Chapters Transcript Video How pain medicine is evolving for physicians and patients One of the things that I'm actually having a different conversation with my patients now, now that I've been in practice for 15 years as compared to when I started, is talking about longevity. You know, patients are living long, people are living longer, and they're going to be living into their 80s and 90s lifespans we've never seen before and living with pain is definitely part of that, um, your hip pain, your knee pain, your arthritis, things like that. Uh, but also pain is a huge biological accelerator for aging. So you want to make sure that you're not in pain to live as long and have the high quality of life that you want to have. Hi, I'm Lindsay Carrillo, director of business development at UCI Health. Hi, my name is Doctor Sunil Verma. I'm the associate Chief Medical Officer for ambulatory and an otolaryngologist here at UCI Health. Welcome to Physician Huddle by UCI Health. Today we're honored to be joined by Doctor Shalini Shah, professor and vice Chair of the Department of Anesthesiology and perioperative Care. She's also the director of pain services at UCI Health. Welcome, Doctor Shah. Thank you for having me. So tell us a little bit about your background, how you came to be at UCI Health, and what you do here. Sure, absolutely. I'm from California. I'm a native Californian, but I did all my education from college onwards, um, on the East Coast. I actually studied to be a diplomat, and then I was in the Middle East. 9/11 happened, and so I had to pivot. So I pivoted like all Indian people do to medicine. There's, there's truth there. Um, and so, um, but it wasn't part of the plan though. Wow, OK. So that's not Indian though, but continue. Um, and then went to med school, and then, uh, residency in anesthesiology at Cornell, and then fellowship in both adult pain and pediatric pain at the Harvard Hospitals. So at the Brigham and BI for adult pain, and then pediatric pain at Children's of Boston. And when I was there, um, UCI actually the chair at the time of anesthesia was looking for a pediatric pain specialist to build a program between CAC and UC Irvine. And so he recruited me to come here and I said, you know, no, I'm really into private practice. I kind of just wanna to do private practice. He said, just. Come over and he sent me a ticket, um, and he said just look at what we're all about and I loved it. I loved the people and the it was a smaller hospital at that time and really warm, um, and so I said I'll try it out, I'll try it out for a few years, but then I'm still gonna go to private practice. But just um stayed here and then after being director of the pediatric pain service for the hospitals, um, became involved in the associate program director for fellowship, the pain medicine fellowship, um, and then UC Irvine was looking for a director of pain, um, and they did a national search so that, so they hired a search firm, um, and that's when I said, you know what, let me put my name in the hat and I applied and got the position and then vice chair and then here we are. Yeah, that's great. So tell us a little bit, are you still involved in the management of pediatric pain patients, or yes, we have, believe it or not, one of the biggest, um, by volume pediatric pain programs in the country. And so normally how pediatric pain is managed is one patient for 8 hours where they meet the psychologist, the physical therapist, and then the doctor. Um, but what we do here it's a little bit different because, you know, philosophically, I don't believe that children should be suffering in pain waiting for an appointment. So we see about 2025 patients a day, um, both in Orange and in Irvine, and try to get them in as soon as we can and really have built relationships in the community with other hospitals and pediatric physical therapists, and we have our own pediatric pain psychologist in-house. We really built this program up so we can, um, treat as many patients as we can. And to be honest, it used to be primarily, um, syndromes, rare syndromes that we saw. Um, a lot of headache, obviously abdominal pain, but now we see a lot of athletes, so a lot of junior Olympic athletes or, um, kids who are trying to maintain their scholarships for, uh, college or trying to get into college. So we see a lot of low back pain and, and those repetitive motions that they do as divers and swimmers. See a lot of those patients. Wow, that is incredible. How long have you been leading the pain management services program? Um, 2016, so it'll be 10 years. Wow, yeah. Tell us a little bit about your leadership of that program. Obviously you're a leader in many ways here at UCI, but you know, I think you've really grown it up and increased reputation. But what were some of your goals when you first took on that role and how has it evolved? When we, when I started here, we had a very small pain program run primarily through PMNR, um, and, um, I started off with one day of a week of pain, and at that time I was considered, did you hear this