The relief of suffering: How to take a holistic approach to pain management
For Dr Jonathan Ramachenderan, becoming a pain specialist was not a pre-planned career path but a natural evolution of his clinical journey.
He was working as a GP anaesthetist in Albany, Western Australia, when his practice pivoted towards palliative care.
“It was unexpected, but as a young GP, I found a wonderful rhythm of work between the fast and acute world of anaesthesia and critical care, balanced with the slow and meaningful work in aged care,” reflected Jonathan.
“This is where I learnt about palliative care, how to talk to patients and their families, how to manage complex symptoms, and how to build on my interest in pain management.”
As a generalist in regional WA, Jonathan’s work was shaped by his patients’ needs, and in Albany, he found that anaesthesia, palliative care and aged care intersected in managing pain.
“In the end, the theme running through my work was relieving suffering and allowing my patients to find meaning – both old and young, in the land of health and well, but also the sick and terminal,” he said.
“Even if it was an acute fracture in a young patient – doing an ultrasound-guided nerve block, providing a safe and excellent anaesthetic, managing their pain post-operatively and helping them rehabilitate and return to function was superbly meaningful to me.
“I tell younger doctors now that clinical life occurs in seasons that match the seasons of your personal life. It never has to stay the same, but it changes as you do and as your family life evolves.”
A holistic approach to care
With fellowship qualifications in pain medicine and general practice (FFPMANZCA, FRACGP), and additional training in palliative medicine and anaesthesia, Jonathan now works across regional and metropolitan WA, in both private and public settings.
“Palliative care is the backbone of what I do; it’s the whole-person lens in which I frame all issues in medicine. That is, we exist as physical, social, psychological and spiritual beings and, as such, management plans need to reflect this,” said Jonathan, who in 2023 delivered a TEDx talk titled ‘The Spiritual Dimension of Medicine’, which has attracted nearly 10,000 views.
Jonathan is a Faculty of Pain Medicine (FPM) New Fellow board member with the Australian and New Zealand College of Anaesthetists (ANZCA), and the Trainee Representative on the FPM Training Unit Accreditation Committee.
He has never forgotten his roots in general practice, hailing generalists as the “masters of diagnosis”.
“Pain is an annoying symptom and all of us want it to completely stop, so this is often the expectation (patients have),” he said.
“In general practice, our work is to rule out red flags and identify the most likely cause… Most times, we are able to treat the cause and manage symptoms, and these issues usually resolve.
“All pain symptoms begin acutely, that is, there is often a trigger, be it trauma, surgery, inflammation, or an infection, and the list goes on.
“But when pain is persistent and the red flags have been ruled out, we need to think broadly about what else could be happening to our patients.”
Lessons in pain management as a GP
Jonathan admitted he made many mistakes as a young GP in managing pain.
“I was good at catching red flags but not at persistent pain management,” he said. “I had a medication-only and procedural approach, and certainly not the whole-person approach I have today.”
Jonathan said it was important for GPs to have a system that was grounded in safety and helping return patients to function – not simply on passive approaches such as medications and surgery.
“What changed for me was that I started reading widely about managing pain, attending courses and conferences, calling up specialists in the city and committing myself to being the ‘pain guy’ in my practice,” he said.
Jonathan completed the Community Program for Opioid Pharmacotherapy, prescribing methadone and buprenorphine for patients with opioid use disorder.
He also started taking on patients with challenging backgrounds and persistent pain.
“I learned a great deal about opioids and, matched with my palliative care work, I learned how to taper, manage and contain patients in general practice with specialist oversight,” he said.
He has never forgotten his roots in general practice, hailing generalists as the “masters of diagnosis”.
GPs’ pivotal role
GPs and Rural Generalists (RGs) are the conductors of the whole-person medical model, according to Jonathan, and play a pivotal role in the assessment and management of pain.
“A great deal of acute and persistent pain can be safely managed in general practice,” he said.
“The principles here are often tied to functional management with a physiotherapist or exercise physiologist, safe use of non-opioid analgesia and escalation of care after a number of non-pharmacological and pharmacological interventions have been trialled.”
Jonathan said it was normal to feel overwhelmed as a GP in training and after first receiving fellowship.
“This is when the learning starts,” he added. “My advice is to have a system of assessment that helps to catch serious illness and keeps patients informed.
“Use encouragement and a roadmap to keep patients engaged and also have colleagues you can ask for help or even a friendly pain specialist, surgeon or physician you call for advice – I love getting calls.”
Inclusive patient communication is also critical, according to Jonathan, who had a simple message for GPs and RGs – mind your words.
“There is great weight in the words we use with patients and in the roadmap we paint for them in the assessment, investigation, and management of pain,” he said.
“Off-hand comments like ‘riddled with arthritis’, ‘lots of bulging discs’, ‘really bad scan’, ‘narrowed spinal column’, and thus forth have a negative impact on our patients.
“These are nocebo words and have a negative impact on a person’s recovery and rehabilitation.”
Communication is key
Jonathan urged GPs not to be afraid to ask for help with complex pain cases.
“The one thing that has never failed me is phoning a friend,” he said.
“I’m not afraid to ask for advice from either my colleague in the next room, the Pain Fellow at a tertiary centre or my local pain specialist.
“Talking a case over certainly helps and also points me toward good resources to use next time. It is also an excellent way to build your network, especially as a country GP.
“Too much meaning in medicine is lost in referral letters to and specialist letters back to GPs.”
