Published April 15, 2021
Editor’s note: Dr. Fiona Campbell, MD, is a professor in the Department of Anesthesiology and Pain Medicine at the University of Toronto, Director of the Chronic Pain Program in the Department of Anesthesia and Pain Medicine at the Hospital for Sick Children (SickKids), and Co-Director of the SickKids Pain Centre. She is also Past-President of the Canadian Pain Society and Co-Chair of Health Canada’s Canadian Pain Task Force, through which she is an advocate for a Canadian National Pain Strategy. Follow her on Twitter @DrFCampbell
In this interview, Dr. Campbell spoke with Pain Research Forum correspondent Prab Ajrawat, an MSc candidate at the University of Toronto, Canada, to discuss her background in pain care, her policy work in Canada, and much more. Below is an edited transcript of their conversation.
What drew you to train in anesthesiology and pain medicine?
After completing medical school in 1984 at McMaster University in Canada, I moved to London, UK, to be with my partner who I had met skiing earlier that year, and by serendipity began my training in anesthesia. I later did a fellowship in pediatric anesthesia at Toronto’s Hospital for Sick Children, also known as SickKids, and then returned to the UK where I cultivated an interest in pain management.
People working in the field of pain often have a personal story underpinning their interest; mine was that my amazing mum was in a catastrophic accident while I was in medical school, and she developed chronic neuropathic pain related to a spinal cord injury. My first consultant job was actually in adult practice, and comprised anesthesia and chronic pain management, in Nottingham, UK.
After a few years, an opportunity presented itself to move back to Toronto, around the time of the SARS epidemic, to take a position as a pediatric chronic pain anesthesiologist at SickKids. Currently, I’m Director of the largest pediatric chronic pain program in Canada and practice clinically in both anesthesia and chronic pain. My undergrad degree was in psychology and I went to medical school as I had wanted to be a psychiatrist; given the impact of pain on mental health and the role of psychology in pain treatment, I feel in some ways that I have come full circle.
How is working with children with chronic pain different from working with adults with chronic pain?
The key differences between working with adults and kids with chronic pain can be broadly grouped into patient and practice differences. Kids aren’t just little adults. Not only are kids physically, cognitively and emotionally less mature, but they have different pain etiologies. They have a preponderance of musculoskeletal pain, abdominal pain, headache, complex regional pain syndrome, somatic symptom disorder, and often a degree of somatization concurrently with other pain diagnoses. They also have very differing impacts on their lives, including changes in their role functioning; pain can interfere with attending school and playing sports, leading to social isolation. Anxiety and depression are common in kids who live with chronic pain. Our patients tend to have parents attached and come as a package, adding to the complexity.
There are also practice differences arising from quite a different model of care. In our program at SickKids, at every intake appointment, there’s always a psychologist, physiotherapist, advanced practice nurse, and a pain anesthesiologist, regardless of whether the appointment is virtual or in-person. Our pain assessment is different as it is tailored to age and cognitive function. In terms of treatment, we take a functional rehab approach, which is very much what I call a 3-P approach comprising Pharmacological, Physical, and Psychological treatments. We’re much less interventional and probably less pharmacological than the adult model of care.
You’ve done work in quality improvement and implementation of science into practice. How did you become interested in that?
When I first arrived at SickKids, one of my mentors, Dr. Stephen Brown, asked me to take over the Pain and Sedation Committee for the hospital. It became apparent to me through the use of institutional surveys that there was dissatisfaction amongst our kids and families with the way that pain was being managed.
Rather than just accept this as fact, I wanted to be more data driven and undertook a benchmark audit to find out the state of play with regard to hospital-wide pain assessment and management practices, and impact on patient outcomes. We learned that pain was inadequately assessed, that it was common and often moderate to severe, but for patients who received any treatment, it was usually very effective.
We shared our results widely using a top-down and a bottom-up approach. By this I mean that we engaged leadership at the hospital as well as all interprofessional staff working across the organization and on all the inpatient units, because good pain practices and raising awareness of pain as an important health issue for patients are really everyone’s responsibility. We developed pain policies, practice guidelines, and implemented a hospital-wide quality improvement plan to drive up standards and reduce variability in care.
Let’s talk more about your health policy and advocacy work. How did it take shape over the years?