new gal got a day a week of pain? That's a lot gal. Um, and so we built it by hiring really good faculty, and one of the things that we really wanted to do is not have inbreeding. So we didn't want to have uh faculty here who did the residency here, who did fellowship here, and then stayed on as faculty because then the teaching program would only have one style of approaching, um, patient care. So we try to recruit faculty from Northwestern, the Cleveland Clinic, you know, other hospitals, USC, so that, that there would be a diversity in treatment options for patients as well. And then the other thing we did is that we really have to penetrate the market. Having one clinic located in Irvine is really not accessible for patients to drive that far. So we've opened up what we just opened up our 9th pain clinic now across the county. So, um, both, I would say it's in access for patients, um, and bringing in good people. Yeah, and is that multidisciplinary then you mentioned that primarily at the time it was physical medicine and rehabilitation. Is it a mix between anesthesiologists and PMNR and are there other specialties? The way we govern ourselves is a little bit different. You've probably seen in spine surgery, you've got orthospine here and neurosurgery spine there, and people are like, Where did I send the referral to, right? And so we didn't want to do that because pain is so multidisciplinary and there's so many specialties that can go into pain management. We say we have one charter, which is the pain committee, which reports to med exec. Um, and anyone who's completed a fellowship in pain medicine, ACGME pain med, uh, pain medicine fellowship, and is board certified can practice under us. So we've got anesthesia, PMNR, we used to have neurology, all sorts of, um, psychiatry, uh, all the specialties can practice under one roof, so there's not doctor shopping within their own institution, you know. So smart. Yeah. Tell us a little bit about how you've grown the educational aspect. You know, I know you have a passion for teaching and residents and you know, fellows, as you mentioned. The teaching program we started in medical school. Medical school historically, as you know, Dr. Verma, didn't teach us anything about pain when we were in med school. No, not really. People aren't in pain when they see a doctor. It's not very common. Unfortunately, I think unfortunately it is just ask what the pain level is and then ask your next question. And you know, not even a follow up like paint's 10. OK, so why are you here? So you know, it's not like there's no education to your point about what we do next and how to manage it. Yes, and we didn't even get much training on opiates, and that's part of the reason why we're in, or we were in the opiate epidemic. Um, and so it starts with medical students. So we formed a consortium across all the UC hospitals through UCOP, through University of California Office of the President, to create, to change the curriculum in UC medical schools. So there is now a formal curriculum for pain and opiates. Um, so all of our medical school students who are graduating throughout the UC system will now understand how to treat pain effectively. And we see it as, you know, our interns or our residents, when they get to the florist, they're writing massive doses of opiates because they don't have that context of, oh, that's too much or that's too little. So we try to teach it, um, at our, when we get our interns across all of the interns, interns that uh come to UCI Health. So we all sit them down, all 400 or 500 or however many there are, and teach them about pain and how to prescribe opioids 101. So great segue. Tell us a little bit about. You know, what is the state of care when it comes to opioids, because you have now seen a few different types of opioid epidemics, and it seems like every once in a while it rears its head again and you have to go out and do a lot of education. So tell us where we're at right now. You know, opiates kind of, when we started practicing, it was actually still to this day in California, physicians can lose their license for the undertreatment of pain. So overprescribing was almost, you had to do it to protect your license. And now we're seeing the pendulum go the other way where people are afraid to even write one script for one tap because they are afraid of the DEA knocking on their door or, you know. You know, losing their license, but I think we've kind of found a middle ground where, um, opiates are not the hero and they're not the villain, but they're part of a treatment, personalized treatment plan, right? Um. And I'll tell you because we wrote, uh, uh, the guidelines for the California Medical boards. We specifically don't want physicians to get in trouble with pain or pain management or overprescribing. So there's a lot of safeguards that we've actually built into our EMR with some of our, um, Epic colleagues to protect physicians here at UCI, um, and or any prescriber here at UCI really. I think that's the hardest, right? Like, so for me