Cite as: Nanda, M. Interview with the 2024 John J. Bonica Award Recipient: Dr. Jan Van Zundert. ASRA Pain Medicine News 2024;49. https://doi.org/10.52211/asra110124.005.

"Less is More."

Dr. Jan Van Zundert is an anesthesiologist and chair of the Multidisciplinary Pain Center, Ziekenhuis Oost-Limburg, Genk, Belgium, and a professor of pain medicine at the Maastricht University Medical Center in The Netherlands. He obtained his PhD in 2005 from Maastricht University. He is the author of more than 150 publications in PubMed-indexed journals, (co)author of 42 book chapters with a Hirsh factor of 33, and editor of the Dutch and English versions of the guidelines, "Evidence-based interventional pain medicine according to clinical diagnoses." His research interests focus on clinical and translational research in interventional pain medicine. He is a member of several national and international associations for anesthesiology and pain medicine.

Monika Nanda: Dr. Van Zundert, reflecting on your impressive career trajectory from anesthesiologist to chair and professor of pain medicine, what key leadership lessons did you learn through this journey?

Jan Van Zundert: The most important thing I learned is that "less is more." As anesthesiologists and pain physicians, we always work in a team where everybody has an important role and contributes to the results. Everyone plays their role in achieving treatment success and patient satisfaction, and the emotional quotient is even more important than the intelligence quotient. It is important that there is confidence and a good atmosphere within the team. As in a football team, everybody has assignments and needs different competencies. Keep it simple and let everyone shine; this also guarantees continuity in patient care and contributes to the whole team's success!

MN: As a prominent figure in the development of guidelines for interventional pain treatment, how do you assess the impact of these guidelines on clinical practices globally?

JVZ: Pain medicine is subjective with no clear delineation of good or bad. We have evolved from a number of specialists who each have their own "favorite"—such as radiofrequency, spinal cord stimulation, opioid treatment, or the biopsychosocial approach—towards a more integrated approach. For pain management, the guidelines can be summarized as "less is more." We must pay attention to the rapid introduction of new medications or techniques often stimulated by the industry. The rapid increase in the use of these ”new kids on the block” is frequently tempered after some years. The objective of treatment guidelines is to promote an evidence-based, balanced approach.

Our guidelines are widely read and often referenced. We started the guidelines with Dr. Maarten van Kleef and a group of colleagues from the Netherlands and Belgium 20 years ago. The guidelines are practice-oriented and designed to help colleagues select appropriate treatments for each patient: "according to the clinical diagnosis." Our guidelines are extensively reviewed by peers worldwide in collaboration with Dr. Steven Cohen for the current update and Dr. Nagy Mekhail for the previous one. Both have done amazing work, and their contributions cannot be overestimated. I want to thank everyone who helped with the different publications.

MN: With your extensive experience in pioneering the use of pulsed radiofrequency for pain treatment, what do you believe are the future directions for this technology?

JVZ: Pulsed radiofrequency is a minimally invasive procedure that has been documented to be effective in different types of neuropathic pain predominantly. It was developed 25 years ago by my mentor and predecessor as academic chair of the department of pain medicine at the University of Maastricht, Dr. Menno Sluijter. To date, very few side effects of pulsed radiofrequency have been reported. For successful treatment, it is crucial to balance safety with effectiveness, a point we also stressed in the guidelines. In fact, "less is more!"

We regularly encounter differences in practice between the United States and Europe. In the United States, neurostimulation is more liberally used, and pulsed radiofrequency is rarely used because of differences in reimbursement systems. However, pulsed radiofrequency is much cheaper and more commonly used in Europe.

MN: Considering your significant role in the World Institute of Pain (WIP), how have your contributions to this international body influenced pain management practices worldwide?

JVZ: The founder and driving force behind the World Institute of Pain was the late Dr. Prithvi Raj. He convinced Drs. Gabor Racz, Serdar Erdine, Ricardo Ruiz Lopez, and David Niv to support and share his ideas on the need for proper training in pain management with a focus on interventional pain treatment. This group followed the example of Dr. Bonica, who realized the need for a multidisciplinary approach to chronic pain.

I joined the World Institute of Pain in its early years because I believe in its mission to improve "interventional pain management" through international teaching and training. The WIP journal Pain Practice provides monthly information on clinical trials and reviews conducted in interventional pain medicine. Pain Practice, Regional Anesthesia and Pain Medicine, and Neuromodulation are influential journals in our field. Most of our publications are found in these journals.

Another important milestone related to WIP is the Fellow of Interventional Pain Practice (FIPP) examination. It is a valuable tool to evaluate a candidate's knowledge about (neuro)anatomy, the indications for interventional pain techniques, and their ability to perform procedures. Many doctors worldwide have passed this exam successfully, which helps ensure that interventional pain management techniques are used appropriately and performed safely.

MN: How do you approach mentoring the next generation of pain specialists, especially in the complex and evolving landscape of pain medicine?

