Early career lessons in navigating pediatric chronic pain care during the COVID-19 pandemic

valeriamartinez-kaigi The Voice of Early Career Psychologists

Grace S. Kao, Ph.D., ABPP
Assistant Professor, Baylor College of Medicine
Board Certified in Clinical Health Psychology
Pediatric Pain Psychologist
Pediatric Pain Medicine Division|Psychology Section
Departments of Anesthesiology, Perioperative, and Pain Medicine and Pediatrics
Texas Children’s Hospital

They say time seems to speed up as one grows older. Indeed, it is strange to look back and recognize I have been serving in my current faculty role for more than five years now. Navigating these past few early career years has been both daunting and exciting. Fresh from completion of a fellowship in pediatric pain psychology, I started my position in a large academic medical center with an eagerness to contribute and hopeful uncertainty about career-building. The challenges, accomplishments, and events of this first season of my career have taught lessons of trusting one’s training, nurturing clinical confidence, building a support team, and growing adaptability and creativity in working within one’s professional system. These lessons have become even more valuable during the COVID-19 pandemic, as systems, procedures, clinical practice, and patient experiences have all been significantly impacted.

Steep learning curves and hard-earned lessons: Making it through those early career years

I was recruited to my current position as a pediatric pain psychologist to serve on an interdisciplinary medical team in a new pediatric chronic pain program. Early in my role, unexpected circumstances, including staffing shifts, resulted in me taking on a program leadership and development role. These responsibilities required a quick transition from a trainee to specialist mindset, as decisions affecting clinic structure, staffing needs, and workflow all needed to be thoughtfully, efficiently, and confidently implemented. These considerations led to a steep learning curve in growing to trust the validity of my clinical training and skillset, while maintaining a teachability and openness to learning about the program development and evaluation process within a large institution. I found the most helpful way this was accomplished was forming strong ties with the rest of my clinical pain service team and approaching administrative decisions with a collaborative approach. My clinical judgment was thus weighed and presented along with others’ well-versed in the field. Through this process, I invested time in familiarizing myself with others’ roles and areas of expertise (e.g., pain medicine, nursing, physical therapy, social work), contemplated prior pain care workflows in conducting needs assessments, and facilitated regular team discussions.

Our interdisciplinary chronic pain program was quickly established within the first few months of beginning my position; however, as very little structure and resources existed for pediatric chronic pain care, much needed to be created and cultivated. We hit the pavement quickly to build a clinical team, secure clinic space, develop patient intake questionnaires, market services, and implement a measurement-based care approach. Even with the clinical build in place, teaching and research pieces were still missing. To begin filling in the gaps, I co-founded a specialty graduate externship program in pediatric pain psychology with a psychology colleague and worked to create and develop an electronic database for retrospective analysis of our clinic questionnaires. This fit well with my belief in the benefits of measurement-based care. In pursuing these ventures, I encountered many bumps in the road towards program creation and career establishment but also appreciated an important lesson: knowing the value of working with what is available to develop venues for academic pursuits, despite the challenges of creating new systems where structure was previously lacking.

Pivoting and applying past lessons: Providing thoughtful care during a pandemic

Over the past year and a half, the most prominent challenge for many healthcare clinicians has been navigating the implications of the COVID-19 pandemic. Early career lessons of trusting clinical training and expertise; building and maintaining team cohesiveness and support; and growing adaptability and creativity continued to be vitally important in navigating care delivery during pandemic times. Applying these lessons meant adapting evidence-based clinical content to an alternate (telehealth, rather than in-person) modality, taking initiative to reach out to and create opportunities for team meetings, and adapting strategies for meeting clinical goals in the context of COVID restrictions.

For our chronic pain program, maintaining our interdisciplinary approach with multiple providers in one patient session was a challenge, given restrictions for social distancing. Pivoting to combine in-person and telehealth modalities was a needed and beneficial adjustment. Administrative and clinical challenges included maintaining effective and regular team communication with limited in-person rounding opportunities, quickly learning new scheduling and clinical workflows for telehealth visits, engaging patients with less team and face-to-face contact, and addressing patient difficulties with functional and social limitations.

For many children and adolescents, it seemed the pandemic and pandemic restrictions prompted more prominent mental health challenges, including increased anxiety about the virus itself, increased depressive symptoms linked to restrictions on social interactions and more sedentary lifestyle, sleep challenges, and school difficulties. Specific challenges often related to chronic pain (e.g., functional disability, school anxiety, and pain-related anxiety and depressive symptoms) were thus exacerbated. Some clinical strategies we responded with include:

  • Applying anxiety management strategies explicitly to COVID-related worries
  • Expanding ideas for behavioral activation and social engagement in depression treatment to include virtual options and outdoor activities
  • More frequently pursuing school liaison work, as school challenges related to virtual learning or return to on-campus format increased
  • More frequently discussing sleep hygiene and tips, given often detrimental pandemic impact on sleep
  • Expanding use of smartphone apps as helpful tools for at-home practice.

Older and (hopefully) wiser: Learning from the past and looking to the future

The transition from postgraduate training to an early career position is not always an easy one; however, the often-steep learning curve and necessary growth allows for valuable lessons learned. For me, this unexpected and life-altering experience in the pandemic age has prompted reflections on my early career lessons, as they laid a groundwork for the strategies, approaches, and ability for adapting to administrative and clinical challenges during this pandemic period. They say time seems to speed up as one gets older. I hope this means the ongoing accumulation of lessons learned and challenges faced continue to grow in us not simply a sense of hastened time but also of increased wisdom and resilience.