PATIENT EDUCATION

I had to relearn how to live.

— Gwenn Herman, Pain Connection-Chronic Pain Outreach Center, Inc.²

People with acute or chronic pain often are unaware of their treatment options or may hold inaccurate or value-laden beliefs about pain that obstruct the path to treatment and relief (Chapter 3). They deserve information that can help them understand and address their condition.

The optimal timing, content, and goals of patient education will vary depending upon the type of pain (acute or chronic), the availability and effectiveness of treatment, and the educational and literacy levels of the patient. Consider the case of acute pain. Although there are only limited opportunities to provide effective pain education to patients who experience unanticipated pain as a result of an injury or medical emergency, acute pain is an appropriate target of patient education. For example, the fear of pain or the experience of poorly controlled pain with outpatient procedures can affect a person’s willingness to undergo needed medical or dental treatment. Education about the likelihood of pain, including its possible magnitude, is therefore important to informed decision making, including decisions about options for preventing or managing pain. There is ample opportunity to educate people who will undergo elective surgery or outpatient procedures about the likelihood and magnitude of acute pain they may experience and to inform them about the availability of methods to prevent or relieve this pain. Postoperative patients surveyed about their information needs placed a high value on information about pain and pain management plans following surgery and discharge (Kastanias, 2009).

With respect to chronic pain, the committee believes education for patients should encompass such topics as those listed in Table 4-1. While the table addresses strictly patient education, families, too, should be seen as an appropriate target for educational efforts. Education for people with chronic pain should not be a one-time effort; as pain progresses, as treatments have greater or dwindling effects, as new treatments become available, the educational process should continue. One advantage of education is that it can enable people with pain to handle many pain-related problems themselves, without having to rely on medical care.

TABLE 4-1

Patient Education: Essential Topics.

People with chronic pain have substantial unmet educational needs. For example, while three-fourths of people with chronic pain who visited an emergency department reported a desire for information about pain treatment options or referrals to pain specialists, only half reported receiving such information (Todd et al., 2010). There is evidence that appropriate education can improve satisfaction with care and outcomes of people with pain (Merelle et al., 2008).

Sometimes, especially in cases of severe persistent pain, a person may have to learn that certain limitations and discomforts appear to be permanent. Someone facing the prospect of lifelong discomfort, disability management, and self-care challenges will require emotional support along with accurate information. The prospect of a permanent reduction in health status and quality of life is not unique to persistent pain. It also confronts people who have other chronic diseases (such as diabetes, asthma, end-stage renal disease, multiple sclerosis, and some cancer and heart disease conditions), and the rich experience of patient education about these other diseases can be mined to improve strategies and expand the supply of materials for patient education about pain. Patient education programs and materials, like treatment choices (Chapter 3), need to be age-appropriate, geared to the person’s and family’s level of comprehension and general health literacy, culturally and linguistically competent, and supported by timely opportunities to ask questions and receive authoritative and useful answers. Families and other personal caregivers deserve information about how to obtain stress relief— including, in the case of people who are terminally ill, respite care—because they, too, are part of the patient’s milieu and need to be able to remain in peak form. Given the importance of patient education on pain, it would be useful to have educational modules—available through different media, such as Internet links (which could also benefit clinicians), pamphlets, and audio connections translated into various languages or geared to different health literacy levels or age groups—that could be selected for individual patients.

Because severe pain affects so many aspects of a person’s life, people with pain and their families can feel overwhelmed. Education can help them devise ways of improving those circumstances that can be improved and coping with more lasting restrictions. Various types of education programs evaluated or in use by voluntary health organizations have benefited people with pain, including

• information on ways to control and cope with pain (American Chronic Pain Association, 2011; American Pain Foundation, 2011; PainKnowledge.org, 2011);
• psychosocial supports for people with pain and their personal caregivers, with a strong patient education component (Porter et al., 2010); and
• encouragement in the use of self-management strategies (Oliver et al., 2001; Moseley, 2003; Trautmann and Kröner-Herwig, 2010).

As noted in Chapter 1, a person’s beliefs about pain correlate with pain treatment outcomes. For example, one study found that people with cancer tend to receive inadequate analgesics and have greater pain if they harbor beliefs such as that cancer pain is inevitable, that side effects of analgesic drugs are unmanageable, that “good patients” do not complain about pain, and that pain distracts physicians from treating the cancer (Gunnarsdottir et al., 2002). Correcting such beliefs and misperceptions should be an important educational goal.

