Is treating chronic pain torture? Internal medicine residents' experience with patients with chronic nonmalignant pain

"Give My Daughter the Shot!": A Content Analysis of the Depiction of Patients with Cancer Pain and Their Management in Hollywood Films

INTRODUCTION

Cinemeducation, the pedagogical use of films, has been used in a variety of clinical disciplines. To date, no studies have looked at the use of film depictions of cancer pain and its management in clinical education. We investigated how patients with cancer pain and their management are depicted in Hollywood films to determine whether there is content that would be amenable to use for cancer pain assessment and management education.

METHODS

A qualitative content analysis was performed. Films that contained characters with or references to cancer pain were searched for using the International Movie Database, the Literature Arts Medicine Database, the History of Medicine and Medical Humanities Database, and Medicine on Screen. After review, 4 films were identified for review and analysis.

RESULTS

Themes that emerged from the analysis concerned the films' depictions of characters with pain, their healthcare providers, the therapies used for pain management, and the setting in which pain management was provided.

CONCLUSIONS

This study demonstrates that patients with cancer pain are depicted in a compassionate manner. Pain management focused on the use of opioids. The settings in which patients received pain management was depicted as not being amenable to providing holistic care. This variety of topics related to pain management covered in the films make them amenable to use in cinemeducation. This study therefore forms the basis for future work developing film-based cancer education modules.

Utilizing a Faculty Development Program to Promote Safer Opioid Prescribing for Chronic Pain in Internal Medicine Resident Practices

OBJECTIVE

To implement a skills-based faculty development program (FDP) to improve Internal Medicine faculty's clinical skills and resident teaching about safe opioid prescribing.

DESIGN

An FDP for Internal Medicine attendings that included a one-hour didactic presentation followed immediately by an Objective Structured Clinical Examination (OSCE) that focused on assessing and managing opioid misuse risk, opioid treatment outcomes (benefits and harms), and aberrant opioid use behaviors. The evaluation compared pre- and three-months-post-FDP changes in faculty's safe opioid prescribing knowledge, attitudes, confidence (clinical and teaching), and self-reported resident teaching.

RESULTS

The 25 Internal Medicine faculty participants had a mean of 13 years in clinical practice, including 10 years precepting residents. During the three months post-FDP, faculty treated a mean of 22 patients with chronic pain on long-term opioids and precepted a mean of seven residents caring for patients on long-term opioids. At three months post-FDP, there were significant improvements in correct responses to knowledge questions (68% to 79% P = 0.008), "high-level" confidence in safer opioid prescribing clinical practice (43.5% to 82.6% P = 0.007) and resident teaching (45.8% to 83.3%, P = 0.007), and improvements in alignment of desired attitudes toward safer opioid prescribing. There were nonsignificant increases in self-reported safe opioid prescribing resident teaching.

CONCLUSIONS

A skills-based faculty development program that includes a lecture followed by an OSCE can improve Internal Medicine faculty safe opioid prescribing knowledge, attitudes, and clinical and teaching confidence. Improving resident teaching may require additional training in safe opioid prescribing teaching skills.

Consensus-Based Treatment Approaches for Managing Concerning Behaviors in Patients on Long-term Opioid Therapy for Chronic Pain: Case-Based Applications

Guidelines recommend careful monitoring of patients on long-term opioid therapy for chronic pain to assess for concerning medication-taking behaviors that may signal opioid misuse or the presence of a substance use disorder. However, specific management strategies to guide providers if concerning medication-taking behaviors emerge are lacking. Therefore, we recruited a Delphi panel—42 experts in chronic pain and opioid prescribing—to develop consensus-based treatment approaches to guide management of the 6 most common and concerning behaviors identified: missing prescriber appointments, taking opioids for symptoms other than pain, using more opioid medication than prescribed, asking for an increase in opioid dose, aggressive behavior, and alcohol and other substance use. The results of that process are published as a separate study. The purpose of the present study was to present clinical cases in which concerning medication-taking behaviors arise in the course of long-term opioid therapy and demonstrate for readers how the Delphi panel’s consensus-based approaches could be applied.

