Jeremiah, would you provide an overview of your educational background and some of the major influences that led you to focus on pain management?
An abiding interest in both medicine and religion, a certain definition, and several very inspiring individuals who for me were mentors – all together – led me to focus on pain management.
Growing up I had an equal interest in a career in medicine and in the priesthood and both of these interests have continuously stayed with me and shaped me. What ultimately provided the greatest influence that led to an integration of these two areas was a definition of anesthesiology that I came across. That definition read, anesthesiology is the art and science of the relief of pain and suffering.
That definition along with meeting a student nurse who was planning to enter CRNA training and two independently practicing CRNAs inspired me to likewise pursue a career as a CRNA. Ultimately I was enrolled at St. John’s Hospital School of Anesthesiology, Springfield, IL and graduated in 1970. A man I very much admired was an osteopathic family physician who cared for our family for many years and when I finished training I wanted to practice in a hospital that was exclusively osteopathic. I could not, however, find one that even knew what a CRNA was. I therefore ended up in private practice in an allopathic hospital in DeKalb, IL.
Back in those days it was not common for CRNAs to be doing regional anesthesia but these are skills I wanted to develop. I ultimately worked out a completion baccalaureate program that incorporated training in regional anesthesia through Chicago College of Osteopathic Medicine and Chicago Osteopathic Hospital.
I was beginning to learn more about pain but not much about suffering and in an attempt to fill this gap ended up pursuing undergraduate and graduate training in pastoral counseling, Christian spiritual direction and Eastern spiritual studies. Eventually I completed the required seminary preparation and was ordained a priest of the Russian Orthodox Church.
During this sojourn I met an anesthesiologist, Dr. Steven Brena, who was then Professor of Anesthesiology and Rehabilitation Medicine. He was a prolific writer and marvelous educator in the integration of medicine, pain and religion and developed and directed the pain fellowship program at Emory University School of Medicine. He invited me to serve a fellowship with him and my rotation and studies were to become part of both a masters and PhD program in Religion and Health Sciences. This individual is truly an enlightened human being and a truly remarkable clinician and educator in the integration of medicine and religion in the treatment of pain and suffering. He is a rare living incarnation and example of an anesthesiology practitioner who has lived, practiced and taught from the definition of anesthesiology I encountered many years ago. To this day he and I remain in frequent contact; he is a most dearly beloved friend and mentor.
Never losing my attraction to osteopathy or the inspiring influence of my osteopathic family physician, my last official educational undertaking was to complete a Diploma in Osteopathy through the Osteopathic College of Ontario. Graduating in 2006 after studying classical, or traditional, European osteopathy and serving required clinical rotations, an osteopathic perspective is now central to my approach to the assessment and treatment of pain.
How did you go about acquiring the multi-disciplinary knowledge base that you offer your patients?
We have all been formed by the allopathic understanding of disease and treatment but that formation most likely did not include an introduction to, or exploration of, the philosophy upon which allopathic medicine rests. Once I became aware that there was a philosophy underlying allopathic medicine this opened up a spaciousness and I began to explore through readings, lectures, seminars, etc. various understandings of why we become ill and the treatment approaches based upon those understandings. It was a great deal of lengthy self-directed exploration and study.
You combine many of the “Western” modalities in your practice, what about “Eastern” modalities, such as acupuncture, meditation, herbal medicines, etc. Where do they fit into pain management from your perspective?
The AANA has a wonderful statement on pain management that I fully embrace. It reads, in part, CRNAs adhere to a total patient care philosophy directed at the promotion and maintenance of health and well being with special emphasis on providing rapid and effective alleviation of pain. We have two foci identified in this statement: (1) a patient’s “inner healing system”, which is basically the autonomic nervous system operating in conjunction with the endocrine and immune systems, and (2) the particular pain a person is experiencing.
Many of the so termed “Western” modalities are often extremely effective in managing and, in some cases, eliminating certain experiences and types of pain. These modalities, however, often carry significant side effects and risks and therefore must be incorporated intelligently and judiciously in order to not cause further harm to a person’s self-healing capacity which may already be impaired either by a disease process or by pain itself. Western medicine can be extremely effective in the treatment of short term pain. Its modalities are far less effective and frequently carry definite risks in the treatment of complicated and chronic pain problems. So called “Eastern” modalities are often far less harmful and the Eastern approaches often have more to offer in the promotion of health and well being.
On the Pain Management Forum for CRNAs, hypnosis as treatment of pain was discussed, would you share your view of hypnosis or other brain/consciousness approaches to pain management?
Yes. On the bottom line of human life all is energy and awareness, or consciousness. Penetrate this for yourself. Keep going and going and going until you get to the very bottom and this is what you will find. The ultimate (if we use that term in its most accurate sense) treatment of all suffering is to treat at this depth, the level of consciousness. One, however, cannot treat at this level unless they themselves are there and can experience it – are awake to it. Otherwise, it will make no sense. Additionally, of course, a patient must be at a level where they are receptive to this type of input.
How do you foresee the economic future of pain management developing for CRNA pain practitioners and what should CRNAs be doing to ensure this development?
We are at a crossroads. Unless many CRNAs wake up and see – really see! – and embrace that anesthesiology is itself pain management, CRNAs will be relegated to a type of operating room technician. Not that there is anything wrong with those who hold the title of “operating room technician”; this is not at all a judgment about those who function extremely well in this capacity. It simply means that we will have lost a true professional identity. Human pain management is much broader than the operating room, obstetrical theatre or areas where sedation is administered. When we see and embrace that on a large scale we will assume our rightful place as true pain specialists. This remains to be seen.
What advice would you offer for those CRNAs that have an interest pursuing pain management?
I would say that they must fundamentally see themselves as a specialist in pain. This must be their internal professional identity. Then one must get thorough training in both diagnosis and treatment.
The NAPES seminars have been very well received, but nothing offers the depth and hands-on experience that you provided with your CRNA pain management rotations in the 1990’s. How do you envision formal CRNA pain management evolving over the next decade, first ideally and then realistically?
Yes, you are correct. The NAPES seminars have been very well received and the three of us who have served as faculty have thoroughly enjoyed all of them.
Ideally I would like to see a formal comprehensive pain fellowship for CRNAs developed through a large hospital based integrative medicine facility where CRNAs would be trained and acquire skills in comprehensive pain diagnosis and treatment. Realistically – if we can successfully move beyond the crossroad point that we are at – I envision more of a distance learning and multiple clinical site experience all coordinated by CRNAs, and hopefully certain select physicians, who are all experts in pain management.
Thank you very much, Jeremiah. Your contribution to nurse anesthesia and in particular pain management is an inspiration to all of us.
You’re welcome! •