Mauricio Polanco García | Barcelona, Spain
I applied to the trainee exchange program driven by my desire to learn pain medicine from the experts on the field. I had the opportunity to spend three months at Utrecht Medical Center in The Netherlands through the ESA Trainee Exchange Programme. There, I not only fulfilled my initial learning goal but I also met amazing people who supported me all the way. I’m very thankful to ESA for allowing me to live such a wonderful experience.
I decided to go to Netherland because Dutch pain schools are very well known, especially the ones focused on interventional pain. Some people call them the Dutch masters of pain, and they have well recognised doctors as Dr. Rohof, Dr. Sluijter, Dr. van Kleef, Dr. Van Wijck and Dr. Huygen. I went to Utrecht Medical Center, a hospital affiliated to Utrecht University which comprises the academic hospital, the military hospital and the Wilhelmina Children’s hospital. In 2011 it became a Centre of Excellence for anaesthesiology training accredited by the European EBA/ESA training accreditation programme. The Hospital has a high complexity patients and very well trained teachers.
The pain clinic is a well-organised, multidisciplinary unit. The team consists of 5 anesthesiologists specialised in pain management, 1 psychiatrist, 1 psychologist, 1 ENT doctor specialised in orofacial pain, 2 nurses specialised in pain treatment and 1 social worker. Almost every day they perform interventional procedures. They are capable of performing any kind of pain intervention, from trigger point injection up to cordotomy for cancer patients. They have periodic multidisciplinary meetings for difficult patients and a service that handle consultations for hospitalised patients with chronic pain.
A pleasant work environment is one of the most important things that any worker wants. At the pijnpoli, the pain unit at UMC, I found open minded doctors willing to teach you all what they know, resident engaged in the learning process and very kind nurses and secretaries.
My mentors, Dr. Hans Knape and Dr. Bart van Wijck, were very kind. Dr. van Wijck is a pain specialist with more than 20 years of experience. He is very well known for his PHD thesis in postherpetic neuralgia and he is a pioneer in the use of epiduroscopy in Netherlands. I also had the great fortune to meet and be taught by Anne Mieke Karsch, Dorien Vrinten, Ruud Stellema, Suleyman Bilecen and Marianne Leenders. During the three months I was mainly in the operating room with them. With their help, I improved my skills in transforaminal injections, intra-articular injections, facet blockade, intercostal blockades and I learned new knowledge about cryotherapy, facial blockades for pain, sympathectomies and advanced procedures as cordotomy, celiac plexus blockades, epyduroscopies and intrathecal catheters.
At the end of the three months I had performed 46 transforaminal lumbar blockades, 21 transforaminal sacral blockades, 13 transforaminal cervical blockades, 8 lumbar sympathetic blockades, 10 sacroiliac injections, 10 funiculus blockades, 4 epidurograms and 1 caudal epidural, 2 cervical epidural, 4 intercostal blockades, 1 thoracic facet denervation, 1 cryotherapy of the suprascapular nerve, 1 impar ganglion blockades, 1 splanchnic blockades, several trigger point injections including a piriform blockade and trochanter infiltration with echo.
I also had time to read and learn about the procedures performed, the pain pathology of the patients and to join the resident in the visit of hospitalised patients. The differences in pain medicine management between countries are small but significant. In The Netherlands they apply national evidence-based protocols for the management of pain patients, which have been published in the journal Pain Practice and are now part of a book called: Evidence-based interventional pain medicine according to clinical diagnoses. The internal protocols of UMC are based on these national protocols so the treatment that patients receive all around the country is very similar. In Spain, however, there are protocols for each hospital and the quality depends on the local literature research and the expertise of the reviewers.
On the other hand, the health system in the two countries is different. In The Netherlands, the Dutch Insurance Council decides which medical procedures are covered based on scientific evidence, but their decisions can be contrasted with new evidence. Whereas in Spain, the national health policies are made by the Spanish National Health System and they are not up to discussion. For instance, the Insurance in The Netherlands stopped covering intra-articular sacroiliac injections and facet denervation. So the pain doctors started a multicentric study called MINT (Cost-effectiveness of minimal interventional procedures for patients with chronic low back pain) to analyse the cost-effectiveness of these treatments. The aim is to reintroduce these treatments if the study shows favorable results. It is an example to follow.
In the case to case scenario, at UMC they make a debriefing before beginning the interventional programme; they work without a radiology technician, they use completely aseptic conditions only for invasive procedure like epiduroscopy and intrathecal catheter placement. But it is so because the rate of infection of other percutaneous injections is null in their hospital. The use of echography for pain management is more widespread in my hospital. However, they are slowly starting to implement this new aid in the treatment of their patients. On the contrary, we don’t performed cordotomy, epiduroscopy, cryotherapy, mannitol infusion for CRPS and s-ketamine iontophoresis.
I want to thank Dr. Knape, Dr. Hoff, Marcella Brun and Anny Lam for all their help and patience; all the pain team at UMC for his kindness and teachings, for the books and the USB. I also want to thank Bart and his wife Ida for their support, the wonderful dinners and the delightful cheese.
In conclusion, it´s been a wonderful experience, I’ve learned a lot, and I recommend the Trainee Exchange Program to everyone.