Optimal pain management for patients with cancer in the modern era

Pain is a common symptom among patients with cancer. Adequate pain assessment and management are critical to improve the quality of life and health outcomes in this population. In this review, the authors provide a framework for safely and effectively managing cancer-related pain by summarizing the evidence for the importance of controlling pain, the barriers to adequate pain management, strategies to assess and manage cancer-related pain, how to manage pain in patients at risk of substance use disorder, and considerations when managing pain in a survivorship population. CA Cancer J Clin 2018;68:182-196. © 2018 American Cancer Society.

Triage processes at multidisciplinary chronic pain clinics: An international review of current procedures

Background: Multidisciplinary pain clinics are considered the gold standard for the treatment of chronic pain, yet access to such clinics is difficult and patients’ conditions deteriorate while waiting. Instituting a triage process is one way of reducing wait time for some patients and ensuring optimal access given the limited resources available. Surprisingly, there are no established guidelines on how to optimally triage chronic pain patients at tertiary multidisciplinary pain clinics.

Aims: The goal of this study was to gather information regarding existing triage systems in multidisciplinary chronic pain clinics worldwide as an initial step toward establishing a definitive evidence-based set of triage guidelines.

Methods: A total of 66 multidisciplinary pain clinics worldwide completed an online survey detailing current triage practices at their clinic. The survey was distributed via international and national pain associations.

Results: Results showed that the vast majority of multidisciplinary pain clinics (94%) use a triage system, yet many difficulties with these systems have been identified (time requirement, administrative burden, lack of control over scheduling, missing high-priority patients, and prioritizing low-priority patients). The level of satisfaction was noted to be higher in those clinics using a structured triage template.

Conclusions: This study identified a need for the elaboration of best practice clinical guidelines for triage processes at tertiary pain clinics. The use of a structured referral template could become a central element to such guidelines.

What do providers want to know about opioid prescribing? A qualitative analysis of their questions

BACKGROUND

In 2012, the US Food and Drug Administration (FDA) responded to the opioid crisis with a Risk Evaluation and Mitigation Strategy, requiring manufacturers of extended-release/long-acting opioids to fund continuing medical education based on the "FDA Blueprint for Prescriber Education." Topics in the Blueprint are "Assessing Patients for Treatment," "Initiating Therapy, Modifying Dosing, and Discontinuing Use," "Managing Therapy," "Counseling Patients and Caregivers about Safe Use," "General Drug Information," and "Specific Drug Information." Based on the FDA Blueprint, Boston University School of Medicine's "Safe and Competent Opioid Prescribing Education" (SCOPE of Pain) offers live trainings for physicians and other prescribers. During trainings, participants submit written questions about the curriculum and/or their clinical experiences.

METHODS

The objective was to compare themes that arose from questions asked by SCOPE of Pain participants with content of the FDA Blueprint in order to evaluate how well the Blueprint answers prescribers' concerns. The authors conducted qualitative analyses of all 1309 questions submitted by participants in 29 trainings across 16 states from May 2013 to May 2015, using conventional content analysis to code the questions. Themes that emerged from participants' questions were then compared with the Blueprint.

RESULTS

Most themes fell into the topic categories of the Blueprint. Five main themes diverged: Participants sought information on (1) safe alternatives to opioids, (2) overcoming barriers to safe opioid prescribing, (3) government regulations of opioid prescribing, (4) the role of marijuana in opioid prescribing, and (5) maintaining a positive provider-patient relationship while prescribing opioids.

CONCLUSIONS

In addition to learning the mechanics of safe opioid prescribing, providers want to understand government regulations and effective patient communication skills. Aware of the limitations of opioids in managing chronic pain, providers seek advice on alternatives therapies. Future updates to the FDA Blueprint and other educational guidelines on opioid prescribing should address providers' additional questions.

Barriers and facilitators to use of non-pharmacological treatments in chronic pain

BACKGROUND

Consensus guidelines recommend multi-modal chronic pain treatment with increased uptake of non-pharmacological pain treatment modalities (NPMs). We aimed to identify the barriers and facilitators to uptake of evidence-based NPMs from the perspectives of patients, nurses and primary care providers (PCPs).

