A call to arms: the credibility gap in interventional pain medicine and recommendations for future research.

Abstract

There is a credibility gap in interventional pain medicine. Our evaluations of the interventions we perform differ significantly from those of our colleagues in other specialties. This has significant ramifications that affect our patients, training programs, and reimbursement schedules. A similar difference of perception exists for some procedures in other specialties (e.g., radiology, interventional cardiology, and spine surgery), but it is particularly conspicuous for pain interventionalists. Even noninterventionalist pain specialists perceive the procedures we perform to be less effective than we do ⇓. For epidural steroid injections (ESI), the most commonly performed procedures in pain clinics across the United States ⇓, clinical trials performed by interventionalists are nearly three times more likely to yield positive results than those performed by noninterventionalist physicians, such as surgeons, rheumatologists, or neurologists ⇓. For evidence-based and systematic reviews on ESI, the conclusions reached by authors who are interventionalists are more than three times as likely to be favorable than those done by noninterventionalists ⇓. These reviews examine the same articles, using the same grading schemes, yet reach dramatically different conclusions. Similar discrepancies exist for other interventions as well, including radiofrequency denervation, sacroiliac joint pain, and intradiscal treatments ⇓. There are several potential explanations for these discrepancies. First and perhaps most obvious is confirmation bias, which is the tendency to seek out or interpret information in a way that confirms one's preconceptions and discounts conflicting evidence. This is a natural human trait. For individual studies, we might invoke a better ability of specialists to design and evaluate clinical trials (e.g., better selection) to account for some of the disparities. As an example, investigators studying ESI should not include individuals with nonspecific axial back pain and should aim to separate leg pain (which is more likely to respond to treatment than …