personally, managing pain in the postoperative period has become, well, it's interesting actually, it's gone in a way that We would give, you know, when I was in resident, we would just give everybody 30 pain pills just for no reason, and nobody really asked back then if you're even taking it. And then the, we sort of have given less and less and realized, I think with a lot of the interventions with IV Tylenol before or, or, and all sorts of things, you actually can avoid pain medication. So, I think a lot of surgeons are comfortable with treating pain in the immediate perioperative period that 3 to 5 to 7 days, but we still get freaked out when a patient calls and says a week or 2 weeks later, I'm still in pain, I don't know what to do. Is it reasonable at that time for a treating physician like me to call, consult a pain specialist, or should we, do you think that we as a surgeon should be more comfortable with managing patients outside of that narrow window that we've developed comfort with? It's a great question. I mean, um, I think for, for sure, we're always available. Call us anytime, but definitely have. Comfort or have that expectation that by 6 weeks you should really be off pain medication. So we, you know, our orthos colleagues do a great job of that for knee pain, for example, knee surgery. We really tell the patients by this time you should be off opiates. And if they're not, then they come and see us. But for sure, if you feel uncomfortable, yeah, and I think I was mentioning my narrow window just because the majority of surgery I do is transral, so there's no incisional pain. But I think all of us have that comfort point where I sort of have that 95/5 rule in my head. And so I know how 95% of my patients, I know exactly how much meds they need, and then after that 5%, I get, I get concerned about some of the considerations that you mentioned. So I've personally found it helpful to be able to rely on colleagues, um, because at the end of the day if there's a better way of treating them or a different tool than just a narcotic, then God bless. I, I, I would love to have that help, and I think a lot of. Um, physicians are in that boat as well. Yeah, I'll tell you, I, healthcare is a team sport. So if I, there's so many things that I can't do, and I look at surgeons and I look at you, I say, how do you guys live this lifestyle and work this hard, and you're operating for 8 hours at a time. Sometimes it's, uh, crazy. But so anywhere we can help our surgeons, we definitely, definitely want to. Or any of the physicians here at UCI, um, but it's important if you're thinking about escalating opiates, let them come to us. What will be that police dog will help navigate. We'll give you some other options because it's hard for us to get a patient once they're escalated, and then they have to come and see us and we try to wean them down. It's, uh, you know, it's very difficult to have that conversation. You know, you talk about surgery and that's like a really specific point in time, but what would you say to like a primary care physician or someone who is managing someone with chronic pain like. Do you have kind of a rule of thumb? These people are very busy, and I'm sure it's a really complex topic, not to ask you to distill everything into one soundbite or anything, but, um, I think our actually at UCI our PCPs do a phenomenal job of managing pain, and they're very reasonable. I hardly ever see very high doses, um, that are being prescribed. I would say if patients need it and they're functional, don't be afraid to prescribe it. I mean, it's, it's. Part and parcel of aging. It's part and parcel of trying to maintain your function and mobility. Maintaining mobility is the and performance is the most important thing, and I think they're doing a great job, um, you know, with the tools that they have. Yeah. And this goes beyond, so we've talked a little bit or quite a bit actually on the management with oral medication. But this is also a specialty that's highly interventional and procedural as well. And so what is, what's the, what is the current state of treatment and, and where are you going with, with interventions for management of pain? Yeah, I would say the field of pain medicine, if anyone ever wants to have hope about medicine, the field of medicine in the future is talk about pain because we're coming out with so many new therapies, modalities, um, devices to treat pain that never existed. I think between cardiology and pain, that sphere. is just exploding in terms of how we can manage pain. And the other part of it, honestly, is, yes, there's great new devices and interventions that we can do, but one of the things that I'm actually having a different conversation with my patients now, now that I've been in practice for 15 years as compared to when I started, is talking about longevity. You know, patients are living long, people are living longer, and they're going to be living into their 80s and 90s lifespans we've never seen before. And living with pain is definitely part of that, um, your hip pain, your