Biopsychosocial pain research in America: the Veterans Health System leads the way.

The pleasure I experience in reading this special issue of Pain Medicine, co-edited so capably by Drs. Bob Kerns and Steve Dobscha, comes not just from the intellectual stimulation of the studies themselves. As a now senior professional in pain medicine, just by reading the table of contents I immediately appreciate the cross-disciplinary academic breadth and quality of the research herein, and the progress we have made over the years. The titles represent traditional domains of our exciting biomedical enterprise, such as modulation of molecular mechanisms, gene therapies, symptom and psychophysiologic measurement, and the epidemiology of disease and illness. However, there are also articles in domains of relevance to our national debate on the organization of health care services, for example, in the sociomedical sciences such as studies of provider and practice factors, barriers to care, and the culture of medicine. If I reflect on where we started several decades ago, we should gain satisfaction in how far our research enterprise has progressed. Pain medicine is really the first specialty to operationally fully embrace the biopsychosocial model in its scientific and clinical enterprise, as George Engel intended; not just brain–mind as in psychiatry and behavioral neuroscience, or body– brain as in neurology, but how the dynamic relationship of mind, brain, and body interacts longitudinally with the environment to influence the course and outcome of pain and pain disorders and diseases. Long before cardiology “discovered” the severe impact of depression on outcomes of cardiac disease and the impact of behaviors on cardiac disease, pain clinicians had translated pain science into clinical teams with a strong biobehavioral clinical enterprise. Pain medicine emerged as a specialty fundamentally defined by the biopsychosocial model, its science and practice conceptually justified by the gate theory of pain perception. Note that in the Veterans Health Administration (VHA), the predominate practice model continues to be biopsychosocial, whereas because of provider economic incentives, outside the VHA pain medicine is increasingly dominated by a conceptually and evidence-challenged procedure-based practice without performancebased justification, and at high cost. The pain specialists’ dilemma reflects the larger problem for all of American medicine—which economically punishes the provider who spends time and effort working with his or her patients to achieve the best decisions and health outcomes. For pain medicine specialists who wish to practice biopsychosocial medicine, the VHA has become an attractive place to practice and do research—and more are signing on. For psychologists and nurses and other professionals wishing to expand their opportunities for practice and scholarly work, the VHA is the place to be. Our mission is to improve the health outcomes of our veterans. The American health is system is beset with competing systems that wish to sustain profitability; because of these pressures they often lose sight of the public health mission to develop an efficient and cost-effective system of care for the public at large. To this end, our Guest Editors Kerns and Dobscha recount the development of biopsychosocial pain research in the VHA as reflected in this special issue. Their tale demonstrates how a small, motivated group representing several intellectual disciplines, when organizationally supported and when focused by effective longitudinal leadership, can work collectively over far distances and at little cost to accomplish much in a large health system. What characterizes this research, and differentiates it from much of pain treatment research today outside the VHA, is that this research is not about products but about the nature of pain and pain disorders, the patients suffering from pain, and the system that cares for these patients. The incentives are provided by the pleasures of engaging in the scientific enterprise: the support of collaborators working together to help solve thorny problems, the fun of teamwork and intellectual exchange, the stable support of the system, the thrill of emerging findings, and the satisfaction that comes from doing things well while contributing to the improvement of the enterprise to benefit patients. It is worth considering the ingredients of VHA’s successes in doing more with less, and the lessons learned that may help the larger U.S. health care system as it debates how to provide better, more efficient pain care for the rest of society. PAIN MEDICINE Volume 10 • Number 7 • 2009