METHODS

We convened eight separate groups and engaged each in a Nominal Group Technique (NGT) in which participants: (1) created an individual list of barriers (and, in a subsequent round, facilitators) to uptake of NPMs; (2) compiled a group list from the individual lists; and (3) anonymously voted on the top three most important barriers and facilitators. In a separate process, research staff reviewed each group's responses and categorized them based on staff consensus.

RESULTS

Overall, 26 patients (14 women) with chronic pain participated; their mean age was 55. Overall, 14 nurses and 12 PCPs participated. Seven healthcare professionals were men and 19 were women; the mean age was 45. We categorized barriers and facilitators as related to access, patient-provider interaction, treatment beliefs and support. Top-ranked patient-reported barriers included high cost, transportation problems and low motivation, while top-ranked facilitators included availability of a wider array of NPMs and a team-based approach that included follow-up. Top-ranked provider-reported barriers included inability to promote NPMs once opioid therapy was started and patient skepticism about efficacy of NPMs, while top-ranked facilitators included promotion of a facility-wide treatment philosophy and increased patient knowledge about risks and benefits of NPMs.

CONCLUSIONS

In a multi-stakeholder qualitative study using NGT, we found a diverse array of potentially modifiable barriers and facilitators to NPM uptake that may serve as important targets for program development.

A comparison of race-related pain stereotypes held by White and Black individuals

Pain judgments are the basis for pain management. The purpose of this study was to assess Black and White participants' race-related pain stereotypes. Undergraduates (n=551) rated the pain sensitivity and willingness to report pain for the typical Black person, White person, and themselves. Participants, regardless of race, rated the typical White person as being more pain sensitive and more willing to report pain than the typical Black person. White participants rated themselves as less sensitive and less willing to report pain than same-race peers; however, Black participants rated themselves as more pain sensitive and more willing to report pain than same-race peers. These findings highlight similarities and differences in racial stereotypic pain beliefs held by Black and White individuals.

Improving Residents' Safe Opioid Prescribing for Chronic Pain Using an Objective Structured Clinical Examination

BACKGROUND

Internal medicine residents care for a sizable number of patients with chronic pain. Programs need educational strategies to promote safe opioid prescribing.

OBJECTIVE

To describe a safe opioid prescribing education program utilizing an objective structured clinical examination (OSCE) and report the resulting impact on residents' knowledge, confidence, and self-reported practices.

METHODS

Using a quasi-experimental design, 39 internal medicine residents from an urban academic medical center were assigned to 1 of 4 groups: 1-hour lecture only, lecture followed by immediate OSCE, lecture followed by 4-month delayed OSCE, and control. Safe opioid prescribing knowledge, confidence, and self-reported practices were assessed at baseline and at 8 months.

RESULTS

At 8 months, knowledge, confidence, and self-reported practices improved in the control and in all 3 intervention groups. The immediate OSCE group had the greatest improvements in combined confidence scores within group (0.74, P = .01) compared to controls (0.52, P = .05), using a 5-point scale. This group also had the greatest improvement in self-reported practice changes (1.04, P = .04), while other groups showed nonsignificant improvements-delayed OSCE (0.43, P = .44), lecture only (0.66, P = .24), and control (0.43, P = .19).

CONCLUSIONS

Safe opioid prescribing education that includes a lecture immediately followed by an OSCE had an impact on residents' confidence and self-reported practices greater than those for delayed OSCE or lecture only groups. There was no difference in knowledge improvement among the groups. Lecture followed by an OSCE was highly regarded by residents, but required additional resources.

How does an undergraduate pain course influence future physicians' awareness of chronic pain concepts? A comparative study

OBJECTIVE

Pain is one of the most undertreated medical complaints, with barriers to effective pain management lying in poor education of health professionals and misconceptions regarding patients in pain. The aim of this study was to assess whether an elective undergraduate course on chronic pain offered in Greek medical schools influences knowledge and attitudes of medical undergraduates about chronic pain and helps them clarify pain-related concepts.

