Medical Trainees' Experiences of Treating People With Chronic Pain: A Lost Opportunity for Medical Education

Gendered Worlds of Pain: Women, Marginalization, and Chronic Pain

The importance of gender is undertheorized in chronic pain research, meaning extant research cannot sufficiently shed light on how chronic pain experience and treatment are connected to institutions and societal structures. Much literature on gender and pain is not critical in orientation, making it difficult to translate data into recommendations for improved treatment and care. Our study takes a critical approach informed by social theory to understand chronic pain among women who experience socioeconomic marginalization. Drawing on a gender-based subanalysis of interview data collected in Canada as part of an institutional ethnography of chronic pain among people who are socioeconomically marginalized, from women's narratives, we identified 4 themes that speak to gender, chronic pain, and marginalization. These are 1) gendered minimization of women's health concerns, 2) managing intergenerational poverty, 3) living with violence and trauma, and 4) gendered organization of family care. Together, these themes highlight how women's experiences of chronic pain and marginalization amplify gendered vulnerabilities in health care, social services, and society in general. Our findings depict a deeply gendered experience of chronic pain that is inseparable from the daily struggle of managing one's life with pain with heavy responsibilities, the baggage of past trauma, and responsibility for others with few resources. We emphasize the importance of chronic pain care and health and social services that are both gender- and trauma-informed. PERSPECTIVE: This article draws on an institutional ethnography (a holistic qualitative methodology) of chronic pain and socioeconomic marginalization to demonstrate the importance of chronic pain care and health and social services that are both gender- and trauma-informed.

What are medical students taught about persistent physical symptoms? A scoping review of the literature

BACKGROUND

Persistent Physical Symptoms (PPS) include symptoms such as chronic pain, and syndromes such as chronic fatigue. They are common, but are often inadequately managed, causing distress and higher costs for health care systems. A lack of teaching about PPS has been recognised as a contributing factor to poor management.

METHODS

The authors conducted a scoping review of the literature, including all studies published before 31 March 2023. Systematic methods were used to determine what teaching on PPS was taking place for medical undergraduates. Studies were restricted to publications in English and needed to include undergraduate medical students. Teaching about cancer pain was excluded. After descriptive data was extracted, a narrative synthesis was undertaken to analyse qualitative findings.

RESULTS

A total of 1116 studies were found, after exclusion, from 3 databases. A further 28 studies were found by searching the grey literature and by citation analysis. After screening for relevance, a total of 57 studies were included in the review. The most commonly taught condition was chronic non-cancer pain, but overall, there was a widespread lack of teaching and learning on PPS. Several factors contributed to this lack including: educators and learners viewing the topic as awkward, learners feeling that there was no science behind the symptoms, and the topic being overlooked in the taught curriculum. The gap between the taught curriculum and learners' experiences in practice was addressed through informal sources and this risked stigmatising attitudes towards sufferers of PPS.

CONCLUSION

Faculties need to find ways to integrate more teaching on PPS and address the barriers outlined above. Teaching on chronic non-cancer pain, which is built on a science of symptoms, can be used as an exemplar for teaching on PPS more widely. Any future teaching interventions should be robustly evaluated to ensure improvements for learners and patients.

A Qualitative Follow-Up to a Survey of Program Directors on Wellness Programming at a Large Healthcare Organization: Interviews of High- and Low-Exemplar Programs

Background

The current research used a qualitative approach to understand which factors facilitate and hinder wellness programming in residency programs.

Methods

Program directors identified from a previous quantitative study as having residency programs with notably more or less resident wellness programming than others (ie, high- and low-exemplars, respectively) were contacted. In total, semi-structured interviews were conducted over Zoom with 7 low-exemplars and 9 high-exemplars.

Results

The results of this qualitative examination suggest common themes across the 2 exemplar groups, such as wanting more resources for resident wellness with fewer barriers to implementation, viewing wellness as purpose-driven, and seeing wellness as a shared responsibility. There were also critical distinctions between the exemplar groups. Those high in wellness programming expressed more of an emphasis on connections among residents in the program and between the faculty and residents. In contrast, those low in wellness programming described more barriers, such as staffing problems (ie, turnover and lack of faculty wellness) and a lack of integration between the varying levels involved in graduate medical education (GME) operations (ie, between GME programs and sponsoring hospitals, and between GME facilities and the larger health care organization).