knee pain, your arthritis, things like that. Uh, but also pain is a huge biological accelerator for aging. So, you want to make sure that you're not in pain to live as long and have the high quality of life that you want to have. So, that's a new thing that actually, I'm not talking. with my patients about and how can we optimize your performance, your vitamins, your health, and not to be quack about it by any means, but just, uh, let's look at your muscle mass and talk about how you can improve the percent of lean muscle you have in your extremities for better performance, a better lifespan. So things like that. Can you tell us more about that? I mean, yes, obviously, you are an expert on all these medications and devices, but touch on some lifestyle things and are these things that like You know, patients really do respond to, do they want additional ideas and, you know, are they able to incorporate that into their lives when it comes to pain management? I think for Orange County for sure. I think people here are very lifestyle focused. They're, um, they take very good care of their health overall, I think, um. I think people are absolutely receptive to it. Most people don't know that by age 60 or 65, you're gonna lose one third of your muscle mass. That's huge. Um, and so just having those kind of conversations, um, they, they seem to be really receptive, including acupuncture or acupressure or, you know, um, Pilates, to be honest, is a, a great type of workout. Um. So yeah, people are definitely res uh responsive to it, but then there's also those patients who say, just give me my narcotics. Well, what I love about the way you approach it is you approach it from the individual patient perspective, from the position of a team, but then you also have scaled your ideas. So you touched on earlier, I mean, I think this is pretty impressive to be a physician and be such an advocate to think how are we gonna educate through the University of California medical schools and create a curriculum and help educate the next level of uh the next uh physicians that we have. Tell us more about how you've worked on the local and national stage for the efforts that you have found important, uh, because that's, that's, that doesn't happen during the working hours. That seems to be a night and weekend and taking time out of the schedule. I think a lot of our listeners, a lot of physicians want to participate in the ways you have. Tell us what you do, and then I'm gonna ask you next, how do you balance it all out. Oh, OK, um. Most people when they finish medical school or are working in healthcare, don't understand how healthcare works. And I think that one of the first things you can do is get part of a national society or your specialty society or a state component of your national society, um. To get involved that way. And what I mean by getting involved is advocacy because healthcare is written by rules of public policy or, you know, congressional rules for by people who have never taken care of a patient. So the rules are not written for the people who are in healthcare, which are patients and physicians, right? And so getting involved in going to Washington DC, we go, I go every year or to Sacramento with our state legislative leaders, um, is really important for me, for me to sit there and tell them, hey, you need to continue access to telehealth, for example, or you need to in. Talk about getting rid of this prior auth process, which is just adding administrative burden for no reason. I understand containing cause, but it's limiting and restricting healthcare. And when you go there, what's really interesting, I don't know if you've ever been to, uh, no, I haven't. I just haven't found the time, yeah, to go sit with your congressman. When I sat in Feinstein's office, you don't speak with Feinstein. You go and you speak with a 2 year old who just finished college or 22-year-old who's their staffer, and they are the ones who inform your senator. And that's really important to speak their language. And so when we're talking about healthcare, I remember one of the staffers like, wait, what's a referral? I'm like, oh gosh, so they really have no idea how healthcare works and they're supposed to be helping inform our Congress how to vote. So it's really important that we go and we inform them of, of what's. I don't think I would be that patient. I don't think I have that patience inside of me to she was a diplomat. I think that really helps to educate a 20 year old. I can barely handle my own children sometimes, but yeah, that's so, so you've learned the language. You've clearly, uh, done this before. You do it often and. And how do you determine your priorities? I mean, so you work with, uh, you're the president of, or the pre tell us about your role at the Orange County Medical Association. I'm the immediate past president, so I was just president. Um, my term finished this summer, and first from UCI, may I say, yes, yes, yes, um. So, one of the things about healthcare that's important, like you mentioned, and I think you're