Education programs also can reduce symptoms and improve functioning. A program consisting of four educational sessions for people with cancer showed “significant immediate and sustained effects . . . on pain and fatigue barriers” among patients who received the intervention, compared with a usual care control group, as well as increased knowledge and measurable improvements in quality of life (Borneman et al., 2011, p. 197). Among people with low back pain, one-on-one education with a physiotherapist led to improved physical functioning, as measured by both straight-leg raise and forward bending. The researchers attributed approximately 77 percent of the leg-raise improvement and 60 percent of the bending improvement to a change in cognition, especially the belief that pain means tissue damage, and to reduced catastrophizing (Moseley, 2004).

Psychosocial education appears to be especially useful. In a German study involving “back schools” for rehabilitation in patients with low back pain, those who received education in the biopsychosocial model showed greater knowledge about their illness and better self-management than those who received more traditional education (Meng et al., 2011). A study of U.S. soldiers completing their training showed that a psychosocial education program improved their knowledge about the effects of low back pain—a malady frequently faced by soldiers—and their ability to cope with it (George et al., 2009).

Patient education assists people with pain and their families, as well as specific high-risk groups, such as soldiers in the example discussed above or people diagnosed with cancer. The next section addresses public education, which can help in the prevention and treatment of pain in the general population.

PUBLIC EDUCATION

We need respectability brought to these conditions.

—Terrie Cowley, The TMJ Association, Ltd., An advocate for people with chronic pain³

Why educate the general public about pain? The committee identified five reasons why public education about pain could be highly beneficial:

• People who have received such education can take steps to avoid pain, such as practicing proper stretching and lifting techniques, and can engage in timely and useful self-management when pain strikes.
• Educated people can give appropriate advice and assistance to family members, friends, and colleagues of people with pain, especially by advising them to refrain from telling injured individuals to simply “bear with it” or “suck it up.”
• In interactions with health care providers, educated people can advocate for and accept appropriate treatment of acute and chronic pain they or family members experience.
• An educated public can act at the community level to minimize hazards that contribute to pain-producing injuries among students (such as in sports programs) and in the general community (such as unshoveled walkways or sidewalks in disrepair).
• Educated citizens can advocate for improved pain prevention and control policy measures, such as reasonable sports helmet requirements, lawful access to medically necessary opioid medications, and health insurer reimbursement of interdisciplinary pain care.

Data with which to measure the extent and accuracy of public knowledge about the science and treatment of pain are limited. A 2002 national telephone survey of 1,000 adults found that “most Americans have little understanding of pain and its treatment” (Partners for Understanding Pain, 2002, p. 2). Specifically, survey respondents tended to overestimate physicians’ training in pain; underestimate the extent to which pain affects people under age 65; and believe that most people complain about pain only to obtain drugs, avoid work, or garner attention. Similarly, a landmark 1997 survey of the public sponsored by the Mayday Fund found that many Americans had only limited knowledge about pain and its treatment, believing, for example, that pain medications are dangerous and should be avoided if possible (Bostrom, 1997).

Although the 1997 and 2002 surveys uncovered persistent deficits in public understanding about pain, they are insufficient to serve as a platform for a major public education effort today. The results are a decade or more old and are focused largely on opioid-related issues that continue to evolve. Additional research into public knowledge about pain would enable public health advocates to

• assess the overall need for public education,
• identify groups most in need of education and the most cost-effective ways of reaching them,
• determine appropriate content domains, and
• craft messages or lessons.

Some existing campaigns, described in Box 4-1, illustrate how public education on pain might take place. Some public health education campaigns outside the pain field illustrate the potential for producing change in pain-related behavior. Tobacco use in the United States has fallen dramatically, for example, partly as a result of systematic public education. Between 1991 and 2009, use levels among high school students declined by 34 percent for “ever smoked cigarettes,” by 29 percent for current cigarette use, and by 43 percent for current frequent cigarette use (Office on Smoking and Health, 2010). Among adults, smoking rates declined by 24 percent between 1992–1993 and 2006–2007 (Giovino et al., 2009). Local combinations of a well-designed public education campaign, community and school-based programs, strong enforcement efforts, and smoking cessation programs have reduced smoking among youth by as much as 40 percent ( Campaign for Tobacco-free Kids, 2011). Mass media tobacco control campaigns are associated with both declines in youth uptake of smoking and adult smoking cessation (Wakefield et al., 2010).

BOX 4-1

Public Education Campaigns on Low Back Pain. Low back pain costs Australia more than AU$9 billion a year (which amounts to approximately US$350-400 per resident) (Walker et al., 2003). Partly to reduce rapidly rising workers’ compensation costs (more...)