Conclusion

This study provides insight into program directors' experiences with wellness programming at a large health care organization. The results could point to potential next steps for investigating how the medical education community can improve resident wellness programming.

Towards an empathic hidden curriculum in medical school: A roadmap

The "hidden curriculum" in medical school includes a stressful work environment, un-empathic role models, and prioritisation of biomedical knowledge. It can provoke anxiety and cause medical students to adapt by becoming cynical, distanced and less empathic. Lower empathy, in turn, has been shown to harm patients as well as practitioners. Fortunately, evidence-based interventions can counteract the empathy dampening effects of the hidden curriculum. These include early exposure to real patients, providing students with real-world experiences, training role models, assessing empathy training, increasing the focus on the biopsychosocial model of disease, and enhanced wellbeing education. Here, we provide an overview of these interventions. Taken together, they can bring about an "empathic hidden curriculum" which can reverse the decline in medical student empathy.

Flipping the hidden curriculum to transform pain education and culture

Though long-sought, transformation of pain management practice and culture has yet to be realized. We propose both a likely cause-entrenchment in a biomedical model of care that is observed and then replicated by trainees-and a solution: deliberately leveraging the hidden curriculum to instead implement a sociopsychobiological (SPB) model of care. We make use of Implicit Bias Recognition and Management, a tool that helps teams to first recognize and "surface" whatever is implicit and to subsequently intervene to change whatever is found to be lacking. We describe how a practice might use iterations of recognition and intervention to move from a biomedical to a SPB model by providing examples from the Chronic Pain Wellness Center in the Phoenix Veterans Affairs Health Care System. As pain management practitioners and educators collectively leverage the hidden curriculum to provide care in the SPB model, we will not only positively transform our individual practices but also pain management as a whole.

Supervised interprofessional student pain clinic program - efficacy with the utilization of zoom

Introduction

Current medical education curricula in pain management are insufficient to match the prevalence of chronic pain and the needs of patient populations. The Supervised Student Inter-professional Pain Clinic Program (SSIPCP) aims to train healthcare professional students to improve their abilities in chronic pain management in interprofessional (IP) teams. Due to the COVID-19 pandemic, Zoom was employed to allow the program to continue. In this study, survey data from students who participated during and before the COVID-19 pandemic were compared to determine if the program carried out via Zoom can maintain its effectiveness.

Methods

Student pre- and post-program survey data were entered into Microsoft Excel spreadsheet and then graphed and analyzed with Sigma Plot. Surveys assessed knowledge in chronic pain physiology and management, attitude towards IP practice, and perceived team skills in the form of questionnaires and open-ended questions. Paired t-tests and Wilcoxon Signed-rank tests were used for two-group comparisons and two-way repeated ANOVA followed by the Holm-Sidak post-hoc tests were used for multiple group comparisons.

Results

Overall, students continued to exhibit significant improvement in major areas assessed even with the use of Zoom. Strengths of the programs were also shared across student cohorts regardless of Zoom usage. However, despite their improvements, students who utilized Zoom stated that they would have preferred in-person program activities.

Conclusion

Although students prefer in-person activities, the SSIPCP successfully trained healthcare students in chronic pain management and working in an IP team through Zoom.

Patient Responses to the Term Pain Catastrophizing: Thematic Analysis of Cross-sectional International Data

Pain catastrophizing is understood as a negative cognitive and emotional response to pain. Researchers, advocates and patients have reported stigmatizing effects of the term in clinical settings and the media. We conducted an international study to investigate patient perspectives on the term pain catastrophizing. Open-ended electronic patient and caregiver proxy surveys were promoted internationally by collaborator stakeholders and through social media. 3,521 surveys were received from 47 countries (77.3% from the U.S.). The sample was mainly female (82.1%), with a mean age of 41.62 (SD 12.03) years; 95% reported ongoing pain and pain duration > 10 years (68.4%). Forty-five percent (n = 1,295) had heard of the term pain catastrophizing; 12% (n = 349) reported being described as a 'pain catastrophizer' by a clinician with associated high levels of feeling blamed, judged, and dismissed. We present qualitative thematic data analytics for responses to open-ended questions, with 32% of responses highlighting the problematic nature of the term. We present the patients' perspective on the term pain catastrophizing, its material effect on clinical experiences, and associations with negative gender stereotypes. Use of patient-centered terminology may be important for favorably shaping the social context of patients' experience of pain and pain care. PERSPECTIVE: Our international patient survey found that 45% had heard of the term pain catastrophizing, about one-third spontaneously rated the term as problematic, and 12% reported the term was applied to them with most stating this was a negative experience. Clinician education on patient-centered terminology may improve care and reduce stigma.