doing actually a lot of this work in your role is treating the community first. And if you establish a market and good healthcare in your community, I think then you can expand it to state and national and or scale it, right? Um, But with the Orange County Medical Association, we've got about 7 hospital or healthcare systems here in Orange County, about 5000 physicians, and so we're overseeing all of that to deliver and decrease barriers to healthcare and really go fight in Sacramento with the CMA or with the AMA in Washington, um. So, that's a little bit of the role that the Orange County Medical Association does. It's really put patients first and physicians first, because that, those are the two drivers of healthcare, of good healthcare. Um, With the AMA, the other thing is, you know, and I, you know, it, the AMA looks at healthcare as a whole, but At, at the, when it comes to delivering or determining how physicians get paid or healthcare gets reimbursed, that's by specialty. So also going with the AMA and sitting on the rucks, there's something called the RC. Most physicians may or may not know about it, but that's what determines your RVU. That's what determines how you get paid for what code, um, and what's covered and what's not covered. So also sitting and, and participating in those kind of panels is really important. And why is that important? Because You know, health care, we, as much as we talk about, oh, the hospital, oh, the, you know, the, the clinics, it's really where one, where one. Sport like I, I mentioned earlier and so if hospitals make money, so do physicians and, and, and, and ultimately patients will get better care. So how do you balance all of this out? So yeah, going back to the previous question, how do you find the time to do all of this and, and do you ever say no? That's a great question. Um, it was hard, and I'll tell you, the way I balance it is I had a really good nanny who lived, who lives, she still lives with me, lives with us, and I think that's when you have help, uh, healthcare or help at home, it makes a huge difference, you know, um. But um I have started to say no. I have, and I'm trying to find peace in saying no to things, um, um, because when my children were younger, they didn't miss me as much, you know, and now they're older, they're in high school, they need. Yeah, this is that time. Yeah, this is the time when you want to be there for them and those weird off nights that you couldn't predict before on the weekends when they have a project to do. Absolutely. Oh, I know, or they're tears after a sports competition or, you know, things like that. It's It's hard, yeah, but also balancing your professional life. I mean, you see a lot of patients and you're overseeing a program and you have all these other roles. So, you know, to Dr. Verma's point, like, is it just a prioritization? You're like, OK, I'm going to take on this role. I'm going to lead the OCMA this year and we're going to sacrifice some things, and then You know, a new season will start after that. I think it's always a push and pull, and, uh, some things go on the back burner, some comes up in the front, and yes, it's a lot of nights and weekend work. It really is. Um, I wish I had a better answer for it. Um, actually, if anyone wants a book recommendation, there's a great book out there. It's called Do Nothing, to your point. About how do you say no. And it talks about how the history of work, right? Um, how it started with the industrial revolution to where we look at work now in, in, in America and how we prioritize work. And this is the first time in America where we have 5 generations alive in the workforce. Right? We've got the boomers, we've got the Gen Z and the alphas and millennials, and everyone has a different idea and concept of work and what it means to work and how to be compensated for work or how to show up at work. Um, so it's, it's a really interesting book, uh, about how we've gotten to the point where we're overworked and really we should be considering, you know, finding that time, that balance to say, I'm not going to do that today or saying no to things. That's so interesting. I mean, it gives two thoughts to mine, uh, that come to my mind. One is my father is going to be 80 years old, uh, this coming in a couple of months. Um, he's a primary care physician. If he, if he was in the room, you would not think he's 80 years old, and he's still seeing patients, you know, he does that 2 times a day, or sorry, 2 times a week for up to him, it'd be 3 times a week. And so that's what keeps him young, that's what keeps him sharp, right? Um, and it's hard not to be influenced by our parents or by people you love, but to your point too, the generational needs back then are different than the generational needs now, and so I sometimes feel selfish when I'm taking time off from work or I say no to an opportunity. Um, because that's not the way I was raised, um, and so that is a very different, um, way of carrying life on, and then I watch my kids who have very a lot of pleasure in saying