It’s been a gradual and natural evolution; I didn’t really have an “aha” moment. It began locally with that benchmark audit, which led not only to an awareness of pain as an important health issue, but also local policy and practice guideline development. I then became involved with provincial, and now national pain initiatives, and ended up with various leadership positions along the way. I remain involved in improving pediatric pain outcomes locally, provincially, nationally, and internationally. I have been very fortunate to work with people in positions of influence who helped this journey.
My first foray into provincial policy was through the CEO at SickKids, Mary Jo Haddad. The SickKids benchmark pain audit that I led really resonated with her and when she was asked to recommend someone to sit on a provincial advisory committee on pain, she put me forward, along with Dr Jennifer Stinson. I was appointed co-chair of that committee, partnering with people in leadership positions in the Ministry of Health.
In that role, I helped build capacity in the community by increasing access to pediatric chronic pain clinics. We made a case that investment in pain services reduced healthcare utilization and were able to influence decision makers to invest $23 million of sustainable funding for both adult and pediatric tertiary chronic pain programs, and also for Paediatric Project ECHO, a virtual mentorship program for community-based healthcare providers that offers specialty knowledge and best practices.
I was then fortunate to be invited by the Federal Minister of Health to co-chair the Canadian Pain Task Force and contribute to a movement advocating for a national pain strategy. The appointment has been a great honor, and it’s my hope that this will lead to the implementation of a national action plan for pain in Canada. I’m cautiously optimistic that it will, because our work has been very well received by Health Canada [the part of the Canadian government responsible for helping Canadians maintain and improve their health].
Tell me more about the Canadian Pain Task Force and its most notable findings.
The task force was established to provide advice and information to guide government decision makers towards an improved approach to the prevention and management of chronic pain in Canada. It’s comprised of people personally impacted by pain, indigenous people, researchers, educators, and health professionals with expertise across different disciplines as well as an external advisory panel and a secretariat that’s funded by Health Canada.
As a team, we were tasked with publishing three reports. One report was around the current state of chronic pain in Canada, which highlighted significant gaps in access to care; a lack of awareness, education, and training around chronic pain; inadequate research and related infrastructure; and a lack of chronic pain surveillance and health system quality monitoring, especially with vulnerable populations – even though we know 1 in 5 Canadians lives with chronic pain, it is a burden unevenly shared, with marginalized populations bearing a disproportionate brunt.
In our second report, we conducted extensive national consultations and reviewed evidence to identify best and leading practices and potential areas for action. Following the second report, our mandate was accelerated by the Federal Minister of Health, Patty Hajdu, who empowered us as a task force to move beyond disseminating information to actually providing recommendations to government on priority actions, to ensure that people with pain are recognized and supported and that pain is understood, prevented, and effectively treated in Canada. Our third and final report, titled “The Action Plan for Pain in Canada,” will soon be published and be linked to different policy levers in government. It will articulate the actions necessary to improve outcomes for people living with chronic pain and to reduce its impact on families, communities, and society in Canada.
Finally, there’s hope on the international stage that pain is going to be taken forward and finally addressed as a real and legitimate entity. Recently the World Health Organization ratified chronic pain as a disease in its own right, which validates chronic pain as a diagnosis with associated International Classification of Diseases (ICD) codes. This will reduce stigma, offer up opportunities for education, and facilitate research and monitoring and surveillance of pain. We don’t have good data on chronic pain in Canada, but once proper diagnostic codes are implemented, it becomes much easier to track.
With the recent emphasis away from opioids and a push for physical and psychological treatments for pain, what are some of the greatest opportunities and challenges from a health policy perspective to incorporate these non-pharmacological approaches?
There are major barriers to accessing evidence-based physical and psychological treatments. These barriers disproportionately affect marginalized populations who are often the least able to pay.
Effective treatment for chronic pain needs to be tailored, and evidence indicates that pain management is most effective when it’s based on a biopsychosocial framework [which recognizes the contributions of biological, social and psychological factors to pain]. Treatment should incorporate the 3-P approach I mentioned earlier together with self-management dimensions. Complementary and spiritual treatments can also be appropriate.
We have a big problem in that Canadians currently have limited and variable access to pain services in primary care, and they wait too long for specialty services. Evidence points to the need for increased availability of wellness-oriented, community-based care for people with mild functional impairment due to pain, and more specialized interprofessional care for those experiencing moderate to severe pain and functional impairment. The bottom line is that we will never have funding or capacity to treat everyone with chronic pain in a tertiary care environment, so we need a more tailored and stepped-care approach.