Continuing professional development needs in pain management for Canadian health care professionals: A cross sectional survey

Background

Continuing professional development is an important means of improving access to effective patient care. Although pain content has increased significantly in prelicensure programs, little is known about how postlicensure health professionals advance or maintain competence in pain management.

Aims

The aim of this study was to investigate Canadian health professionals' continuing professional development needs, activities, and preferred modalities for pain management.

Methods

This study employed a cross-sectional self-report web survey.

Results

The survey response rate was 57% (230/400). Respondents were primarily nurses (48%), university educated (95%), employed in academic hospital settings (62%), and had ≥11 years postlicensure experience (70%). Most patients (>50%) cared for in an average week presented with pain. Compared to those working in nonacademic settings, clinicians in academic settings reported significantly higher acute pain assessment competence (mean 7.8/10 versus 6.9/10; P < 0.002) and greater access to pain specialist consultants (73% versus 29%; P < 0.0001). Chronic pain assessment competence was not different between groups. Top learning needs included neuropathic pain, musculoskeletal pain, and chronic pain. Recently completed and preferred learning modalities respectively were informal and work-based: reading journal articles (56%, 54%), online independent learning (44%, 53%), and attending hospital rounds (43%, 42%); 17% had not completed any pain learning activities in the past 12 months. Respondents employed in nonacademic settings and nonphysicians were more likely to use pocket cards, mobile apps, and e-mail summaries to improve pain management.

Conclusions

Canadian postlicensure health professionals require greater access to and participation in interactive and multimodal methods of continuing professional development to facilitate competency in evidence-based pain management.

The Pain Medicine Curriculum Framework-structured integration of pain medicine education into the medical curriculum

Medical practitioners play an essential role in preventing pain, conducting comprehensive pain assessments, as well as promoting evidence-based practices. There is a need for the development of innovative, interprofessional and integrated pain medicine curricula for medical students. The Pain Medicine Curriculum Framework (PMCF) was developed to conceptualise a purposeful approach to the complex process of curriculum change and to prioritise the actions needed to address the gaps in pain medicine education. The PMCF comprises four dimensions: (1) future healthcare practice needs; (2) competencies and capabilities required of graduates; (3) teaching, learning and assessment methods; and (4) institutional parameters. Curricula need to meet the requirements of registration and accreditation bodies, but also equip graduates to serve in their particular local health system while maintaining the fundamental standards and values of these institutions. The curriculum needs to connect knowledge with experience and practice to be responsive to the changing needs of the increasingly complex health system yet adaptable to patients with pain in the local context. Appropriate learning, teaching and assessment strategies are necessary to ensure that medical practitioners of the future develop the required knowledge, skills and attitudes to treat the diverse needs of patients' experiencing pain. The historical, political, social and organisational values of the educational institution will have a significant impact on curriculum design. A more formalised approach to the development and delivery of a comprehensive pain medicine curriculum is necessary to ensure that medical students are adequately prepared for their future workplace responsibilities.

A Scoping Review of Gaps Identified by Primary Care Providers in Caring for Patients with Chronic Noncancer Pain

Introduction/Aim

Primary care providers (PCPs), who provide the bulk of care for patients with chronic noncancer pain (CNCP), often report knowledge gaps, limited resources, and difficult patient encounters while managing chronic pain. This scoping review seeks to evaluate gaps identified by PCPs in providing care to patients with chronic pain.

Methods

The Arksey and O'Malley framework was used for this scoping review. A broad literature search was conducted for relevant articles on gaps in knowledge and skills of PCPs and in their health care environment for managing chronic pain, with multiple search term derivatives for concepts of interest. Articles from the initial search were screened for relevance, yielding 31 studies. Inductive and deductive thematic analysis was adopted.

