Editorial: Pain Medicine Training in Latin America

Editorial

Despite Latin America being home to approximately six hundred and sixty million people,¹ there is a very small number of certified pain physicians practicing within the region (Table 1) considering the total population. The current shortage of pain management specialists, while a serious issue, also presents a significant opportunity for growth, particularly in expanding education and training within the field.^2,3

Table 1 Total Number of Certificates by Country, Fellow of Interventional Pain Practice (FIPP) and Certified Interventional Pain Sonographer (CIPS) Certified by World Institute of Pain, Pain and MSK Interventional Ultrasound Certificate (PMUC) Certified by American Society of Regional Anesthesia and Pain Medicine, and [Text Wrapping Break]Accredited Doctor in Interventional Pain Techniques (MATID) Certified by Latin American Academy of Interventional Pain Physicians

Pain medicine specialists are crucial to combating the significant biopsychosocial challenges pain creates. Fellowship training is essential for obtaining the knowledge and skills necessary for pain management. This editorial describes how pain medicine practice has developed in Latin America in relation to an academic standard for the appropriate development of the specialty.

Tackling the global pain crisis requires improved pain education. To address this shortcoming, The United States National Institutes of Medicine designated pain education as a national priority, and The International Association for the Study of Pain (IASP) offers curricula for diverse pain professionals.^4,5 Furthermore, there exists a growing movement to extend the duration of pain medicine fellowships, which have remained unchanged over the past 25 years, despite the growth of the field in technologies and knowledge.⁶ Despite this growth, few countries offer formal fellowship training in pain medicine. In Latin America, unique healthcare challenges such as limited resources and cultural diversity complicate pain management, which requires a multidisciplinary approach for effective treatment. Promoting fellowship training in these countries can elevate life quality and advance pain management practices regionally.

Pain medicine specialists are experts in diagnosing, treating, and managing pain conditions. They provide therapies, medications, and interventions to alleviate pain and improve function in acute and chronic pain conditions. Typically, fellowship training requires a minimum of a one-year program post-residency in a multidisciplinary pain department. Several organizations provide proficiency certificates in interventional pain medicine, including the World Institute of Pain (WIP), as well as Fellow Interventional Pain Practice (FIPP) and Certified Interventional Pain Sonologist (CIPS) certifications, which are the most common in Latin America. Of note, some countries offer a combined pain medicine and palliative care fellowship, although it is important to clarify that these are distinct specialties with varying scopes and goals. Palliative care is not limited to pain but addresses the physical, emotional, social, and spiritual requirements during severe illness. Unlike pain medicine fellowships, palliative care programs traditionally do not involve interventional pain procedures. Thus, to address the dearth of pain training in Latin America, we assessed current physicians via an online survey across Latin America and have accessed data from several accrediting organizations, including WIP, the American Society of Regional Anesthesia and Pain Medicine (ASRA), and the Latin American Academy of Interventional Pain Physicians (ALMID) to provide a better view of the pain education training landscape (Table 1).

Current Status in Select Countries of the Region

Brazil

Registration in pain medicine is overseen by Regional Councils of Medicine (CRM), which recognize a physician’s specialization. In pain medicine, three pathways exist for obtaining this subspecialty registration - 1. Complete a residency program in pain medicine, which is accredited by the Ministry of Education (MEC) and provides the right to obtain the subspecialty registration via the Specialist Qualification Registry (RQE) 2. Completing postgraduate courses, which necessitates completing modules and two years of supervised practice prior to qualifying for the title exam 3. Completing a fellowship which involves training under a pain physician for clinic and procedural skills for 1–2 years. Training varies in Brazil, with many residency programs emphasizing clinical management over interventional skills, and Brazil lacks a specific certification for interventional pain management. However, as of January 2024, there are 99 certified Brazilian physicians with FIPP, 35 with CIPS, 6 with Pain and Musculoskeletal (MSK) Interventional Ultrasound Certificate (PMUC), and 2 with Accredited Doctor in Interventional Pain Techniques (MATID).

México

Pain medicine and palliative care training often occur in combination. The Jalisciense Institute of Pain Relief and Palliative Care exclusively offers officially recognized pain medicine and palliative training. Trainees must complete one year of pain medicine and one year of interventional training within the same site, or complete one clinical year of pain medicine and palliative care and one year of interventional training at a separate program. Eighteen institutions offer pain medicine and palliative training and seven for interventional pain management. However, the interventional year is exclusively open to anesthesiologists. As of January 2024, there are 19 certified Mexican physicians with FIPP, 6 with CIPS, 2 with Pain and MSK Interventional Ultrasound Certificate (PMUC), and 2 with Accredited Doctor in Interventional Pain Techniques (MATID).

Colombia

Colombia has nine programs in pain management and palliative care endorsed by the Ministry of Education. These titles are granted by universities, the only entities authorized to certify specialists in Columbia. Programs are of 1–3 years of duration, with 2-year programs for generalists and 1½-year programs for specialists. Some programs are exclusively for anesthesiologists, while others allow for various other specialties. Foreign titles are validated if their training conditions are equal to or exceed current university programs. As of January 2024, there are 23 certified Columbian physicians with FIPP, 2 with CIPS, and 4 with Accredited Doctor in Interventional Pain Techniques (MATID).