no to anything, especially to me, yeah, like, wow, I really, really spoiled you guys, um, but it is, it is very different and, um, people have different expectations of what they want in their personal life and what they want in their professional life, so. And it changes for us too as we continue to work, um, so that's, that's pretty interesting. I also think it's impressive that beyond everything you're doing, you also had a time to read a book called Don't Work on the plane or what? when are you doing this? Like, so that's, let's just recognize that that it wasn't even a textbook. So that's pretty impressive. Thank you. I love all this positive. This is a great energy here. It's just therapy for everybody. This is how we get people to talk. So what's next for you? What's next? I don't know. That's a great question. I think about that. Should I have a next? I typically have never, you know, there are some people who plan out their 5 year strategy, their 10 year strategy, 50. I don't even know what I'm gonna wear the next day, let alone plan out a strategy like that. So I kind of see what's coming, where I can serve, where, where people need me, um, and go from there. Makes total sense. Yeah. The good thing, the, the one thing I will tell you, um, is. Wherever I can find value, but putting together a good team. That's most important. And one of the things I've realized that is that if, for example, if you have an um You know, analogy of an iceberg. You've got most people when they work on a team or they come to work, they work at the above the iceberg line. Then you've got some people who are a little bit more intuitive and can really be at the interface line. But when, what we need to do, or what I try to do is get below that waterline and see how do teams work well, how do people work well, what do they need? Um, and some, it could be, you've got a single mom on your squad, you know, a PA, we have a, uh, you know, a physician assistant who's amazing, but she's a single mom, and I don't know how she does it. So, supporting her to her full ability is, you know, Really important to us. So it's things like that trying to flex and push and pull where what people need to be successful at work. And to that point they're gonna need different outs at different points in their life, right? So just like you mentioned, maybe when the kids are young or if this person's in a special situation, being able to flex that, that physician or the physician assistant or that team core team member off and on. Uh, because we are living longer, we're expected to, frankly, work longer in order to be able to afford things, so you can't work at 100% every day or every week or every, you know, for all time periods. So I think that's. Pretty important as a leader for you. I mean, you just recognize that in having a diverse team that not everyone's gonna be the same and, and running it on the same sort of speed at all times, including yourself. You are so right. And just I may run on a frequency, but that doesn't mean I should expect that out of everyone that works with me. Yeah, I, I've had to learn that, you know, um, and controlling and managing your own emotions too, like, how come this is not done yet, you know? Yeah, absolutely, yeah. So, I mean, you've accomplished so much and you've been a leader here for a long time. Is there any advice you would give to someone who's just kind of starting out but has ambitions? They want to be a leader in addition to being a physician and Anything that you learn that you kind of wish you could have told your younger self. Yeah, I think the 1st, 1st and foremost, it's important to be a good doctor first. That's the, I think you would agree with that. Before you can serve or serve anywhere else, you've got to do your job and do it well. And it really takes 5 years to really understand what you're doing and understand your patients and what will cause a complication and what will not. Right, so honing in on your practice as a good physician first is, is paramount. Um, apart from that, I would say, believe it or not, most people don't have the bandwidth or the frequency to get involved or want to do nights and weekend work. So if you do and you show up and you, you know, you execute on a small task, likely you'll be asked for the next task as well, and you just take it from there. And it's, if I, my advice is if you go with the mindset where you can serve. Whether it's your community, whether it's the state, whether it's national, wherever you feel that you can put value and serve people, um, you're already a leader. Yeah, great. I think that's a great place. Yeah, there we go. Amazing. Thank you so much for coming. You're great. Love it. This has been Physician Huddle by UCI Health. Thank you for joining us. This was an episode of the Physician Huddle podcast by UCI Health, produced by Brett Shahen, Angelica Yagubi, and Victor Ting. For more episodes, information on clinical trials at UCI Health, or to refer a patient, view the show notes or visit clinical connection. UCIhealth.org. Created by
