees from the very beginning. The committees were academics so can you imagine there was me and five academics who were against what I was saying? So I had to convince really, I did have to convince them in rooms. I remember it so well, many meetings I had that I would talk like I'm talking to you. They would say quiet and they would ask me a hundred thousand questions. And I was able to answer those questions, not because I'm a genius, but because I, to me, I looked at the literature, I met Chastad, I actually met him, and we went to a number of meetings with him in Europe. You know, as you can see, I'm quite, passionate about what happened. But to answer your question, the College eventually did agree to finally accept if we were to bring in guidelines. They reckoned there was enough evidence to show that this was a legitimate thing we were bringing in. They don't want me to do the studies again, they just want to know what am I basing this on? And then they make the decision. So I had to convince the decision makers that what we were doing was good medicine, which eventually at times became bad medicine because of what happened with the abuse of the system. So that's what answers your question. Why did the college get involved? There was abuse in the system, but they realized that they couldn't stop it. So the only thing they could do is make regulations. So it's based a lot on fiscal considerations and not on medical considerations.

Dr Karmy: 9:28

Lets go to Ontario medical association, a section of chronic pain, right? So OMA is sort of our, union and they negotiate for our fees. They create new quotes that for new services that are being provided. First of all, somebody had to form it or to take the initiative to form it. And then second question is, as always, who should lead the section?

Dr Howard Jacobs: 10:05

So when we started the section on chronic pain, there was a lot of opposition. I have to take credit for this development in the fields because I was the one that actually developed the section. Long story short after many battles to get it recognized, we were a probation section for a year, and then we pushed for, to get it a full section. When we pushed for a full section, again, this is the politics of medicine, which is our topic today, the policy of medicine was, the academics finally, after all these years, decided that, maybe chronic pain is something special. Maybe we should be involved now more than it was after we had done all the work. So they stood up in opposition to me who was nominated to be the first chair of the section. No, actually Peter was the first chair, but I was the backbone behind it. He got elected the first time by an over sounding result. And then when it came to my election, which was three years later, he then asked me to stand for chairman. The academics went crazy. But he was an anaesthetist, they could accept him, but they hated the idea that I would become the chair. Their argument was, oh, he's not a specialist, he's not this, he's not that. It was all these stupid comments, but in the day, I prevailed. And then I took the section, I managed that section and it helped the specialty overall by having a section. We then had recognition we brought out guidelines, and we dictated to the college, not dictated, but we spoke to the college, and the college respected that we were a section, and that it gave us a lot of access to further developments in the field, which is at that time is when we started to develop the actual guidelines for clinics in Ontario. And that's when we developed guidelines for standardization of clinics, which as today are pretty strict. And they brought in the change of scope practice.

Dr Karmy: 12:02

So let's maybe go back to Canadian Academy of Pain Management. That was actually started around the time I started in the field. I started around 2002. I would say it came out maybe 2003 or four. As you've said, it is the biggest multidisciplinary society of clinicians and unlike more a lot of other societies that are just anesthesiologists and physiatrists, this one actually embraces the fact that chronic pain management is multidisciplinary and some patients may respond better to occupational therapy, some may respond to physiotherapy, some I may respond to injections. So it's a group of clinicians but clinicians from various different fields. So how did that come around?

Dr Howard Jacobs: 13:01

So I went to the States to the American Academy of Pain Management back in 1998, I started going to their meetings. And they asked me to speak at one of the meetings. So I came from Toronto and therefore, a novelty. So I gave a talk on the cervicogenic headaches, which was very interesting to the chiropractors in the group. As you can imagine they knew about cervicogenic headaches, but had never heard an MD say, this is okay. The head of the the academy was a psychologist and, I became friendly with him and I said to him, would you be interested in helping me start a Canadian academy? He became very interested in the idea. And we arranged to get set up and we decided we'd make a North American Academy of Pain Management and have the first meeting of the Canadian Academy in Vancouver. So I was nominated to the first president of the Academy and the Americans came up. There was over a thousand people who attended that meeting. Actually, there's a CTV interview and CBC interview of me back at that time, where they were all impressed that we were opening an academy.

