Dr Sumit Gulati

I consider myself amongst the cohort of trainees who has seen more changes and upheavals in anaesthetic and pain training than has ever been witnessed in such a short period of time. Starting in 2006-2007 with MMC, increased role of PMETB and GMC in training leading to significant changes in the pattern of exam and rolling out of new curriculums in 2007 and in 2010 are only some of the highlights. Faculty of Pain Medicine (FPM) came into existence in 2007 and set up structured training in Pain Medicine. The highly commendable effort of the FPM in formalizing the Advanced Pain Training is a success story that continues to be bettered with introduction of Higher Pain Training and Fellowship by examination amongst other things.
 
Decisions:
Having set my thoughts on Advanced Pain Training it was decision time in year three. I had the choice to join the excellent local programme in Leeds/Bradford, or explore something further afield.  I decided to explore an Out of Programme Pain Fellowship and focused on London for my year out.
 
The opportunity to train out of programme is an exciting prospect and yet a daunting one as it brings one out of their professional and personal comfort zone. I set my mind up to take the challenge and found myself applying for a prestigious London fellowship in the beginning of 2010. The approvals and paperwork ensued leading on to a successful application and interview in April 2010. The excitement was soon followed by the painstaking arrangements to move regions for a year, which I must admit appears trivial in hindsight compared to what I gained. 
 
My pain training can be best described as a tale of two cities. Leeds and London, both vibrant in their own unique way, and both with an enviable record in training and academia.
 
Getting to Grips:
The transformation from several years of Anaesthetic practice to full-time Chronic pain was interesting and full of challenge. In the first few weeks of supernumerary training, sitting in clinics for upto 8 hours and trying to understand the patient’s medical and social problems and expectations was a major learning curve.  This curve remained steep for the first few months, especially as hitherto someone else used to liaise with the GP, chase up investigations, dictate letters, organize theatre lists and follow up and discharge patients. Not only was there a dejavu of SHO years, I was now face to face with a new specialty, a new patient subgroup and a different way of working. Challenges gave way to a ‘can-do’ thrill and I soon started to look forward to those long Fridays, which often started with a run in the Regents Park and ended with a walk down to a central London restaurant or pub.
 
Diverse experiences:
Training:
While the competency based assessment and training underpins the Advanced Pain Training, the unique flavour that each pain department offers leads to vastly differing experiences. Unlike Anaesthesia, Pain Medicine is known for a uniquely diverse style of practice, often based on the experiences of the team, the available services, patient subgroups, and interpretation of evidence base There is no Other place Other than London to see this. I was fortunate to be in a fellowship, which was very balanced in its approach. I spent the first six months in an Orthopaedic Centre of Excellence with a patient subgroup of complex spinal pain, spinal cord injury, peripheral neuropathy, hypermobility, CRPS, rheumatological and joint problems and the next six months were spent seeing a patients with cancer, visceral, pelvic, neurological, maxillofacial pain and headache. 
 
Teams:
While the composition of Pain teams remains roughly similar, the interaction and level of involvement of Specialist nurses and allied health professionals differs across the board. I continued to learn and understand the dynamics of and roles of different members and whom to seek help from and refer patients to.  For example, it wasn’t until my last 6 months That I realized the difference between a hands-on and hands-off physiotherapist because in the Orthopaedic hospital the same physiotherapist did everything.
 
Patients:
The eclectic cultural mix, characteristic of London was interesting as the values and beliefs differed in regards to how they would deal with their pain and the treatment offered.  The stark contrasts often required different management approaches not only for the myriad clinical conditions but also to factor in the difference between the well heeled and the underprivileged, the English and non-English speaking, the war veterans and the victims of torture,
 
Training:
Training in Pain medicine differs from Anaesthesia in content and delivery. History taking, examination, diagnosis making and carrying out complex procedures require a combination of supervision, self-directed learning and attendance at relevant courses. Time constraints during a busy Outpatient clinic often means that teaching and discussions over a cup of coffee or during a long Operation is not often possible.
 
Working in London offers the opportunity to attend some excellent meetings being held right at the doorstep, the most memorable one I attended was in Guys Hospital with a live workshop by European, American and UK specialists. London deanery is unique in offering a monthly study day for APTs. It not only brought some of the best speakers, it also got together the fifteen odd APTs who would end up discussing passionately about their training programmes and future prospects over a drink in a Russell Square pub. 
A national survey that I conducted in June 2011 showed that 95% of the APTs were overall satisfied with their training programme, while they reported lesser satisfaction in training of advanced interventions and paediatric pain.  Overall the survey indicates that the goals of training are being met satisfactorily in most departments and I consider this as a resounding success for the Faculty and Regional advisers.
 
Management experience:
The APT year provides a great opportunity to enhance management experience, and understand functioning Of pain clinics and patient pathways. I had the opportunity to coordinate the National Pain Audit at my hospital, which is an ambitious project to improve quality of care and access to pain services. I also represented the FPM in BMJ Careers fair.
 
Networking:
An exchange of ideas and information has never been more important as it is today. London has about 38% of all the APTs in UK and several fellowships.  This offers an unparalleled opportunity to network with peers, senior specialists, researchers and managers and learn not only about the clinical aspects but also the political map of the future of pain services in NHS.
 
Challenges and Opportunities:
A precarious situation prevails currently, where APTs may outnumber the consultant jobs available in the NHS in coming years. FPM is mindful of this situation and I understand that they are taking remedial action. Challenges lead to opportunities and I can foresee the Pain consultant stepping out of the confines of hospital and emerging in more innovative roles as a leader, clinician and trainer.
I congratulate the FPM, RAs and Educational Supervisors across the two cities for taking the pain training from strength to strength and working tirelessly with the unified aim of putting the Faculty on top of the world map for Pain training. I hope to be able to join them in future in raising the standards as a Fellow and a consultant.