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Pain Education Lacking in Medical Schools

 Pain education in North American medical schools is “limited and fragmentary,” according to a Journal of Pain study of 117 U.S. and Canadian medical schools (2011;12:1199-1208). The researchers found that vital curricular pain content is presently going unaddressed.

“The more we come to know about what’s being taught in pain, the more glaringly obvious the gap between theory and practice becomes,” said co-author Beth B. Murinson, MS (Biomath), MD, PhD, associate professor and director of pain education in the Department of Neurology, Johns Hopkins School of Medicine, Baltimore.

Chronic pain alone affects at least 116 million U.S. adults, many of whom receive inadequate assessment and treatment, according to the Institute of Medicine. Yet, until the Journal of Pain study, pain education had not been adequately evaluated, the study authors reported; pain education was only described in terms of simple presence or absence of criteria.

To remedy this issue, the researchers performed a systematic review with a detailed process metric. They discovered that pain is most often taught in the context of a more general required course that is not focused on pain—an approach the researchers called fragmentary. Of U.S. medical schools, only 3.8% reported having a required pain course. An additional 16.3% of U.S. medical schools offered a designated pain elective. The total number of pain sessions taught at a single school ranged from one to 28, with a mean of nine and a median of seven. A large number of U.S. medical schools do not report teaching any pain courses and an equally large number commit fewer than five hours to pain education over four years.
 
Asked about the status of contemporary pain education, Steven D. Passik, PhD, professor of psychiatry and anesthesiology, Vanderbilt University Medical Center, Psychosomatic Medicine, Nashville, said in an email: “It is lacking in almost every respect—not enough time spent, not enough breadth of the psychological and other complications of pain, not nearly enough case-based understanding. Generally it is an hour on opioid pharmacology and little else. Given that pain is the most common reason people go to the doctor, it is a travesty that more time is not spent on it.”
 
Areas particularly underserved, said Dr. Murinson, are pediatric pain, cancer pain and medicolegal issues pertaining to opioids. “There’s literally almost nothing on these topics,” she added. “Kids should not suffer needless pain. And, clearly, cancer patients should not endure untreated pain.” Geriatric pain also is not addressed sufficiently, according to the study.
 
Pain education currently focuses on basic science, but more pragmatic education is needed, according to Dr. Murinson. “There’s a groundswell for more clinically focused education,” she commented. The study recommends that the number of required, integrated, pain-focused courses be increased, as part of a more organized, formal delivery of pain education. Dr. Murinson has developed a curriculum for pain, an 18-hour course at Johns Hopkins University. Her personal mission is “to understand better how medical students grow and develop as clinicians.” Emotional as well as intellectual skills are important. “We’re asking how to facilitate students’ progress toward becoming highly compassionate physicians.”
 
Carol Aschenbrener, MD, chief medical education officer, Association of American Medical Colleges (AAMC), Washington, D.C., stated in an interview that the Journal of Pain study was limited by the great variability in the extent of data reported by medical schools. (Data from AAMC was used in the study.) She added, “There are many areas where we can improve, and [pain education] is one of them, but we shouldn’t focus just on medical school.” She recommended a competency-based approach with attention to developmental pathways, in which certain kinds of training might best be introduced in “residency and the initial years of practice.” She also recommended not developing curricular materials independently, but pooling them in a resource such as AAMC’s MedEdPortal, a free, peer-reviewed collection of teaching materials.
 
The Journal of Pain study is important, said Dr. Passik. “It documents just how bad the problem is and gives a recent perspective, i.e., that this problem has been known for a long time, and if anyone was laboring under the misconception that it had improved with all the attention to pain that has characterized recent years, this [study] demonstrates that it has not.”

Dr. Murinson reported no relevant financial disclosures. Dr. Passik disclosed being a speaker at Cephalon, Janssen, Millennium Laboratories and Quest Diagnostics; a consultant for Ameritox, Cephalon, Covidien, Endo, Janssen, Pfizer, PharmacoFore, Millennium Laboratories, Purdue Pharma and Quest; and receiving research funding from Covidien.
 
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