Cite as: Machi A. Interview with a leader in the field: Jose De Andrés - 2022 John J. Bonica Award recipient. ASRA Pain Medicine News 2022;47. https://doi.org/10.52211/asra110122.042 

Jose De Andrés, MD, PhD, EDRA, FIPP, EDPM, has been named the 2022 John J. Bonica Award recipient and will present his lecture at the 21st Annual Pain Medicine Meeting on November 19 in Orlando, FL. The award is given annually to recognize an individual for their outstanding contributions to the development, teaching, and practice of pain medicine in the tradition of John J. Bonica, MD, a champion of multidisciplinary collaboration in the evaluation and treatment of patients with pain.

Dr. De Andrés is a professor of anesthesiology with tenure at Valencia University of Medicine in Valencia, Spain. He is also the chair of the departments of anesthesiology, critical care, and multidisciplinary pain management at Valencia General University Hospital.

He is interviewed by Special Projects Associate Editor Anthony Machi, MD, associate professor in the department of anesthesiology and pain management and regional anesthesiology and acute pain medicine program director at the University of Texas Southwestern Medical Center in Dallas.

Without a doubt, to have been chosen for this award is very special to me because of what the name of John Bonica implies. I am especially honored because I had the opportunity to meet him in person.

Anthony Machi: You are recognized as an exceptional, leading researcher, educator, and clinician within the field of pain medicine. Can you outline your journey? What personal qualities or characteristics have been most important along the way? How did you decide to focus on pain medicine?

Jose De Andrés: From the time I was studying for my degree in medicine, it was clear to me that I wanted to specialize in anesthesiology. My motivation was to help people to avoid suffering. I understood early in training the power of anesthesia to induce unconsciousness and provide analgesia. Since the start of my specialization, I have been motivated by the selective control of pain through regional anesthesia techniques. To be able to achieve selective analgesia while maintaining consciousness, permitting faster recovery, has fascinated me.

During my training, there was no established school for regional anesthesia in Spain. General anesthesia predominated as the anesthetic method. I had to look abroad to find an opportunity for training in regional anesthesia. I was extremely lucky that Professor Michael Stanton-Hicks was then at the University of Mainz in Germany. I had read the book on regional anesthesia that he had written with Raj and Nolte and, without thinking, wrote a letter to him, requesting a fellowship. I was fortunate to have an affirmative response and joined him at the anesthesia department at the University of Mainz. At that time, Prof. Stanton-Hicks was developing a multidisciplinary pain clinic at the Johannes Gutenberg University of Mainz and organized the first meeting to discuss the problem of complex regional pain syndrome (CRPS) and its diagnosis. The training, mentorship, and leadership that Professor Stanton-Hicks gave me were fundamental to my career development. His transfer to Cleveland Clinic Foundation and his dedication to pain medicine guided my own decisions.

With this educational background and desire to develop my professional activity in an academic environment, I pursued work in different hospitals that provided the possibility to train both undergraduate and postgraduate trainees. In so doing, I have been able to pass on what I know to other generations and expand the knowledge of an area as important as adequate pain control in our patients. I continue to refer to the basic sciences when it comes to clinical practice, utilizing my base of knowledge in anatomy, physiology, and, later, neurosciences with imaging, and finally bioengineering.

Anthony Machi: What drives your professional curiosity?

Jose De Andrés: My professional curiosity has always been to escape routine and be able to individualize my professional activity with patients. That is why I have always tried to keep my knowledge up to date. When I started as an anesthesiologist, I was fascinated by being able to control pain without loss of consciousness, which led me to training in regional anesthesia. This guided my search for pain control through minimally invasive procedures rather than systemic pharmacology. Likewise, understanding the mechanisms of pain, its individualized application in each person, and the possibility of quantifying the results of treatments have been a constant in my search.

Anthony Machi: How do you define success?

Jose De Andrés: Success has many facets. It starts with humility and perseverance at work. It is guided by the confidence in believing that what one dreams of can be achieved.

At times, progress may seem slow and there may be more failures than successes, but perseverance generates strength of character, and courage helps one achieve success.

I've always put passion into everything I've done, and I've tried to balance work with passion. Sometimes putting feelings into what one does can make one suffer when setbacks occur, but it can also magnify the successes. Every day I strive to be happy in my work.