METHODS

An electronic questionnaire with 6 demographic and 21 pain-related items was uploaded on SurveyMonkey. The questionnaire was open to medical students in every Greek medical school for 1 month. Students were asked to respond to questions regarding various aspects of pain taught in the aforementioned course. In specific, they were asked to respond to questions regarding the definition, types, and adequacy of treatment of chronic cancer and non-cancer pain. They were queried about their knowledge of pain clinics, health practitioners who run them, and types of treatment available there. There were also questions about opioid use in cancer and non-cancer chronic pain patients and regarding the likelihood of opioid addiction.

RESULTS

According to their responses, medical students had good knowledge about the definition and consequences of pain, and those who attended the pain course had greater knowledge regarding the adequacy of treatment of chronic pain and were more familiar with the recent classification of types of pain. Students who did not have exposure to the undergraduate pain course had little information regarding pain clinics and had poor knowledge regarding the use of opioids in cancer and in nonmalignant chronic pain. All students expressed concerns regarding addiction to opioids.

CONCLUSIONS

Although students enter medical school with little knowledge about pain issues, pain awareness can be positively influenced by education. A curriculum about pain should not only teach the basic science of pain but also present treatment strategies available and address the socio-emotional dimensions of pain. Additionally, if misconceptions about opioid use and addiction are properly elucidated early in medical education, the future health practitioners will be one step forward in achieving the goal of alleviating suffering patients' pain.

Rules and values: a coordinated regulatory and educational approach to the public health crises of chronic pain and addiction

Chronic pain and opioid addiction are 2 pressing public health problems, and prescribing clinicians often lack the skills necessary to manage these conditions. Our study sought to address the benefits of a coalition of an academic medical center pain faculty and government agencies in addressing the high unintentional overdose death rates in New Mexico. New Mexico's 2012-2013 mandated chronic pain and addiction education programs studied more than 1000 clinicians. Positive changes were noted in precourse and postcourse surveys of knowledge, self-efficacy, and attitudes. Controlled substance dispensing data from the New Mexico Board of Pharmacy also demonstrated safer prescribing. The total morphine and Valium milligram equivalents dispensed have decreased continually since 2011. There was also a concomitant decline in total drug overdose deaths.

E-learning module on chronic low back pain in older adults: evidence of effect on medical student objective structured clinical examination performance

The Institute of Medicine has highlighted the urgent need to close undergraduate and graduate educational gaps in treating pain. Chronic low back pain (CLBP) is one of the most common pain conditions, and older adults are particularly vulnerable to potential morbidities associated with misinformed treatment. An e-learning case-based interactive module was developed at the University of Pittsburgh Center of Excellence in Pain Education, one of 12 National Institutes of Health-designated centers, to teach students important principles for evaluating and managing CLBP in older adults. A team of six experts in education, information technology, pain management, and geriatrics developed the module. Teaching focused on common errors, interactivity, and expert modeling and feedback. The module mimicked a patient encounter using a standardized patient (the older adult with CLBP) and a pain expert (the patient provider). Twenty-eight medical students were not exposed to the module (Group 1) and 27 were exposed (Group 2). Their clinical skills in evaluating CLBP were assessed using an objective structured clinical examination (OSCE). Mean scores were 62.0 ± 8.6 for Group 1 and 79.5 ± 10.4 for Group 2 (P < .001). Using an OSCE pass-fail cutoff score of 60%, 17 of 28 Group 1 students (60.7%) and 26 of 27 Group 2 students (96.3%) passed. The CLBP OSCE was one of 10 OSCE stations in which students were tested at the end of a Combined Ambulatory Medicine and Pediatrics Clerkship. There were no between-group differences in performance on eight of the other nine OSCE stations. This module significantly improved medical student clinical skills in evaluating CLBP. Additional research is needed to ascertain the effect of e-learning modules on more-advanced learners and on improving the care of older adults with CLBP.

It made my life a little easier: primary care providers' beliefs and attitudes about using opioid treatment agreements

OBJECTIVE

To understand primary care providers (PCPs)' experiences, beliefs, and attitudes about using opioid treatment agreements (OTAs) for patients with chronic pain.