The back pain campaigns described in Box 4-1 and tobacco control campaigns represent one type of public education—social marketing—which uses simple messages, advertising techniques, and other marketing approaches to persuade large numbers of people to change behavior or support changes in public policy (Kotler and Lee, 2008). Other public education strategies include more neutral informational and awareness-building efforts. Like social marketing, these efforts seek people out proactively. In the pain context, such efforts could alert people to the range of available treatments and categories of health professionals who treat pain, to available educational resources, or to the fact that pain is both a physical and a psychosocial condition. These strategies also might also focus on reducing risk factors for pain. For example, they could remind people with frequent headaches to avoid using analgesics daily or near-daily to minimize the development of medication-overuse headache (Loder, 2006).

Many educational tools are useful in reaching the public:

• website content, listservs, and social media;
• fact sheets distributed to target audiences, such as opinion leaders or community meeting attendees;
• leaflets, to raise awareness and be retained as personal references;
• informational reports and studies;
• pamphlets distributed at schools, workplaces, churches, public meetings, and other venues;
• signs at health facilities and in health professionals’ offices;
• media outreach;
• coalition building among stakeholders;
• surveys of public or professional attitudes used to garner media attention;
• wellness classes at health facilities, gyms, senior centers, and adult education programs, for example;
• instructional videos; and
• attempts to influence purveyors of popular culture, such as television and movie scriptwriters.

An advantage of comprehensive educational efforts is that content can be far more complex than simple messages delivered via the mass media. Also, most of these approaches can be tailored to specific audiences, segmented by health status, risk group, demographic characteristics, language skills, or preferred educational media. Some educational initiatives could target nonhealth professionals who receive people’s initial reports of pain, such as employers, teachers, and clergy (Chapter 3), or third-party payers and others who influence the course of pain care. An additional advantage of public education overall is that it can draw people into public decision-making processes, for example, by encouraging them to ask their employer to make sure that their health insurance plan sufficiently covers pain management or advocate that their local public schools have an injury prevention policy, especially in sports programs.

Illustrating the capacity of public education about health issues, the American Cancer Society (ACS) has been effective in its long-term efforts to promote cancer screening and early detection. ACS began as a public education organization in an era when cancer was rarely talked about openly, and used film and other media to engender emotion and gain support for cancer research and care (Cantor, 2007). The organization maintains a nationwide 24-hour help line and offers information about local resources, clinical trials, awareness building, smoking cessation, and specific cancers (ACS, 2011). Additionally, ACS actively advocates for public policies to increase cancer prevention, care, and research and participates in prohealth coalitions (ACS et al., 2008).

Over a shorter time frame, end-of-life educational efforts have been similarly instrumental in such areas as making more Americans aware of the importance of advance directives (Ulrich, 1999; Patient Self-Determination Act, Public Law 101-508, Secs. 4206 and 4751 of Omnibus Budget Reconciliation Act of 1990). Prominent among these end-of-life educational efforts was the Last Acts campaign, a coalition-based enterprise that engaged in multiple public and professional education initiatives (Karani and Meier, 2003). For example, one Last Acts product was a national report card indicating how well each state was protecting end-of-life decisions and ensuring high-quality care for people with terminal illnesses (Robert Wood Johnson Foundation, 2003).

Public education is undertaken by many other nonprofit organizations dedicated to combating a single disease or constellation of health conditions. Typically, their efforts mix patient (and family) and public education. Alzheimer’s disease, for example, is targeted by multiple groups that have both public and patient education as part of their mission:

• The Alzheimer’s Association maintains a website with access to such materials as a chartbook and a list of ten warning signs of the disease (Alzheimer’s Association, 2011).
• The American Geriatrics Society’s Foundation for Health in Aging administers a Patient Education Forum with online answers to such questions as: “What effect can Alzheimer’s disease have on a caregiver?” and “How important is early detection and diagnosis of Alzheimer’s disease?” (American Geriatrics Society, 2011).
• A California Alzheimer’s disease task force adopted a statewide plan to reduce stigma, ensure that information clearinghouses have reliable information, increase access to public information, and promote public education (California Health and Human Services Agency and California Council of the Alzheimer’s Association, 2011).
• The National Institute on Aging maintains an Alzheimer’s Disease Education and Referral Center.

Educational efforts by these and many other organizations have helped make the country more aware of Alzheimer’s disease and have assisted individuals and their families in finding information and support.

