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Associate Professor Roger Goucke reflects on his career in pain medicine
After completing his medical training in Sydney, Associate Professor Roger Goucke practised as a general practitioner in Papua New Guinea, South Korea, Vanuatu and the UK. He then returned to Western Australia to train in anaesthetics. During the 1990s, his focus became pain medicine, and he was a key player in having it classified as a specialty. He currently works in the department of pain management at Sir Charles Gairdner Hospital in Perth and is a clinical associate professor in the school of medicine and pharmacology at the University of Western Australia.
“As a specialty, pain medicine is relatively young. There was a big effort in the mid 1990s to make it a specialty in its own right and it was recognised as such in 2005. I was on the planning committee that made the submissions to the Australian Medical Council to create a faculty of pain medicine. I was also involved in designing the training program and helping set up the accreditation process for the larger hospitals where people can do advanced training in pain medicine. One of my career highlights has been visiting these new training centres. We’ve also had several trainees through Sir Charles Gairdner Hospital and the benefits have flowed both ways. I’ve made some great contacts and friends. I’ve also helped the Hong Kong College of Anaesthetists set up their faculty of pain medicine.
It was the “whole-person” side of pain medicine that appealed to me. I started out in general practice, and because GPs manage a lot of chronic pain they are an ideal group to specialise in pain medicine. The pain specialty evolved out of the anaesthetics area after World War II, so it’s more often associated with that specialty. From my own perspective, it helped having a background in both anaesthesia and general practice.
If I had any regrets, it would be that I didn’t do much psychiatry when I was younger. The psychosocial side of pain includes depression, anxiety and distress, so in the clinic I see lots of patients with behaviour and mood disorders. If I was 21 and doing medical training again, I might come back as a psychiatrist! You’ve got to win people over to get them motivated to go forward, to stop or reduce drugs and become self-managers.
A large component of managing pain is psychological. This involves working on changing patients’ beliefs, attitudes and behaviour toward their pain and that is now at the forefront of what we do in pain clinics. A lot of people have the wrong view of what’s going on in their body. They may think their headache is a blood vessel bursting or a tumour growing. They watch too much TV! So you need to explain the correct mechanism causing the pain and you need to reset their thinking, attitudes and expectations about it. In some cases, this may be enough to get the patient feeling well enough to go back to work.
Drug management of pain has also changed dramatically. When people don’t respond to simple painkillers, it’s easy to prescribe stronger ones such as morphine which can become problematic over the longer term. Much of the work in pain clinics involves helping patients get off morphine-like drugs. These days newer drugs are available to better manage nerve damage pain. Surgery — cutting out the pain — is now hardly ever done, but in the past 10 years there has been increased interest in neuromodulation, which is the application of electricity via tiny catheters on wires close to the spinal cord. This is not new technology as we used this idea to treat intractable angina and back pain in the 1980s. The evidence base is growing but it’s still very expensive.
My latest hobby has involved developing a pain education program for the developing world. It’s called Essential Pain Management and I’ve run it in Fiji, the Solomon Islands, Papua New Guinea, Rwanda and Tanzania, plus its just been translated into Vietnamese and Mongolian. This has given me a terrific opportunity to revisit countries I worked in 35 years ago. It teaches practitioners how to recognise, assess, measure and treat pain. We have also developed a 4-hour instructors’ course on running the program, and in some countries these are taking off very well. It seems we are meeting a need.
One of the strengths of pain medicine is that it’s not just a medical field. Many different types of practitioners such as physiotherapists, occupational therapists and nurses have contributed a huge amount. They are represented by the multidisciplinary Australian Pain Society which I have been very involved in. Being a pain physician, you also see such a wide spectrum of presentations: chronic renal stones, irritable bladder, gynaecological pelvic pain, thoracic pain following surgery, chronic abdominal pain, intractable headache and, of course, lots of back pain. Cynics say it’s the dumping ground for patients other doctors can’t fix – and that’s the challenge. What a great job if your colleagues are sending impossible patients to you and you can help them. That’s the exciting thing about pain medicine."