DESIGN

Qualitative research study.

PARTICIPANTS

Twenty-eight internists and family medicine physicians at two health centers.

APPROACH

Semistructured telephone interviews, informed by the Integrative Model of Behavioral Prediction. Themes were analyzed using a Grounded Theory approach, and similarities and differences in themes were examined among OTA adopters, nonadopters, and selective adopters.

RESULTS

Participants were 64 percent female and 68 percent white, and practiced for a mean of 9.5 years. Adoption of OTAs varied: seven were adopters, five were nonadopters, and 16 were selective adopters. OTA adoption reflected PCPs' beliefs and attitudes in the following three thematic categories: 1) perceived effect of OTA use on the therapeutic alliance, 2) beliefs about the utility of OTAs for patients or providers, and 3) perception of patients' risk for opioid misuse. PCPs commonly believed that OTAs were useful for physician self-protection, but few believed that they prevent opioid misuse. Selective adopters expressed ambivalent beliefs and made decisions about OTA use for individual patients based on both observed data and a subjective sense of each patient's risk for misuse.

CONCLUSIONS

Substantial variability in PCP use of OTAs reflects differences in PCP beliefs and attitudes. Research to understand the impact of OTA use on providers, patients, and the therapeutic alliance is urgently needed to guide best practices.

A research agenda for enhancing appropriate opioid prescribing in primary care

The challenges facing patients and providers in managing ongoing opioid analgesic therapy for chronic pain are complex. Benefit of long-term opioid therapy, for which there are scant data, must be balanced against myriad potential undesired outcomes, including safety problems, ranging from mild toxicities to overdose and death; inadequate efficacy, which may mean continued patient suffering and unwarranted exposure to toxicities; and misuse of these potent medications. To help patients and providers navigate these challenges and optimize therapy, we present a research agenda in which we first characterize appropriate ongoing opioid prescribing and then describe three areas where quality improvement work is needed: 1) developing brief validated measures of patient-reported safety, efficacy, and misuse that improve outcomes; 2) designing evidence-based algorithms to guide changes in therapy when issues related to safety, efficacy or misuse are identified; and 3) promoting use of patient-centered, multi-modal treatment plans.

Optimizing pain management through collaborations with behavioral and addiction medicine in primary care

Chronic noncancer pain (CNCP) affects many primary care patients, and carries a large human and economic burden. In response to the widespread perception that pain is underdiagnosed and undertreated, regulatory bodies have encouraged more comprehensive services to address pain syndromes. Significant hurdles exist in treating CNCP in primary care settings, and interventional therapies and pharmacotherapy often do not provide complete symptomatic relief. This article describes a multidimensional and interdisciplinary approach to the treatment of CNCP. The utility of collaborations with behavioral and addiction medicine specialists optimizes care and advances models of patient treatment within a primary care patient-centered medical home.

Which skills are associated with residents' sense of preparedness to manage chronic pain?

OBJECTIVE

To identify gaps in residents' confidence and knowledge in managing chronic nonmalignant pain (CNMP) and to explore whether specific skills or pain knowledge was associated with global preparedness to manage CNMP.

DESIGN

Cross-sectional web-based survey.

SETTING AND PARTICIPANTS

Internal medicine residents in Bronx, NY.

MAIN OUTCOME MEASURES

The authors assessed the following: 1) confidence in skills within the following four content areas: physical examination, diagnosis, treatment, and safer opioid prescribing; 2) pain-related knowledge on a 16-item scale; and 3) global preparedness to manage CNMP (agreement with, "I feel prepared to manage CNMP"). Gaps in confidence were skills in which fewer than 50 percent reported confidence. Gaps in knowledge were items in which fewer than 50 percent answered correctly. Using logistic regression, the authors examined whether skills or knowledge was associated with global preparedness.