Results

The studies included in this review reflected a variety of study designs, settings, and methods. However, consistent themes emerged with respect to gaps in knowledge and skills for assessment, diagnosis, treatment, and interprofessional roles in chronic pain, as well as broader systemic issues including attitudes toward CNCP. A general lack of confidence in tapering high dose or ineffective opioid regimes, professional isolation, challenges in managing patients with CNCP with complex needs, and limited access to pain specialists were reported by PCPs.

Discussion/Conclusions

This scoping review revealed common elements across the selected studies that will be useful in guiding creation of targeted supports for PCPs to manage CNCP. This review also yielded insights for pain clinicians at tertiary centers for supporting their PCP colleagues as well as systemic reforms required to support patients with CNCP.

"It feels like an endless fight": a qualitative study exploring healthcare utilization of persons with rheumatic conditions waiting for pain clinic admission

Background

Individuals living with a rheumatic pain condition can face delays in accessing pain clinics, which prevents them from receiving timely treatment. Little is known regarding their specific healthcare utilization in order to alleviate pain while waiting to obtain services in pain clinics. Hence, the aim of this study was to explore the perceptions and experiences of persons living with rheumatic conditions regarding healthcare utilization while waiting to access a pain clinic.

Methods

In this qualitative descriptive study, semi-structured interviews were conducted with adults living with a painful rheumatic condition that reported either being waiting for admission in a pain clinic, having been referred but then denied pain clinic services, or having received services during the previous six months, in the province of Quebec, Canada. The interviews were transcribed verbatim, and an inductive thematic analysis was performed.

Results

Twenty-six individuals were interviewed (22 women and 4 men; mean age 54 ± 10 years). Three themes were identified: 1) lacking guidance in identifying solutions to their complex and multidimensional needs, 2) struggling to obtain and maintain services due to systemic access barriers, and 3) displaying resilience through a search for accessible and sustainable self-management strategies.

Conclusions

The current approaches and structures of health services fail to adequately answer the service needs of individuals experiencing painful rheumatic conditions. Important shifts are required in pain education, in increasing access to multidisciplinary approaches at the primary care level and in breaking down barriers individuals with chronic pain face to receive appropriate and timely care.

Ten-year mixed-method evaluation of prelicensure health professional student self-reported learning in an interfaculty pain curriculum

Introduction:

Student perspectives on interprofessional pain education are lacking.

Objectives:

The purpose of this study was to evaluate ratings of knowledge acquisition and effective presentation methods for prelicensure health professional students attending the University of Toronto Centre for the Study of Pain Interfaculty Pain Curriculum (Canada).

Methods:

A 10-year (2009–2019) retrospective longitudinal mixed-methods approach comprising analysis and integration of quantitative and qualitative data sets was used to evaluate 5 core University of Toronto Centre for the Study of Pain Interfaculty Pain Curriculum learning sessions.

Results:

A total of 10, 693 students were enrolled (2009–2019) with a mean annual attendance of 972 students (±SD:102). The mean proportion of students rating “agree/strongly agree” for knowledge acquisition and effective presentation methods across sessions was 79.3% (±SD:3.4) and 76.7% (±SD:6.0), respectively. Knowledge acquisition or presentation effectiveness scores increased, respectively, over time for 4 core sessions: online self-study pain mechanisms module (P = 0.03/P < 0.001), online self-study opioids module (P = 0.04/P = 0.019), individually selected in-person topical pain sessions (P = 0.03/P < 0.001), and in-person patient or interprofessional panel session (P = 0.03). Qualitative data corroborated rating scores and expanded insight into student expectations for knowledge acquisition to inform real-world clinical practice and interprofessional collaboration; presentation effectiveness corresponded with smaller session size, individually selected sessions, case-based scenarios, embedded knowledge appraisal, and opportunities to meaningfully interact with presenters and peers.

Conclusion:

This study demonstrated positive and increasing prelicensure student ratings of knowledge acquisition and effective presentation methods across multifaceted learning sessions in an interfaculty pain curriculum. This study has implications for pain curriculum design aimed at promoting students' collaborative, patient-centered working skills.

See commentary: Trouvin A-P. “Ten-year mixed method evaluation of prelicensure health professional student self-reported learning in an interfaculty pain curriculum”: a view on pain education. PAIN Rep 2022;7:e1031.

Students attending learning sessions at the University of Toronto Interfaculty Pain Curriculum (2009–2019) in Toronto, Canada, self-report high ratings of knowledge acquisition and effective presentation methods.