JVZ: Several scientific associations have elaborated a curriculum for pain specialists. These are mainly based on the principles of Bonica and Raj. These curricula should form the basis for the training. As you state, the landscape is evolving rapidly, and it is a vast task to follow the publications in the field. Therefore, the elaboration and regular updates of guidelines are important. The guidelines adequately summarize the most recent literature, which we hope will help the next generation of pain physicians.

MN: Can you share an example where your leadership significantly changed the approach to pain management in your institution or beyond?

JVZ: In the early 1990s, we had to train in pain medicine abroad. Later, we started the training in Belgium and have trained more than 60 fellows who are now well-established pain specialists, many of whom have started as chairs of pain centers in their hospitals.

Another example is the introduction of "shared decision-making," where the pain specialist discusses the possible outcomes and potential side effects of a treatment with the patient. Based on this information, the patient and the pain specialist select a treatment option. For example, in our practice, interventional treatment of trigeminal neuralgia is based solely on shared decisions as there are different treatment options, each with its advantages and disadvantages.

MN: What challenges have you faced in integrating multidisciplinary approaches within pain centers, and how have you addressed them?

JVZ: Early in my career, the pain center was created as part of the anesthesiology department. Anesthesiologists specializing in loco-regional anesthesia utilized techniques such as injection therapy, (pulsed) radiofrequency treatments, various ablation therapies, and neuromodulation. The referring physician requested a given treatment. We had to demonstrate that our diagnostic process was more complex and required input from other specialties, such as physical medicine and rehabilitation, neurosurgery, psychiatry, psychology, and physiotherapy.

Gradually, colleagues began to appreciate multidisciplinary discussions and realized that the outcome was not always an interventional treatment. Where possible, more conservative treatments are used, cognitive behavioral therapy has found its place, and surgery is performed after careful evaluation. Continuous communication with different specialties was necessary to achieve multidisciplinary cooperation.

MN: Given your extensive involvement in clinical trials, what advice do you have for future research in pain medicine?

JVZ: In pain medicine, it is very challenging to conduct clinical trials that meet the criteria of randomized controlled trials with a sufficient number of patients and satisfactory follow-up. Ethical considerations and blinding issues limit the use of a placebo comparator. It is difficult to motivate patients with poor treatment outcomes to continue over several months, and the selection criteria are often so stringent that the recruitment rate is extremely slow. Moreover, individual patient characteristics can weaken the value of extrapolating RCT outcomes.

In the n=1 model, patients serve as their own control while treatment parameters are adapted. Treatment allocation is randomized, and outcome is measured at different time points. These studies have fewer missing data. Compared to large population trials, n=1 trials are less resource-demanding and time-consuming. In 2011, the Oxford Centre for Evidence-Based Medicine listed n=1 trials as high level 1 evidence for intervention-based research.

Another important direction in pain research is the development of "prediction models." These models may aid in the evolution toward personalized or precision medicine, allowing for more accurate prognosis and better prediction of treatment success. Prediction models estimate an individual's probability of developing a health outcome (eg, treatment success) using demographics, risk factors, prognostic factors, clinical observations, and test results. Interventional pain medicine is moving more toward personalized or precision medicine.

MN: As a leader, how do you foster innovation within your teams and projects?

JVZ: Innovation is necessary and welcome but should be implemented stepwise. Initially, the treatment should be tested in preclinical trials. Subsequently, certain cases should be tested, followed by clinical trials. The innovation should be introduced into clinical practice only when the efficacy and safety are documented. Innovations can lead to hype, and their use may be heavily promoted, but even here, "less is more!"

MN: Looking back, what professional achievements are you most proud of, and why?

JVZ: We are the largest training center in Belgium. I am particularly proud of all the people we have trained who remain active in pain management. To date, none of them have encountered serious complications.

MN: How do you prioritize and manage the wide array of roles and responsibilities in your professional life?

JVZ: Impossible! I experience this daily. As a manager, you need to be able to switch rapidly because events are often unpredictable. One must be attentive to opportunities and use them. However, maintaining good relationships among team members is the most important aspect.

MN: What strategies do you employ to ensure the translation of research findings into clinical practice?

JVZ: Research should be built progressively. A new treatment modality should be tested in translational animal experiments to clarify its mode of action. This should also define its safety for and effect on animals. Clinical trials should confirm effectiveness, safety, and long-term effects because we primarily deal with patients suffering from chronic pain.

MN: How have your international teaching and speaking engagements shaped your views on global healthcare?

JVZ: International engagements have highlighted the differences between countries. Healthcare systems vary, including differences in reimbursement systems, availability of certain treatments, and advertising practices. Through international contacts, we were alerted earlier to the dangers of opioid use. In Europe, prescription habits and product availability slightly limit extensive use. Warnings from the opioid crisis in other regions helped alert European doctors. This awareness allowed for limited prescription and use. Discussions with colleagues from different countries are always enlightening because they offer different perspectives.

MN: What advice would you give to young professionals aspiring to lead in the complex field of pain medicine?

JVZ: Young professionals should realize that "less is more." It is of no use to start invasive treatments when conservative management has not been fully explored.

They should be part of a team and participate in discussions and the establishment of treatment plans. Their opinion on management issues is of extreme value.