Dr Karmy: 14:09

And Canadian Academy of Pain Management now has a certification program for chronic pain, which is another way of getting certified in the field. It provides educational courses.

Dr Howard Jacobs: 14:28

It's still active, right?

Dr Karmy: 14:29

Yes, I'm still a member.

Dr Howard Jacobs: 14:32

Very nice. I'm waiting for my Nobel Prize from the Academy as well.

Dr Karmy: 14:36

So let's maybe go back. Yeah, the change of scope which was I think a big step forward. A change of scope was sort sort of like an apprenticeship that lasts a year where you work under supervision of a more experienced physician who does chronic pain management So it means that there's actually a formalized way of educating physicians to do chronic pain in the same way that there is a formalized way to the residency program to educate, let's say, obstetrician and gynecologist. So that brought with it a lot of credibility to the field. And this was before there was such a thing as pain residency program, which exists today. And it was before there was such a thing as pain felt, which also exists today. So it was really the closest at that point in time that one could come to having an educational program. One point that I should mention is that the change of scope program was actually closed down around 2018, 2019 and at that point, there was already PAYNE Fellowship Program and PAYNE Residency Programs, which started maybe 2014 or so. Interestingly enough when change of school programs were closed down, or even before that the fellowship programs and residency programs did not incorporate high frequency nerve blocks into their curriculum. And also they made a point of not allowing family doctors to be trained in this field. Do you have any thoughts as to why the fellowship and residency program, one, don't accept family physicians. Because you'd think that actually because chronic pain is multidisciplinary, diagnosis is important. Family doctor's outlook is much more multidisciplinary than anesthesiologists who are much more single procedure focused. They typically strong as diagnosticians because through their residency program they typically are trained to make diagnosis because some of them may work in emergency departments, et cetera, et cetera. Yet none of these programs accepted family physicians and none of these programs incorporated high frequency nerve blocks as part of their curriculum. Any thoughts?

Dr Howard Jacobs: 17:32

Getting to the fact that family medicine residents have gotten into the program. It's an interesting story because at the beginning, I advocated for family practice and I sent someone a representative physician who a member of the OMA. I asked her to try and make waves with the College of Family Physicians in order to, support their admission into the program. And then I found out subsequently from one of the people that started the residency programs in Canada, that they had no objection. It turned out that the College of Family Physicians of Canada, they objected. So I think it was political. I think they were advised. I don't know. I can't. This is my opinion. I'm entitled to my opinion. I believe that there was pressure put on the College of Family Physicians to not accept chronic pain as a subsection like they did emergency medicine or they did with sports medicine. Which is more important. I'll get into trouble for this, but I think chronic pain is far more important. They're both important, but the morbidity from chronic pain as it affects society is far more than the morbidity from sports injuries. They're both important and they both should be there. But the idea that they wouldn't accept chronic pain as a subspecialty, especially when so many family physicians have been doing it for so long with a change of scope had made no sense. So this I believe it's not the problem of the fellowships not allowing family docs. It is the College of Family Physicians. So if I was back in the game, I would be pushing the College of Family Physicians to change their attitude and to change their mind on this. I would lobby strong, I would make their life miserable, and I would push for this. I told you before, in order to try and stop the abuse, they tried everything and couldn't succeed. So now they're on their way out. They're on their way to destroying chronic pain in the province. So there's a real regression of what's actually happening. This is unheard of. So we build up this full specialty. We build up that thousands of patients every day are coming to us. We don't offer ice cream, we don't offer sandwiches and we don't offer champagne, but they still show up to get a three inch needle stick in their neck. There must be something in what we're doing. So they are regressing the specialty by not allowing this to happen, and by taking away the scope of practice, they will eventually run out of doctors. It's only a matter of time before, you'll end up where I am, not practicing the same intensity as I was before. And eventually there'll be no primary care pain specialists with the expertise that is needed in order to treat this. So change of scope is a huge deal. Now they've destroyed it. So this is horrible and painful for me to see what's happening. And it is, I believe, political and financial that's pushing this. I believe it's political pressure that's doing it. And I believe that this is going to be a disaster for chronic pain in Ontario. I believe because there's no way that the fellowship programs will ever in my lifetime, and probably yours, fill the void of what's going to be left by, by the doctors through attrition at this time. This is probably the most important part of this discussion. The go forward position of what will happen to chronic pain in Ontario.