[The cross-sectional field "pain medicine" in medical studies at the University of Leipzig-What has been achieved? : An analysis of self-estimation of students before, during and 5 years after establishment of the cross-sectional field]

BACKGROUND

The field of pain medicine was established as an obligatory subject area of medical schools in Germany in 2016. No prior study has evaluated the effects of this curricular change on students' competences in the field of pain medicine.

OBJECTIVE

The aim of this study was to find out to what extent the introduction of the additional subject "pain medicine" positively influenced the students' acquisition of competences measured via a self-assessment.

MATERIAL AND METHODS

A longitudinal and interdisciplinary curriculum for pain medicine was developed according to the current recommendations for curriculum development for medical education. In parallel, a questionnaire was created for the students' self-assessment of their own level of knowledge and the importance of pain medicine teaching content on a 5-stage Likert scale. The surveys were conducted before the implementation of the curriculum (2014), directly after the first cohort finished (2016) and 5 years after the implementation (2019) and compared by Kruskal-Wallis test.

RESULTS

The implementation of the curriculum has led to significant improvement in relevant aspects. For example, students now feel better prepared overall for the treatment of pain patients (2.67 in 2014 vs. 3.18 in 2019). Individual sub-aspects such as taking a pain history (3.63 vs. 4.10) or drawing up an analgesia scheme (3.56 vs. 4.14) are now also subjectively better mastered.

CONCLUSION

Even though the results are encouraging, there is further potential for improvement in some sub-areas. For example, the students' rating regarding the question about their preparation for treating patients in pain is not yet satisfactory. Therefore, the curriculum should be developed further with a focus on competence orientation. Digital teaching formats can be integrated as well as interprofessional units and simulated patients. Additionally, the examination formats should be further developed towards standardized practical examinations.

Effectiveness and Dissemination of the Interprofessional Pediatric Pain PRN Curriculum

INTRODUCTION

Cultural transformation is needed for health care to be sensitive to children's pain. The Pediatric Pain Practice Registered Nurses (PRN) Curriculum is the first free, open access, downloadable, interprofessional pain continuing education (IPPCE) curriculum developed to empower health care professionals to translate evidence-based pain care into clinical practice. To evaluate the curriculum and its experiential flipped-learning strategies, we used a mixed methods approach.

METHODS

Interprofessional pediatric teams from eight health care systems evaluated the curriculum after attending Pediatric Pain PRN Courses in the Fall of 2017 (N = 90). Qualitative methods were used to evaluate the acceptability, feasibility, and utility of the curriculum and IPPCE strategies. Pain knowledge and attitudes were measured pre-IPPCE/post-IPPCE with the Pediatric Healthcare Provider's Knowledge & Attitude Survey Regarding Pain (PHPKAS). Web analytics were used to describe dissemination for the first year after the curriculum's webpage launch.

RESULTS

Learners rated their achievement of course objectives as moderate-great. PHPKAS scores significantly increased (P < .0005); but significant differences in physician and nurse PHPKAS question responses pre-IPPCE/post-IPPCE were found. Within 2 years of the IPPCE, three health care systems were certified as Childkind Hospitals, five Pediatric Pain PRN Programs were established, and various practice changes and improved patient outcomes, such as decreased hospital lengths of stay and emergency department returns for pain, were realized. Curriculum dissemination was global.

DISCUSSION

Results support the acceptability, effectiveness, feasibility, utility, and global dissemination of the curriculum and IPPCE strategies. More rigorous patient outcome data are needed; however, this study demonstrated the benefit of a free, open-access, downloadable, interprofessional health care provider continuing education curriculum.

Integrative pediatric pain management: Impact & implications of a novel interdisciplinary curriculum

OBJECTIVES

Objectives of this paper are to: 1) Describe a novel interdisciplinary, integrative pain curriculum for pediatric residents. 2) Describe changes in residents' understanding of pain epidemiology, physiology, and management; application of the biopsychosocial model in pain management; and understanding and application of non-pharmacologic approaches to pain management.

DESIGN, SETTING

This study was done in a pediatric residency program within an urban pediatric teaching hospital. It employed both anonymous, Likert-scale surveys administered via Qualtrics, as well as open-ended, free response questions.