We need to develop and implement innovative care pathways and to expand access to evidence-based physical and psychological pain management approaches under federal benefit plans and under PharmaCare [a publicly funded insurance program in Canada for medications] for pharmacological management.
Can you say a little bit more about access to care in Canada? And where do you see the Canadian healthcare system moving in the future in terms of pain medicine?
Canada has fantastic pockets of clinical services, pain research and knowledge mobilization, and educational programming across our country. These all need scaling up but in the meantime we need to make sure clinical services are equitably distributed to reduce variability in care.
For example, there are 11 pediatric pain clinics in Canada. Five of them are in Ontario, due to the provincial funding by the Ministry of Health about which I spoke earlier. But this leaves many provinces and territories without tertiary care. Even now during the COVID-19 pandemic with virtual services that reduce barriers, some remote rural communities don’t have internet access and most marginalized populations are still not getting access to the care they need.
As for pain medicine, we do need to build capacity in the system. We need healthcare professionals with the knowledge, skill, and judgment to manage pain from primary care through to tertiary care. The Association for the Faculties of Medicine in Canada [AFMC] is developing a uniform curriculum that I hope will be implemented across all the medical schools, so that all medical students come out with a basic knowledge of pain assessment and management practices and an understanding of what pain is and how it impacts Canadians.
One of our big problems is that practitioners in primary care may have little idea how to look after people living with pain. We know that veterinarians get five times more pain education than do medical students – this really needs to be addressed. The standardized curriculum is near completion and I think it’s going to be rolled out very soon. I’m hoping that other faculties, not just of medicine, will undertake an approach similar to the AFMC but tailored to their jurisdictions.
We have a national pain medicine residency program through the Royal College of Physicians and Surgeons of Canada that is very innovative in that the program is available to physicians with different specialty backgrounds. It is housed within anesthesiology, but it takes from other professions or disciplines within medicine. A big gap is that the pain residency program isn’t available to physicians who specialize in primary care; perhaps a similar program is needed in our College of Family Physicians. There are a lot of physicians interested in pain as a specialty within primary care and this needs to be harnessed.
You are Past-President of the Canadian Pain Society. Can you tell me about this organization and your past experience as president?
The Canadian Pain Society is the Canadian chapter of the International Association for the Study of Pain. We are the Canadian interprofessional home of pain clinicians, researchers, trainees, increasingly people with lived experience of pain, and even policymakers. It was a great honor to be President.
Under my tenure, I really wanted to take a more strategic approach to the way things were done and to broaden the mandate to include patient engagement and advocacy. In order to move the agenda forward to improve pain outcomes, we all need to work together with people who have lived experience of pain and with clinicians, and not just limit the organization to those involved in research and education.
The society has a very vibrant membership. We have terrific annual scientific meetings, a grants and awards program, and we’ve pivoted to providing excellent webinars. Our awards program celebrates key clinicians, researchers, and trainees, and we have recently developed a mentorship program.
Shifting gears, what were some of the greatest challenges that you faced as you advanced in your career?
At one point I was looking after five children born within five years and that was probably the biggest challenge from a time management perspective. I’ve truly had more opportunities than challenges, but I am white and privileged. As a woman, I suppose I have faced some inequities and sometimes feel excluded from the old boys’ club, but I’m pretty tough and on balance have not found discrimination to be a major deterrent in my own career. These old boys’ clubs definitely still exist and I’ve become increasingly mindful of the importance of EDI [equity, diversity, inclusion] as a key societal issue. I’m really working hard at trying to be an ally “in the moment” when I see discrimination happening, not just for women, but for anyone other than white privileged males.
My main challenge now is that there is always just too much to do. I am fortunate to have my five kids, an awesome life partner, and a competitive sports angle to my life.
What career advice would you give to an early-career researcher who’s interested in health policy?
You will need passion, experience, and an interest in improving the way things are done at a systems-based level. There are opportunities for formal training in health policy; I didn’t go that route, but I suspect it would be very helpful. Also, in any new endeavor, I suggest you start low and go slow. Find leaders who may share your interest and can mentor and provide supports along the way. See what’s happening in your local, regional, and national jurisdictions. Talk to your members of parliament where you see things that need to be addressed, and do not be afraid to jump in!
Prab Ajrawat is an MSc candidate at the University of Toronto, Canada.