Currently, public education about pain is not conducted in a large-scale, systematic, coordinated, and strategic way as in the tobacco, cancer, end-of-life, and Alzheimer’s disease examples. Some organizations, such as the American Pain Foundation and the Mayday Fund, certainly promote public awareness. Several patient-oriented groups focused on single pain conditions or issues—such as the National Fibromyalgia Association, Women with Pain Coalition, and American Chronic Pain Association—take strong advocacy positions. The issue of access to opioid medications has sparked numerous public advocacy efforts over the past two decades. But neither the federal government nor a coalition of pain organizations that could assemble more resources has designed and undertaken a campaign to increase public awareness of such topics as the pervasiveness of pain and the need to treat it, the multiple causes and effects of pain, the fact that pain involves a complex mind–body interaction, and the range of available and useful treatments. Without such an effort, it appears unlikely that public awareness of these issues will increase substantially in the near future or that the cultural transformation envisioned by this committee (Chapter 1) can be achieved.

On the federal level, informing the public about pain has not received sustained priority attention from the Centers for Disease Control and Prevention (CDC), the Office of the Surgeon General, the Agency for Healthcare Research and Quality (AHRQ), or the National Institutes of Health (NIH), although CDC, AHRQ, and NIH all have displayed an appreciation for the importance of pain. CDC, for example, has publicly released a fact sheet on pain (CDC, 2006); AHRQ conducted an early study on back pain and publicized the results (Chapter 3); and NIH has assembled a Pain Consortium (Chapter 1). Pain also does not receive focused attention in the latest Healthy People report (Chapter 2).

Public education is a normal public health activity; indeed, “inform, educate, and empower people about public health issues” is one of the Ten Essential Public Health Services that every public health agency is expected to provide (CDC, 2011). Public education enhances the effects of each of the concentric circles of major influence on disease control: policy, community-wide environmental control measures, community awareness support and action, work and school support, clinical expertise, family involvement, and patient self-management (Clark and Partridge, 2002).

Advocacy, especially at the state level, may be an appropriate education-related activity for organizations interested in reducing the burden of pain in society. To illustrate, the Massachusetts Pain Initiative has supported state legislation to require pain assessment and management in all health facilities, extend the expiration date of scheduled drugs to comply with federal law, require pain management and prescription drug abuse training for all prescribers, and establish a prescription monitoring program task force (Massachusetts Pain Initiative, 2011).

Just as public education programs may require the combined financial resources of several organizations, advocacy efforts typically require the combined voice of a strong coalition. Given the multiple barriers to better pain prevention and care, such a combined effort may be needed to have a significant impact at the federal level; in state capitals; and with key private organizations, such as health insurers, health professions training and accreditation authorities, health professions examination boards, large health care providers, employers, schools, and sports officials. Effective, multifaceted, and coordinated advocacy is a necessary condition for cultural transformation.

Patient and public education, the two topics addressed in the first part of this chapter, help shape the demand for pain care. The following sections turn to the supply of health professionals adequately prepared to provide pain care, beginning with physicians.

PHYSICIAN EDUCATION

Pain management and physical rehabilitation were never addressed in my medical school curriculum nor in my family practice residency. My disability could have been avoided or lessened with timely treatment, and I could still be the provider instead of the patient.

— A physician with chronic pain⁴

Did we have as students a single lecture on migraine, and did anyone tell us that migraine is not just a tiresome form of occasional headache which someone else rather boringly suffers from?

—William Gooddy, Foreword to Migraine, by Oliver Sacks, p. xxii.

The case for including comprehensive education about pain in medical education is powerful. People have sought out physicians for pain care for centuries. Pain treatment is an essential component of clinical practice, as recognized in state medical practice acts and by the Federation of State Medical Boards in its model Medical and Osteopathic Practice Act:

Practice of medicine means . . . offering or undertaking to prevent or to diagnose, correct and/or treat in any manner or by any means, methods, or devices any disease, illness, pain, wound, fracture, infirmity, defect or abnormal physical or mental condition of any person. . . . (Federation of State Medical Boards, 2010, p. 4).

The widespread prevalence of pain (Chapter 2) demonstrates the need for medical educators to recognize it as a common and often severe condition. Yet there are strong indications that pain receives insufficient attention in virtually all phases of medical education—the lengthy continuum that includes medical school (undergraduate medical education), residency programs (graduate medical education), and courses taken by practicing physicians (continuing medical education [CME]).

