The following should be noted:
The Comprehensive Pain Program (CPP) is located in Toronto Western Hospital and is part of the University Health Network, Toronto, Ontario. Because of the hospital's affiliation with the University of Toronto, the CPP is open to trainee doctors and other health care professionals. The CPP offers several, but not all, forms of treatment for chronic non cancer pain patients.
Patients MUST be referred by a physician. Self-referrals are not accepted, as the CPP physicians operate under the publically funded health care system (OHIP).
The CPP 's goal is to obtain first a clear diagnosis for all patients and then offer a treatment plan that addresses both "body and mind". Therefore the approach to patient care is holistic in nature, even though some treatments may not be offered at the CPP, and require referral to other facilities.
There is a waiting list of 3-4 months.
A comprehensive referral by a physician is mandatory. Such a referral includes a) a comprehensive summary of the patient's pain condition including investigations and previous treatments, as well as previous psychiatric history and related treatments in case they existed, and b) copy of consultations, tests and surgical reports if available.
Once a referral is received, it is filed and dated. Certain cases may be given priority due to the nature and duration of underlying condition.
When openings occur, the patients are mailed a letter asking them to call within 30 days, at which time they will be given an appointment with any of the 3 doctors who work at the program, including Dr. Mailis Gagnon.
The consultation is at least 2 hours long, therefore the patients are advised by the secretarial staff to allocate adequate time for registration, filling out proper forms and seeing the clinical staff.
If the referring physician feels the patient requires a medically justified urgent referral, he/she should contact the CPP directly, so that he/she may speak to the staff and justify why the consultation should be expedited.
WHAT HAPPENS WHEN THE PATIENT ARRIVES AT HIS/HER APPOINTMENT
The patient must register and obtain a registration card.
The patient is then given a number of forms to fill that will be reviewed during the consultation.
A detailed history is obtained first by the clinic coordinator, the nurse practitioner and/or the consultant.
This is followed by a detailed and thorough musculoskeletal and neurological examination by the consultant.
The patient is expected to be disrobed to facilitate the examination.
The patient is advised that one or two trainees may be present in order to fulfill our obligation as an academic pain clinic.
The consultant and the team then establish a plan of action regarding investigations if needed and treatment.
The patient will usually be brought back after investigations or to check the effectiveness of proposed treatments.
Further investigations and consultations are usually organized by the CPP at the Toronto Western Hospital, unless the patient prefers them done in their local area.
The CPP offers (if it is considered appropriate) drug therapy and makes suggestions for physical therapies, alternative treatments, nerve blocks, cognitive behavioural treatments and/or surgical consultations if indicated. Many of these treatments are NOT available in the premises and patients must be sent elsewhere.
The CPP does NOT offer "chronic pain management" across the lines of intense multi- and interdisciplinary treatments employing behavioural/ cognitive techniques and physical restoration. Such programs are specialized and most often than not funded by third parties (workers' compensation, car insurance after a car accident etc) and are specifically accredited for this. However, the CPP may make a referral to such a program.
Some patients will be offered a 4-day admission to the hospital for interdisciplinary investigations and consultations. Admissions are reserved for patients with unclear diagnosis, which in turn is necessary in order to establish a treatment plan.
Patients without a family doctor or a steady consultant will be seen in consultation and recommendations will be made to the referring physician. However, the CPP staff will NOT provide primary care to the patients.
In regards to a patient who already is or may be considerate appropriate to receive Long Term Opioid Therapy, the CPP staff will make recommendations to the referring physician in regards to the appropriateness of such therapy.
The staff will accept to prescribe opioids ONLY a) during the period of adjustment and optimization of the treatment, b) provided that the referring physician or family doctor is willing to take the patient back once the patient is stabilized. In all other cases, the CPP staff is happy to provide advice and steady follow up to the referring pshysicians who must continue to prescribe the patient's medications.
INAPPROPRIATE/ INCOMPLETE REFERRAL
A referral is considered incomplete when the physician fails to provide adequate information as requested or provides only minimal information. An example of incomplete referral is: "Mr. X has a long history of back pain, has undergone multiple back surgeries and uses large doses of opioid medications. Please see" (while no further information is forwarded). This, unfortunately, occurs often, particularly when the patients, who usually have complex histories, are referred from busy clinics.
Such a referral is rejected. A covering letter is sent back to the referring physician with the referral returned. The physician, therefore, must initiate a proper referral again. When patients call to inquire about an appointment, they are advised that the referral has been returned and should contact their own physician, so that they can be re-referred.
FAILURE TO GRANT A CONSULTATION
Given the length of time devoted to consultations and the waiting list for the program, cancellations should be done at least 48 hours in advance, to allow the staff to fill the "slot".
"Failure to show" results in refusal to grant another appointment, unless in extenuating circumstances.
Patients who arrive late, may or may not be accommodated, depending on staff bookings and availability for the day. They will be given either another appointment or have to wait until other patients complete their consultation.
Patients who are immobile or wheelchair-confined are advised to come with a chaperon, so they can be assisted during the consultation for undressing and transfers. There is no staff available to assist on these matters.
Patients referred for consultation who are bed-bound and have to be transported by ambulance, cannot be accepted, as the clinic has no facilities to accommodate such patients.
All referrals are reviewed by clinic staff to make sure they are appropriate and complete. Referrals are rejected if they contain minimal information as stated earlier, if the patient has a condition that is not covered under the expertise of the clinic, or if the patient has been seen, investigated and treated before by the CPP and all treatments have been exhausted.
Patients who are abusive to the staff either in person or by phone are brought to the attention of Dr. Mailis Gagnon and may not be granted a consultation.
REQUESTING SECOND OPINION
Such request from other pain clinics are accepted as regular referrals, provided adequate documentation has been sent.
If a patient seen by other CPP staff clinicians requires a second opinion, Dr. Mailis Gagnon will review the consultant's file. If she feels that the consultant has missed a particular diagnosis or certain treatments can be further offered, she will accept to see the patient, otherwise, consultation with another pain clinic will be recommended.
LOCATION OF COMPREHENSIVE PAIN PROGRAM
Comprehensive Pain Program
Toronto Western Hospital
4F811, 399 Bathurst Street,
Toronto ON M5T 2S8