INTERVENTIONS

We provided a multidisciplinary pain education curriculum to pediatric residents with a focus on pain neuroscience, a history of pain management, the biopsychosocial model of care, and exposure to non-pharmacologic interventions to pain management over six hours of instruction conducted in two blocks of three hours each.

OUTCOME MEASURES

Self-identified changes via survey measuring resident physician knowledge, comfort, approach, and management of pediatric pain through an interdisciplinary pain curriculum.

RESULTS

Prior to this training, many residents were not confident in their understanding of pain neuroscience, the biopsychosocial model of care, and non-pharmacologic interventions. At completion of training, residents indicated positive changes in knowledge of, and comfort with, all of the domains taught. Ninety percent of residents indicated that the curriculum changed the way they conceptualized, approached, and/or managed pain, and reported thinking more holistically about pain management. Nearly all residents indicated they would like to have more training (98 %, N = 57) in integrative modalities.

CONCLUSIONS

Pediatric resident physicians are receptive to training in an interdisciplinary, integrative, pediatric pain management education intervention, and subsequently show positive changes in knowledge and comfort levels. There is a need and desire for additional pain education in resident training programs.

Unmet needs in the management of functional impairment in patients with chronic pain: a multinational survey

Background: A survey of European Pain Federation 2019 attendees was conducted to identify unmet needs in chronic pain patients. Materials & methods: Four questions were asked focusing on functional impairment in chronic pain, including who are at increased risk and ways to better identify and manage these patients. Results: In total 143 respondents indicated that key issues were lack of knowledge, lack of resources/time to assess and manage chronic pain and lack of sufficient tools to identify patients at risk for functional impairment. Education and training of primary care physicians, simplified guidelines and practical tools for assessment and use of multidisciplinary teams to treat chronic pain were recommended. Conclusion: There are many unmet needs in the management of functional impairment in chronic pain patients.

Erratum: Notice of duplicate publication: Qualitative research and pain: Current controversies and future directions

Much of what we know about the meaning and experience of pain has been facilitated through qualitative research. However, qualitative inquiry continues to be underrepresented in the pain literature relative to quantitative approaches. In this Commentary and Introduction to the Special Issue on Qualitative Research and Pain, we present a collection of high-quality, cutting-edge qualitative studies in pain that highlight theoretical and methodological advancements in the field. The articles included in this Special Issue feature a range of designs (e.g., grounded theory, phenomenology, qualitative description), methods of data collection (e.g., interviews, object elicitation, photovoice), and populations (e.g., immigrant women, individuals with heart disease). Throughout this Commentary we also address three common controversies regarding the quality of qualitative research and the stance we took on them for the Issue. These primarily deal with the procedure-related issues of sample size, generalizability, and saturation. We discuss how a more substantive-centered approach to evaluation—that is, an approach that considers the methodological and theoretical significance of the work—is crucial for advancing qualitative research in pain.

Continuity of care and chronicity in medical students' education: 'adopt' a chronic patient

Purpose: Nowadays chronicity is one of the most frequent aspects of care doctors have to deal with. Students need to know and learn clinical, relational, social and managerial elements of chronicity and changes that disease causes in patients, families and doctors themselves. Methods: Students are supervised by a family doctor, in taking care of 'their' patient and of his/her family. They are asked to keep an updated diary, participate in the periodical revision of the medical history and write an end-report. Two focus groups were conducted, adopting a constructive qualitative approach in order to analyse results. Results: The focus groups and the SWOT analysis show common themes such as innovative learning and multidisciplinary approach. Clinical evolution of the disease, mental and body changes and the diagnostic and therapeutic future planning were also revealed. Conclusions: The main goal of this innovation was understanding the importance of a continuous clinical relationship and of the role of the doctor as 'therapy itself'. The project was demonstrated to be able to teach the future physicians how to practice more empathetic medicine and to improve the skills needed in a complex relational environment including that of chronic disease.