Dr Karmy: 20:59

In my experience, nerve block is incredibly powerful and useful tool. It's not silver bullet. It doesn't help everybody, but for patients for whom it helps, it really makes a huge difference in their lives. Given that they don't accept family doctors at this point, and there's probably a political reasons for that, but why not train their fellows and their residents how to do nerve blocks? So, along with some of the things that are being trained to do, like radiofrequency ablation procedures, X ray guided cortisone epidurals, stimulators that you implant with wires right around the spinal cord. Why not train them to do something which is simpler, safer will often help a much larger proportion of patients, with various types of pains? Why not incorporate that into their training?

Dr Howard Jacobs: 21:58

People who have started the programs remember people who have come up over the years during the history we've discussed. So they have a bias towards anything related to this because of the long history. So instead of them embracing and accepting what has been accepted. They're living in the past. They are the old school that are not giving up and are the people who refuse to accept the changes. Even though there's no question that the evidence is overwhelming, the point of view of the type of studies that have been done, the observation studies, and every argument in the book is made in order to try and stop this. And again, it is a purely political, financial thing. And it is a personal vendettas that have gone on for years because there is a hatred between primary care physicians and anesthesiologists. And basically the programs that are being run, the chronic pain programs are all, are basically anesthesiologists who said, Screw you, family docs we're going to take it back what we believe is our specialty.

Dr Karmy: 23:06

Anyway, so thank you for talking to me about pain management. It was awesome. And that's it for now.

Dr Howard Jacobs: 23:16

Thank you. I was, it was nice to relive the old times and so I hope it gave you what you needed.

Dr Karmy: 23:23

In the interview, there was more discussion about billings. Fundamentally, we have a problem in medicine in general that's not unique to chronic pain management where we get paid on the basis of procedures we perform rather than outcomes for the patients. And because of that, often physicians optimize their practices for maximizing the number of procedures rather than optimizing patient outcomes. Dr. Jacobs made some suggestions for and how the OHIP billing system could be changed so that pain doctors would not be rewarded for just maximizing the number of procedures done on each patient. Dr. Jacobs was so concerned about how pain physicians are compensated is because, as you can see from the interview, he feels that some of the highest billing physicians in the field have a negative impact on the reputation of the field as well as ability of the field to survive into the future. While Dr. Jacobs had a very successful career, the final chapter of Dr. Peter Rothbart's career was rather sad. However, he was the person who developed and essentially invented the field of high frequency nerve blocks and had one of the biggest pain clinics in Ontario. He was forced out of the field. He gave up his license to practice medicine and eventually he had to shut down his clinic. There were multiple reasons for these developments, but I am sure that all the enemies he created over the years trying to promote nerve blocks and chronic pain management did not help. It did, however, leave behind a brand new field of medicine. A brand new approach to treating chronic pain and a number of institutions that support the field. With disappearance of one of these institutions, mainly change of scope of practice, that allowed physicians to be trained to perform nerve blocks, the number of practitioners will become fewer over time. However, I do not want to make it sound like the field will disappear tomorrow, while acess to nerve blocks will become more limited over time, given the number of young physicians trained in nerve blocks, I suspect that it will take at least 5 to 10 years before patients will notice that they are having difficulty accessing the treatment. Thank you.