Introduction by Croakey: Patient-centred care is a strong focus of a large medical radiation sciences conference kicking off in Adelaide today, on Kaurna Country.
The Australian Society of Medical Imaging and Radiation Therapy’s (ASMIRT) 19th National Conference is being held in conjunction with the New Zealand Institute of Medical Radiation Technology (NZIMRT), with around 900 delegates attending.
Marie McInerney is reporting for the Croakey Conference News Service, and has been speaking with two sisters who are bringing interdisciplinary collaboration to efforts to improve pain management.
Marie McInerney writes:
The days of thinking people can’t be experiencing real pain unless there is proof of injury or illness from a CT scan or X-ray must end, researchers told medical radiation science professionals at a conference this week.
For too long, there’s been a lingering belief among many health professionals that “it can’t be pain without pathology”, said Kate Dahlenburg, a diagnostic radiographer working at Logan Hospital in Brisbane.
Dahlenburg and Sophie Shephard, a pain physiotherapist in Wagga Wagga, were speaking ahead of the Australian Society of Medical Imaging and Radiation Therapy’s (ASMIRT) 19th National Conference, being held in conjunction with the New Zealand Institute of Medical Radiation Technology (NZIMRT) in Adelaide on Kaurna country.
They helped kick off discussions with an engaging pre-conference workshop on evolving understandings of pain and pain management, urging radiographers to explore a deeper understanding of their patients’ pain, particularly when its cause doesn’t show up in medical imaging.
Participants in the session, like many other radiographers who contributed to the research, acknowledged they had not received specific training on pain in their undergraduate studies.
They had also heard derogatory comments used by other health professionals about patients whose pain wasn’t evident from imaging, which included labelling such patients as ‘drug seeking’ and a ‘frequent flyer’.
“We have to believe patients when they say they are experiencing pain,” Dahlenburg said.
Sisters collaborating
Dahlenburg and Shephard are sisters who, “through happenstance”, have begun working together to find how lessons from allied health and medical spheres may resonate for the radiography profession, and improve patient experiences in the imaging department.
In their research, published last year in the Journal of Medical Imaging and Radiation Sciences, they give examples of where pain does not equal pathology, including with fibromyalgia where a patient may experience severe widespread muscle and joint pains in the absence of any defining abnormalities on imaging.
Their 90-minute workshop set the tone for other sessions focused on patient-centred care that are coming up at the trans-Tasman conference, which runs from 27-30 March.
ASMIRT and NZIMRT are bringing together more than 900 medical radiation professionals – CT, MRI, general, angiography, and veterinary radiographers, sonographers, nuclear medicine practitioners, mammographers, radiation therapists, and students, from across Australia and Aotearoa/New Zealand.
As well as looking at patient-centred care and workforce issues, speakers will also focus on artificial intelligence (AI) and other technological advances, with an opening plenary keynote address on Friday on ‘AI in medical imaging and radiation therapy: current innovations and future potential’ by futurist Craig Rispin.
A timely article in Nature this week looks at the promise and risk of multimodal generative medical image interpretation, which the authors dubbed GenMI.
They wrote that GenMI could one day “match human expert performance in generating reports across disciplines, such as radiology, pathology and dermatology”.
However, they warn, “formidable obstacles remain in validating model accuracy, ensuring transparency and eliciting nuanced impressions”.
Croakey will publish more on AI and other conference news in the coming weeks.
Shifting concepts of pain
At the workshop, Dahlenburg and Shephard talked about the shift from an historically dominant biomedical model of pain, which conceptualises pain as the direct result of tissue injury or pathology, to a biopsychosocial model, which recognises many varied and dynamic factors can contribute to someone’s unique pain experience.
Their research provides a number of examples to illustrate, including cases of phantom limb pain. They also cite a famous UK case where a builder experienced and was treated for severe pain after a 15 centimetre nail had pierced through his boot. As expected, the man had severe pain, requiring sedation with midazolam and fentanyl.
“However, a ‘miraculous’ recovery took place when the nail was pulled out and his boot removed, and doctors realised that the nail had not injured the foot at all: the nail had penetrated the space between two toes,” they wrote.
A more complex understanding of pain is crucial to patient care, they said, given an estimated 3.2 million people in Australia live with chronic pain, contributing to a total cost of $73.2 billion dollars in 2018.
More than $12 billion of that is related to direct health system costs.
The workshop heard that, while mental health problems are considered risk factors for chronic pain, research is showing that chronic pain can often be the cause rather than the consequence of mental health problems.
Three Australians die unexpectedly every day due to poorly managed pain and the associated misuse of prescription pain medications, the researchers said.
Gaps in care and evidence
Some radiographers have a really high level understanding of pain, but the researchers said they found that pain knowledge is generally lacking among the radiography profession.
While it is clear that radiographers want to improve pain management in the imaging department, Dahlenburg said there is a real gap in the pain literature relating to radiography, meaning that the profession is currently “left out of the conversation”.
Dahlenburg and Shephard currently have another paper under review, which explores Australian radiographers’ understanding of pain. It reveals that one in six radiographers surveyed do not feel confident managing pain of patients with acute trauma, and one in four lack confidence with severe chronic pain.
It’s clear why, they told the workshop. While most radiographers, like other health professionals, have an intuitive sense of pain, only 12 percent of those surveyed reported having received any training on pain and pain management in their degrees – a big gap given that patients reporting pain are commonly referred for medical imaging.
As a result, radiographers may disbelieve or dismiss patient reports of pain if there is no evidence of pathology and there’s a risk they may show less empathy and sensitivity in the movement of patients for imaging examinations, they said.
That in turn can invalidate and distress patients in pain, and decrease their likelihood of seeking healthcare in future.
Their presentation quoted one radiographer from Dahlenburg’s master’s research:
Measuring and treating someone’s pain based on x-ray findings is the biggest failing with most of the ED clinicians I have met in my career. Treat the pain, not the x-ray.”
Dahlenburg and Shephard said there are a range of “obvious things” that radiographers often already do in response to someone in pain. These include modification of their examination, using imaging aids like sponges or slide sheets, gentle and slow movement of pain affected areas and appropriate pain relief if required.
But they led the workshop through many additional techniques and approaches, including different uses and understandings of language and environment and contextual factors that would validate patients’ pain and help make the consultation feel safe.
Simple examples included validating patients’ pain, being patient and kind, offering patients the opportunity to ask questions and choice of positioning, promoting autonomy wherever possible, maintaining conversation throughout examinations, using de-threatening language (for example, ‘discomfort’ rather than ‘pain’), or distraction-based techniques, such as offering for the patient to listen to music or watch a movie for longer examinations.
These approaches should be even more nuanced when imaging people who are neurodivergent, who may experience or express pain differently.
“Often pain is under-recognised and under-treated as a result,” said Shephard, who is AuADHD (autistic and also having Attention-Deficit/Hyperactivity Disorder (ADHD)), and an Australian Physiotherapy Association (APA) Titled Pain Physiotherapist.
Trauma-informed care should also be “baseline standard”, being mindful of situations which could be potentially retraumatising or cause distress, she said.
One example discussed in the session included disrobing for imaging examinations, considering whether it is necessary or just ‘default practice’ and ensuring the patient has choice and control.
Even if health professionals don’t want to get into “the really nitty, gritty neurobiology of pain”, Shephard said they can still look for ways to “help improve patient experiences and things that we can do differently to help support people better, no matter whether we’re working in medical imaging or RT or physio or medical”.
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Also read Marie McInerney’s preview article, Action urged on new cancer treatment facility, as medical radiation professionals gather for conference.