RESULTS

Of 145 residents, 92 (63 percent) responded. Gaps in confidence included diagnosing fibromyalgia, performing corticosteroid injections, and using pain medication agreements. Gaps in knowledge included pharmacotherapy for neuropathic pain and interpreting urine drug test results. Twenty-four residents (26 percent) felt globally prepared to manage CNMP. Confidence using pain medication agreements (adjusted odds ratio [AOR], 5.99; 95% confidence interval [CI], 2.02-17.75), prescribing long-acting opioids (AOR, 5.85; 95% CI, 2.00-17.18), and performing corticosteroid injection of the knee (AOR, 5.76; 95% CI, 1.16-28.60]) were strongly associated with global preparedness.

CONCLUSIONS

Few internal medicine residents felt prepared to manage CNMP. Our findings suggest that educational interventions to improve residents' preparedness to manage CNMP should target complex pain syndromes (eg, fibromyalgia and neuropathic pain), safer opioid prescribing practices, and alternatives to opioid analgesics.

"I feel uncomfortable 'calling a patient out'": educational needs of palliative medicine fellows in managing opioid misuse

CONTEXT

During the past 10 years, advocates of palliative care have sought to be included earlier in the course of patients' illnesses. Palliative care providers may thus be more likely to care for patients who misuse and abuse opioids.

OBJECTIVES

To assess whether hospice and palliative medicine (HPM) fellows see patients at risk for opioid misuse and how competent they perceive themselves to be to treat pain in these patients.

METHODS

An electronic survey was distributed to 102 HPM fellows. The survey included questions assessing self-perceived competency in care for patients who misuse opioids. Responses were rated using a Likert scale of one to seven, where one=strongly agree and seven=strongly disagree; any number greater than two was considered to be nonagreement.

RESULTS

Fifty-seven (56%) fellows from 34 programs responded to the survey. In the previous two weeks, 77.2% of respondents had seen at least one patient with a substance use disorder (SUD) and 43.9% had treated a patient whom they were concerned was misusing opioids. Half (47.2%) of respondents stated that they have a working knowledge of addiction, 41.4% agreed their training has prepared them to manage opioid misuse, and 36.8% felt they knew how to differentiate pain from addiction. Only 21.1% were satisfied with how they treat symptoms in this population. Fellowship training in opioid misuse was associated with increased satisfaction.

CONCLUSION

HPM fellows regularly see patients who are at risk for opioid misuse and feel unprepared to treat pain in these patients. There is a need for more education of fellows in this area.

What can we learn from first-year medical students' perceptions of pain in the primary care setting?

OBJECTIVE

Pain concerns are one of the leading causes of visits to primary care. However, practicing physicians find managing pain frustrating and complex. There is little information about how undergraduate medical students approach pain and its management. This study aimed to explore first-year medical students' perceptions of pain-related patient encounters in the primary care setting.

DESIGN

Qualitative analysis was used to explore first-year students' reflective journals written during an early clinical experience in primary care. Using iterative process for text analysis, entries referencing pain-related encounters were coded by two independent researchers with 94% inter-rater reliability. Themes and categories were sought by immersion crystallization.

RESULTS

Three themes emerged from the students' journals: positive, negative, and neutral perceptions of pain-related encounters. With further analysis of the journals, acute, chronic, end-of-life, iatrogenic, and emotional pain categories also emerged. Most journal entries were negative, and chronic pain generated the most negativity.

CONCLUSIONS

First-year medical students identified pain as a major concern in their early clinical experience. Students' perceptions of pain-related encounters can inform curriculum design and may ultimately benefit both physicians and the patients.

Randomized trial of web-based training about opioid therapy for chronic pain

OBJECTIVES

The treatment of chronic noncancer pain with chronic opioid therapy has increased rapidly, but medicine residents receive little training concerning this therapy. Therefore we conducted a trial to determine if an interactive web-based training focusing on shared decision-making for chronic opioid therapy improves knowledge and competence compared with exposure to practice guidelines.

METHODS

A randomized controlled educational trial of 213 internal medicine residents from 5 medicine residencies participating in the Residency Review Committee for Internal Medicine's Educational Innovations Project comparing access to interactive web-based training (COPE: Collaborative Opioid Prescribing Education) or access to the Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Pretraining and immediate posttraining knowledge test; pretraining and 60-day posttraining self-reported competence, satisfaction, patient-centeredness, and selected clinical behaviors were analyzed using t tests, Pearson chi, and Generalized Estimating Equations.