Anthony Machi: What has been your most rewarding accomplishment?

Jose De Andrés: It is difficult to choose a rewarding accomplishment because highlighting one implies diminishing the value of others. My thought is that each progress and achievement has a professional reinforcement effect, which gives you energy for the next challenge and the next effort to achieve. That is why I feel fortunate to have had several reinforcements and recognitions in my professional career that have helped me to continue progressing every day. Without a doubt, to have been chosen for this award is very special to me because of what the name of John Bonica implies. I am especially honored because I had the opportunity to meet him in person.

Anthony Machi: Who has been important to you as a mentor or sponsor? What did they do that impacted you and your career?

Jose De Andrés: I have to say that throughout my career and in the search for training, I have been very fortunate to find people with a high level of knowledge who have generously wanted to share it with me. This is a gift in which there are no words to thank. To all, I send my most sincere gratitude.

However, there are two people who especially helped me with their leadership and mentorship. I have previously explained the role that Prof. Stanton-Hicks played in the beginning of my career. Subsequently, I made a stay as a visiting professor at the Cleveland Clinic Foundation. This had a great influence on my career due to activities that I carried out there and the professional group that I had the opportunity to interact with. The other person is Dr. Gabor Racz, who accepted me to do a fellowship at Texas Tech University in Lubbock, and who shared his knowledge of pain medicine in all its aspects. While I was in Lubbock, I participated in a pain department with an outstanding group of professionals that provided me with a rich network for future collaborations. Moreover, I have been fortunate to maintain a relationship with both men and am so thankful for that.

Anthony Machi: Can you describe one or more of the most difficult professional challenges you have had in your career? How did you overcome it/them?

Jose De Andrés: Undoubtedly, every professional career is full of challenges, especially when you want to innovate and change trends. Throughout the years, but especially at the beginning, we had many difficulties in publishing our research in functional anatomy for the practice of regional anesthesia and pain management. I remember the many rejections and how the anesthesia journals directed us to anatomy journals (for not being a topic of interest to them) and the anatomy journals sent us back to the anesthesia journals, indicating that they were not interested in it because it was outside their interest.

In relation to the clinical treatment of pain, the most difficult situation was with the neuromodulation systems (spinal cord stimulator [SCS] and intrathecal drug delivery pump) and the compatibility of the systems with magnetic resonance imaging (MRI). One day, a neurologist told me that I had to explant an SCS because the patient needed an MRI, and the radiologists would not do it because he had an SCS implanted. I spoke with the patient, who did not want to explant it because he was very happy with its performance, then with the radiologists who adhered to the non-compatibility protocol, and then with the manufacturing company that also referred me to his technical file. Ultimately, I had to explant the system, but I decided to share the lessons of the situation and encourage the creation of a protocol that would make it possible to perform an MRI on a patient with a neuromodulation system. I published two articles from this experience, one in Anesthesiology and the other in Anesthesia & Analgesia. I will never forget the revision process of the first article, which lasted more than a year and involved two different editors-in-chief. I had to learn in detail the physics associated with the electromagnetic field produced by an MRI to be able to answer all the queries and finally saw the article published. For years, thanks to our protocol, we were able to do multiple MRIs not only to patients from our hospital but also referrals from other hospitals. Now everything is easier with compatible systems, but then, our groundbreaking work allowed us to overcome a fundamental challenge for patients who were under our responsibility.

Anthony Machi: In your view, which of your studies has had the most impact on the practice of pain medicine and why?

Jose De Andrés: All the articles that an author produces are important and require effort. Perhaps throughout all the years of scientific production, our articles on applied anatomy have had the greatest impact on broadening the knowledge of clinicians and improving their practice by better understanding the role that the different structures have both procedure performance and outcomes.

In recent years we have made a great effort to generate outcome data for the practice of neuromodulation. There have been three important areas of research in which I believe we have influenced the vision of clinicians in the practice of chronic pain:

1. Using 3D computational modeling of the spinal cord for the management of SCS, and explaining its importance in determining models of programming and improvement of results, such as the frequency of neural activation in tonic stimulation or the polarity and distance of electrodes or contacts
2. Studies of biomarkers in patients with chronic pain and their variations during SCS therapy and correlating these with results, in the search for the optimization of markers for predicting results
3. Using machine learning to facilitate identification of predictive markers with the clinical trial: Predictive Clinical Decision System Using Machine Learning and Imaging Biomarkers in Patients with Neurostimulation Therapy.

