“30 years of DGS – and still far from reaching our goal”

Interview with Dr. med. Gerhard HH Müller-Schwefe, President of the German Society for Pain Medicine eV (DGS)

Dr. Müller-Schwefe, the DGS, which has been committed to pain patients for 30 years, is calling for adequate pain therapy care to finally be ensured across the board in Germany. How can this be achieved?

Müller-Schwefe: We currently assume that there are around 15 to 17 million patients in Germany who suffer from chronic pain and that around 10 percent of them suffer from severe, highly problematic pain. On this basis, we urgently need demand planning to ensure the care of chronic pain patients. The statutory health insurance associations are responsible for planning the need for specialists and general practitioners based on the population.

We know exactly how many surgeons, anesthesiologists, internists, general practitioners and orthopedists we need per 100,000 inhabitants. Since the field of pain medicine does not exist and pain medicine is currently only an additional title, there is no reliable planning of needs for pain patients. Continuity in patient care is also not guaranteed. If, for example, a general practitioner who only offers pain medicine ends his professional activity as a contract doctor and cannot find a successor general practitioner who has a pain qualification, then pain therapy in this practice is at an end. It can happen that 400 or 800 patients with chronic pain suddenly no longer have a contact person.

How many pain doctors do we need?

Müller-Schwefe: If you assume that a pain doctor can carefully care for 300 patients per quarter, then based on the population, you arrive at a need of around one pain doctor for every 15,000 patients. If we do not manage to establish pain medicine as a specialty, the care of pain patients will continue to be unsecured and the currently very long waiting times will continue to exist due to this lack of care.

What is the average wait time for pain patients before they get an appointment with a pain specialist?

Müller-Schwefe: It varies somewhat regionally. In most centers they are between three weeks and nine months, with a trend towards nine months, three weeks being the exception. The waiting time depends, among other things, on the diagnosis. Tumor patients and trigeminal neuralgia patients, i.e. those with the most severe pain disorders, get an appointment more quickly, while others have to wait longer. This in turn conflicts with the patient's right to adequate medical care. The Basic Law guarantees the right to physical integrity. Failure to provide pain relief can constitute bodily harm.

What do you think makes a pain doctor special – professionally and personally?

Müller-Schwefe: Doctors who specialize in the diagnosis and treatment of patients with chronic pain diseases need a whole range of skills, completed specialist training in a clinical field and theoretical knowledge of how pain becomes chronic and which treatment concepts are effective. The training should correspond to the complexity of the chronic pain disorder, ie convey functional orthopedic, neurological, psychological, psychiatric, anesthesiological and pharmacological content.

In addition to this specialist knowledge, which is defined in further training in specialist pain therapy, they require a considerable degree of empathy in order to deal with and engage with the health system's most difficult patients. The lives of these people often consist of a series of catastrophes: disturbed social relationships, job loss, problems in the relationship and even separation. These patients often no longer have confidence because they have experienced that their perception of their chronic pain illness is not believed. In order to regain this trust, a high level of empathy and communicative competence is necessary. Pain therapists also need a network in order to be able to offer their patients help across disciplines, in accordance with the model of multimodal pain medicine.

Why does the introduction of the specialist title of pain medicine fail?

Müller-Schwefe: The German Medical Association is currently leaning towards reducing the number of specialist titles and merging specialist areas rather than creating new ones. There is also concern that areas of care could be taken away from individual specialist areas. This concern is unfounded. I believe we can treat pain patients efficiently if we have appropriately trained doctors. It wouldn't cost any more money because the ineffective treatment is the most expensive treatment of all. We, the German Society for Pain Medicine and the patient organization German Pain League will continue to pull together to implement the patient's right to adequate care.

What can politics contribute to this?

Müller-Schwefe: Personally, I believe that this matter must be regulated at the highest political level. The Federal Ministry of Health and the Federal Joint Committee must address this issue and vehemently demand adequate care. Otherwise, the slowness and special interests of the specialist areas will outweigh the need to adequately care for pain patients. The Ministry of Health is the supervisory authority for the National Association of Statutory Health Insurance Physicians and I believe Federal Health Minister Gröhe has an obligation to intervene on behalf of patients. We will only improve patient care if we have adequate contact points in the form of medical care structures.

You have also recently started offering further training to pharmacists and physiotherapists. What skills do these professional groups need when dealing with pain?

Müller-Schwefe: The incredibly large market for over-the-counter painkillers - around 150 million packs are sold every year - shows that the first port of call for pain is often the pharmacy. In order to be able to optimally fulfill his advisory function, the pharmacist therefore needs basic knowledge of the mechanisms of pain chronification as well as sensible pharmacological and non-pharmacological strategies. That's why we train pharmacists and their teams and certify them as competent pharmacies. The certification is valid for one year.

Physiotherapists have incredibly intensive contact with patients with chronic pain. It is therefore extremely important for this professional group to understand how pain becomes chronic and which aspects, for example psychological ones, play a role. We train physical therapists to recognize fear avoidance strategies and teach them how to help their patients learn techniques to help themselves.

How do you assess the care situation in palliative medicine? What is there to do here?

Müller-Schwefe: One of the core elements of adequate palliative care is appropriate pain medicine care. Here, too, there is still an enormous need for improvement because it depends too much on chance as to whether patients find appropriate care structures in their end-of-life phase. I am on the board of an inpatient hospice and it took ten years until we had the money to get the hospice up and running. Every year we have to finance 10 percent of the costs from donations in order to be able to keep the hospice running. There are significant deficits in Germany here. We experience e.g. For example, patients are often deported from hospitals to nursing homes due to a lack of structures. However, these are not equipped to care for patients in the end-of-life situation with problematic and painful illnesses. This is a catastrophe, but unfortunately it is not happening publicly. Otherwise there would be a huge outcry because death and dying affects everyone.

German Society for Pain Medicine eV (DGS)

The German Society for Pain Medicine eV (DGS), with more than 4,000 members, is the largest European specialist society that is committed to a better understanding and better diagnosis and treatment of chronic pain. It is organized nationwide in more than 120 regional pain centers where interdisciplinary pain conferences are held. The primary goal of the DGS is to improve care for people with chronic pain. This can only be achieved by establishing algesiology in medicine. This includes quality assurance in pain medicine through the establishment of therapy standards as well as the improvement of training, further education and training in the areas of pain diagnostics and pain therapy for doctors of all disciplines. The DGS publishes the pain therapy guide in which all members are listed. Together with the German Pain League eV, the DGS organizes the annual German Pain and Palliative Care Day in Frankfurt/Main.