Costa Rica

Pain medicine training faces a shortage, as its relatively large size compared to its smaller population requires professionals to seek education abroad. However, the College of Physicians and Surgeons requires incorporating professionals trained abroad to go through a rigorous process. Having strict requirements regarding who can undergo their rigorous evaluation process for recognition further limits the number of trained pain physicians who can practice. Some applicants have completed two-year programs and others only one year, yet they must all undergo the evaluation process to be recognized as sub-specialists in Clinical Pain and Therapy. Notably, this title does not differentiate in terms of interventionism. The evaluation encompasses a written assessment regarding knowledge related to pain and an oral assessment that requires application of this knowledge. Strong commitment is present on the part of medical authorities to ensure that pain medicine professionals possess the necessary competencies, yet despite these efforts, it is not uncommon for physicians to lack sufficient training. As a result, as of January 2024, Costa Rica only has 1 FIPP and one MATID certified physician.

Argentina

There are no official pain medicine residencies or fellowships in Argentina. While no formal training for pain management specialization exists, regulations require basic specialization in a 4-year residency program. Post-basic experience in pain medicine is also required as a 2-year program, with a curriculum following the IASP guidelines. Regulations mandate a 4-year residency in anesthesiology, pain management mentoring, and certification and periodic recertification. There are training courses for pain treatment, that are endorsed by national universities, and interventional courses without university endorsement. Through these courses, Argentina has 13 FIPP certified, 3 CIPS certified, and 8 MATID certified physicians. The Latin American Federation of Associations for the Study of Pain (FEDELAT) conducts interventional courses through the Argentine Association for the Study of Pain (AAED).

Perú

In Peru, no specific governing body guides pain medicine practice. The Medical College of Peru (CMP) fails to recognize degrees obtained in foreign programs, ruling that the subspecialty has no official presence in the territory. Certification is also lacking, and as of January 2024, there are 2 FIPP, 2 CIPS, and 1 MATID certified physicians. Fortunately, the Ministry of Health published a standard to guarantee comprehensive care for patients affected by pain. Regarding medical personnel, the standard requires a degree and specialist registration with training at a National Health Authority recognized center.

Bolivia

The 2023 approval of the Subspecialty in Pain Medicine by the Bolivian Society of Anesthesiology, Resuscitation, and Pain marks a transformative milestone in Bolivia, and it now is resulting in guidelines for creating a 1-year pain residency. This certification ensures adherence to national and international standards and addresses the need for enhanced pain care. The National Pain Commission was simultaneously established, comprised of anesthesiologists specialized in pain medicine including 2 FIPP, 1 CIPS, 1 PMUC, and 2 MATID physicians Their objectives include providing adequate pain management, enhancing accessibility through subspecialized physicians, and integrating pain units into national systems. Additionally, they organized the initial National Interdisciplinary Congress on Pain Medicine, at which they detailed requirements for opening a pain center and establishing a residency program. They placed Bolivian pain medicine upon four pillars: a modern vision inspired by best practices, respect for the Statutes and Regulations of the Colegio Médico de Bolivia, collaboration among specialized physicians, and a commitment to benefiting patients.

Chile

Anesthesiologists are heavily involved in pain management in Chile; however, education remains insufficient resulting in improvisation in patient treatment. Training is heterogenous, as several diplomas for pain management exist including a two-year fellowship in pain and interventionism. As of January 2024, there are 4 FIPP and 1 MATID certified Chilian physicians. Performing interventional procedures requires a certification, although due to no formal impediment, anyone can perform pain procedures.

Paraguay

Paraguay lacks legislation regarding pain treatment resulting in administration by individuals with neither specialization nor recognition by the Ministry of Health or Medical Board. Various specialists manage pain with some receiving training in Argentina. There are no physicians with certifications from WIP, ASRA, or LAMID, and only one anesthesiologist is partially accredited by the European Diploma in Pain Medicine. While pain management is evolving in Paraguay, education, certification, and legislative support are needed for further development.

Nicaragua

Nicaragua has only eight pain specialists, mainly trained in Mexico, with no formal subspecialty registry. There was an association of pain specialists that led education in pain medicine and intervention, although this was disbanded due to politics. As of January 2024, only 1 MATID certified pain physician resides within Nicaragua. No programs offer training in pain medicine, and the Military Hospital is the only institution where anesthesiology residents train for one month with pain specialists.

Ecuador

Ecuador has no organized pain management training, with their few trained physicians having been taught outside the country. As of January 2024, Ecuador is home to only 1 FIPP certified pain specialist. Although anesthesiology incorporated pain management into their curriculum, there is no specific training for chronic pain management.

El Salvador

El Salvador currently lacks an official pain management training program, with only one national hospital offering palliative care education. There are just twelve certified pain physicians with at least a year of approved training.

Guatemala

The field of pain medicine in Guatemala lags in development, characterized by inadequate measures to ensure access to pain management and treatment. This underdevelopment stems from the absence of educational programs and awareness campaigns. Presently, only four public or government-funded hospitals offer pain management and palliative care.

Conclusion

Pain medicine is an integrated discipline that has gained recognition in many countries. We believe that the training standard should include at least a one-year formal fellowship program in Latin America. As pain encompasses a range of complex conditions requiring interdisciplinary collaboration and nuanced understanding of the specialty, efforts should be made to recruit specialists and ensure proper training in established programs. The LAPS has initiated an annual meeting with the support of pain medicine leaders in each country in Latin America and thought leaders throughout the globe to promote networking and international collaboration with the aim of growing pain medicine in Latin America. The LAPS goal is to advocate for policies and regulations that prioritize formal pain management education and treatments with technologies and resources that our patients deserve. We believe that chronic pain training should be collaboratively developed with international pain societies. It is essential that pain medicine and interventionism are recognized in order to prevent and address chronic pain. Thus, we advise the creation of the Educational Initiatives by the LAPS education taskforce to level the training playing field both here in Latin America and throughout the globe (Box 1). Only with collaborative, continued effort, will we be able to bring proper pain training education to our physician colleagues and patients.

Box 1 Initiatives by the Latin America Pain Society (LAPS) education taskforce