Anthony Machi: As you look back, has there been a defining moment in your career? If so, can you describe it?

Jose De Andrés: There have been multiple important moments. From a clinical point of view, when I was appointed chair of the department of pain management at my institution, I was able to apply my own guidelines to the portfolio of services and patient management. Following this, my institution appointed me director of three ICUs, the anesthesia department, and the pain departments. However, I maintained my clinical and research activity in the area of pain. From the academic point of view, becoming a tenured professor at the University of Valencia following a competitive exam was a dream come true. At the level of scientific societies, I have devoted my activities to supporting the projects of the European Society of Regional Anaesthesia and Pain Therapy (ESRA). Holding the three most important positions on its board of directors: Treasurer, General Secretary, and President, were honors after years of service to the society.

Anthony Machi: Where do you see the most potential for future research in pain medicine? Which question(s) may be most influential to future practice?

Jose De Andrés: Without a doubt, technology will continue to progress, allowing the modulation of many more structures and functions; however, the future lies in personalizing the treatment of chronic pain. The key step is to improve the patient selection tools for the application of procedures. This involves improving the diagnostic process and having objective and predictive data through imaging and biological biomarkers. The day will come when systems integrate biological information and adapt their operation to the patient's own biological evolution, achieving improved results. On the other hand, in order to recover the function lost due to disability associated with chronic pain, we will continue to progress not so much in regenerating but in restoring function with biological strategies.

Anthony Machi: Do you have advice to offer current trainees or early career professionals who seek to do research in pain medicine?

Jose De Andrés: Research in pain medicine can have more difficulties than other branches of medicine due to the impact of the placebo effect and the ethical connotations related to the possible suffering of patients. Furthermore, when studying invasive techniques, blind comparison is often difficult to apply on many occasions and impossible in other situations.

In addition, trainees must carefully review the published information and, based on the gaps they see, state their hypothesis and objectives they seek to achieve with their work. From my point of view, errors in these aspects are the errors that are the most problematic when reviewing articles for publication and generate the most frustration for those who have put great effort into their research. For this reason, perhaps my best advice is that for a good research project, the study methodology is the key factor. Without an exact and well-structured method, the validity of the results obtained is of limited value. A good adviser both for the design of the study and for the statistical treatment, before starting, is essential to achieve the final success of the research.

Anthony Machi: How has involvement in ASRA Pain Medicine contributed to your success? How has your relationship with ASRA Pain Medicine evolved over time?

Jose De Andrés: My relationship with ASRA Pain Medicine started at the beginning of my professional career. In Orlando 32 years ago, I did my first two poster presentations and, since then, both with poster presentations and later with lectures, I have maintained a constant relationship with this society. In each ASRA Pain Medicine meeting I attend, I learn something, thanks to the excellent scientific programs that these meetings always have. In addition, I have been able to share knowledge and projects with my colleagues that have undoubtedly helped guide me and promote milestones in my professional career.

Through my positions on the ESRA board, I worked to bring both societies closer, to work together, and to strengthen our ties. We created the joint membership process and supported the role of Regional Anesthesia & Pain Medicine as our common journal, reinforcing its impact among all anesthesiologists.

Anthony Machi: How much of your success would you attribute to hard work, and how much would you attribute to luck or other circumstances?

Jose De Andrés: It is always desirable to have luck because it is undoubtedly a great help, but, without effort and perseverance, nothing is possible. Each person must rely on their own strength and on their own motivation. Knowing how to work within a team and be able to get involved in working groups in which mutual synergies help to carry out very complex projects has been very productive for me. It is in these groups where I learned to relate, to give up my personal ambitions, and to emphasize the result of the group. These experiences allowed greater successes than any individual pursuit could have.

The best tips I can share are strive every day and share with a team to achieve the greatest success.

Anthony Machi: What do you love about your job?

Jose De Andrés: What I like the most is to feel useful and enjoy everything I do. As I said before, each small step brings me closer to my goal. With each small daily achievement that I enjoy, I am happy, even on the most difficult days, in this journey that is our profession.