Changes in Opioid Prescribing Behaviors among Family Physicians Who Participated in a Weekly Tele-Mentoring Program

A weekly tele-mentoring program was implemented in Ontario to help address the growing opioid crisis through teaching and mentoring family physicians on the management of chronic pain and opioid prescribing. This study assessed opioid prescribing behaviours among family physicians who attended the tele-mentoring program compared to two groups of Ontario family physicians who did not attend the program. We conducted a retrospective cohort study with two control groups: a matched cohort, and a random sample of 3000 family physicians in Ontario. Each physician was followed from one year before the program, which is the index date, and one year after. We examined the number and proportion of patients on any opioid, on high dose opioids, and the average daily morphine equivalent doses prescribed to each patient. We included 24 physicians who participated in the program (2760 patients), 96 matched physicians (11,117 patients) and 3000 random family doctors (374,174 patients). We found that, at baseline, the tele-mentoring group had similar number of patients on any opioid, but more patients on high dose opioids than both control groups. There was no change in the number of patients on any opioid before and after the index date, but there was a significant reduction in high-dose opioid prescriptions in the extension for community healthcare outcomes (ECHO) group, compared to a non-significant increase in the matched cohort, and a non-significant reduction in the Ontario group during the same comparable periods. Participation in the program was associated with a greater reduction in high-dose opioid prescribing.

Teaching Safe Opioid Prescribing During the Opioid Epidemic: Results of the 2018 Clerkship Directors in Internal Medicine Survey

BACKGROUND

Educating medical trainees across the continuum is essential to a multifaceted strategy for addressing the opioid epidemic.

OBJECTIVE

To assess the current state of internal medicine clerkship content on safe opioid prescribing and opioid use disorder, and barriers to curriculum implementation.

DESIGN

National Annual (2018) Clerkship Directors in Internal Medicine (CDIM) cross-sectional survey.

PARTICIPANTS

One hundred thirty-four clerkship directors at all Liaison Committee of Medical Education accredited US medical schools with CDIM membership as of October 1, 2018.

MAIN MEASURES

The survey section on safe opioid prescribing and opioid use disorder education in the internal medicine clerkship addressed assessment of current curricula, perceived importance of curricula, barriers to implementation, and plans to start or expand curricula. Descriptive statistics were used to summarize responses, and Pearson's chi-square and Fisher's exact tests for statistical comparisons.

KEY RESULTS

The survey response rate was 82% (110/134). Overall 54.1% of responding institutions reported covering one or more topics related to safe opioid prescribing or opioid use disorder in the internal medicine clerkship. A preponderance of clerkship directors (range 51-86%) reported that various opioid-related topics were important to cover in the internal medicine clerkship. Safe opioid prescribing topics were covered more frequently than topics related specifically to opioid use disorder. The main barriers identified included time (80.9%) and lack of faculty expertise (65.5%).

CONCLUSIONS

Clerkship directors agreed that incorporating safe opioid prescribing and opioid use disorder topics in the internal medicine clerkship is important, despite wide variation in current curricula. Addressing curricular time constraints and lack of faculty expertise in internal medicine clerkships will be key to successfully integrating content to address the opioid epidemic.

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

Purpose

Chronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients.

Methods

We undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity.

Findings

Care providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain.

Conclusion

Defining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.

Third-Year Medical Students' Reactions to Surgical Patients in Pain: Doubt, Distress, and Depersonalization

CONTEXT

Medical students have limited instruction about how to manage the interpersonal relationships required to care for patients in pain.

OBJECTIVES

The objective of this study was to characterize the experiences of medical students as they encounter pain, suffering, and the emotional experiences of doctoring.

METHODS

We used qualitative analysis to explore the content of 341 essays written by third-year medical students who described their experiences with surgical patients in pain. We used an inductive process to develop a coding taxonomy and then characterized the content of these essays related to empathy, patient-clinician interaction, and descriptions of clinical norms.

RESULTS

Students found it difficult to reconcile patient suffering with the therapeutic objective of treatment. They feared an empathic response to pain might compromise the fortitude and efficiency required to be a doctor and they pursued strategies to distance themselves from these feelings. Students described tension around prescription of pain medications and worried about the side effects of medications used to treat pain. Students felt disillusioned when operations caused suffering without therapeutic benefit or were associated with unexpected complications. Although patients had expressed a desire for intervention, students worried that the burdens of treatment and long-term consequences were beyond patient imagination.

CONCLUSION

These observations about patient-doctor relationships suggest that there is a larger problem among clinicians relating to patient distress and personal processing of the emotional nature of patient care. Efforts to address this problem will require explicit instruction in skills to develop a personal strategy for managing the emotionally challenging aspects of clinical work.