RESULTS

The web training group had greater increase in knowledge with training (chi(2)=72.06, P<0.00001) and greater self-rated competence in the management of outpatients with chronic pain (chi(2)=6.48, P=0.01), and specifically in the use of opioids in this management (chi(2)=5.17, P=0.02). Residents in both groups reported more satisfaction with managing chronic pain care after training (chi(2)=52.72, P<0.0001), though the web training was superior on subscales concerning training adequacy (chi(2)=4.94, P=0.026) and relationship quality (chi(2)=5.79, P=0.016).

CONCLUSIONS

Exposure to an interactive web-based training focused on shared decision-making and communication skills was more effective than exposure to compatible practice guidelines for knowledge and self-reported competence in the management of chronic noncancer pain.

Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education

BACKGROUND

Physicians report they feel ill-prepared to manage chronic noncancer pain (CNCP), in part because of inadequate training. Published studies and clinical observation demonstrate that trainees lack confidence and reflect negative attitudes about CNCP. Overall, there is minimal published guidance on specific specialty roles and responsibilities in CNCP management.

OBJECTIVE

The purpose of this study was to assess resident preparation, confidence, and attitudes about CNCP across graduate medical education programs and to assess resident perception of roles and responsibilities in CNCP management.

METHODS

In 2006 we surveyed residents from 13 graduate medical education programs in 3 institutions about CNCP and report quantitative and qualitative analyses of survey responses from 246 respondents.

RESULTS

A total of 59% of respondents rated their medical school preparation and 36% rated their residency preparation as "fair" or "poor"; only 17% reported being "confident" or "very confident" in assessing patients with CNCP; and 30% used negative or derogatory terms (eg, manipulative, irritable, needy) to describe patients with CNCP. Respondents from postgraduate years 3-6 were more than twice as likely as postgraduate year 1 or postgraduate year 2 respondents (44% versus 21% and 20%, respectively) to use negative or derogatory terms (P  =  .0007). Respondents were significantly more likely to report that pain specialists are "good" or "excellent" in managing CNCP compared with generalists (73% versus 6%; P < .0001).

CONCLUSION

Education in pain management should begin in medical school and continue through graduate medical education, regardless of specialty. Early and sustained training interventions are needed to foster empathy in caring for patients with pain. Residency and fellowhip training should impart a clear understanding of each specialty's role and responsibilities in pain management to better foster patient-centered pain care.

Development of a comprehensive e-learning resource in pain management

OBJECTIVE

The prevalence of chronic nonmalignant pain (CNMP), the lack of confidence and reward among trainees and providers caring for patients with CNMP, and the lack of a comprehensive curriculum in pain management prompted the creation of the Virginia Commonwealth University (VCU) Chronic Nonmalignant Pain Management curriculum, an innovative e-learning resource. This article describes the development of the curriculum and presents initial evaluation data.

DESIGN

The curriculum is organized into six modules that cover 20 specific Accreditation Council of Graduate Medical Education competency-based objectives. Broad content and effective instructional design elements promote its utility among a range of learner levels in a variety of medical disciplines.

RESULTS

Twenty-four physician reviewers and over 430 trainees (medical students and graduate medical residents) have evaluated the curriculum. Of the respondents to course evaluation questions, 85.7% (366/427) stated that they would access the practice resources again, 86.3% (366/424) agreed that the treatment of CNMP was more important to them after completing the curriculum, 73.9% (312/422) stated that they would make changes in their behavior or practice, and 92.3% (386/418) stated that they would recommend the curriculum to their colleagues. Qualitative data are uniformly positive. Results of pretest and posttest scores and item analyses have been used to make content changes.

CONCLUSIONS

The VCU Chronic Nonmalignant Pain Management curriculum is an e-learning resource that has the potential to fill a significant training void. Design and content changes have been made as a result of initial evaluation data. Data from ongoing evaluation will allow curricular refinement.