Deficiencies in preparing physicians to manage pain were documented and explored in depth during the First National Pain Medicine Summit, convened in November 2009 by the American Medical Association’s Pain and Palliative Medicine Specialty Section Council (Lippe et al., 2010). The genesis of the summit was widespread concern that current knowledge about pain management is not being well integrated into medical practice and that pain care in general is “delayed and inadequate.” Nearly 100 representatives of some 30 physician organizations participated in this exercise. The summit agenda was built around a two-stage Delphi, or group consensus development, process. The first stage produced strong criticism of current physician training in pain care:

• Training was seen as poor or “not leading to competency” at both the undergraduate and residency levels in all suggested areas of pain treatment. Rated highest was pharmacologic therapy training at the residency level, but even in that area, only 53 percent of respondents agreed that the training led to competency. None of the areas received a majority of “yes” votes to the question of whether adequate care was being provided in that area.
• Participants identified three top barriers to adequate pain care: workforce issues that create a shortage of competent pain care providers, a lack of knowledge among physicians and/or people with pain regarding the field of pain care medicine, and a lack of public knowledge about pain issues. All three factors were seen as barriers by more than 90 percent of respondents.
• The average score for the question, “How well does the present system of credentialing and certification ensure competency?” was 2.65 (where 1 was “not at all” and 5 was “completely”).

Themes extracted from respondents’ comments in the first Delphi round were used to identify five topics that became the subject of work group discussions in the second round:

• What should all physicians know about pain medicine?
• How should pain medicine be taught?
• What are the parameters that define the field of pain medicine?
• What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine?
• What are the barriers, besides the absence of competent pain medicine physicians, that prevent people from receiving adequate care?

The summit therefore may have laid the groundwork for substantial improvements in physician education about pain. The summit work group discussing the question, “What should all physicians know about pain medicine?” concluded that most medical school education still treats pain mainly as a symptom. “Cure the disease, and cure the pain” is the assumption, which ignores the emerging recognition that persistent pain requires direct treatment (Chapter 1). The group found little consistency in teaching across medical schools, among departments in the same school, and even within departments (Gallagher, 2010). Identified as chief flaws were a lack of breadth in the presentation of the topic, a lack of integration of basic science and clinical knowledge, and a lack of clinical role models—especially specialists treating chronic pain—in most academic medical centers. The results included “negative generalizations about patients with chronic pain” and “further alienation and misunderstanding of the patient and chronic pain.” Moreover, this first work group observed that pain management is spread out over many clinical specialties, creating confusion about “who is in charge” of developing, documenting, and reporting best practices and pain care guidelines. As a result, there are “no standards for measuring the effectiveness of treating pain in clinical practice.” The work group also noted the paucity of information about treating pain in children.

The summit work group discussing the question, “How should pain medicine be taught?” echoed the first group’s findings and focused on the need to make pain training more comprehensive, “incorporating the needs of the primary care practitioner and the pain care specialist” alike (Burchiel, 2010, p. 1452).

The work group discussing the question, “What mechanisms do we need to establish the competency of a physician who wishes to practice pain medicine?” identified the need to determine competency through medical education, assessment, and documentation through all three stages of education. Meeting this need will require oversight of education by accreditation authorities and oversight of practice by licensure and certification authorities, including greater attention to CME (Follett, 2010). This work group’s discussion suggests that improvement could be realized if organizations such as the Accreditation Council for Graduate Medical Education (ACGME) and the National Board of Medical Examiners took steps to require pain training of most residents and include questions about pain on physician licensure examinations, respectively.

Finally, the competencies work group determined that “competing, overlapping, and sometimes conflicting efforts of the various organizations involved” mean there is no “single-party” ownership of the pain medicine specialty. This makes it difficult to develop a uniform process for training, certification, and demonstration of competency, a situation further complicated by the availability of pain treatment by nonphysicians “whose variable training and certification add even more disparity to the mix” of competencies of different practitioners.

The summit findings emerged against a backdrop of continually expressed concerns that most physicians are not equipped to provide high-quality pain care. One concern is that too many physicians harbor outmoded or unscientific attitudes toward pain and people with pain (see Chapter 3). For example, physicians are described as having “pain apathy” that inhibits them from engaging in active treatment (Notcutt and Gibbs, 2010). The perspective of scholars in medical anthropology or social medicine provides a theory about this lack of interest:

. . . in our studies over several decades, we found that “the medical gaze” soon becomes the dominant knowledge frame through medical school, that time and efficiency are highly prized, and that students and their attendings (that is, clinical educators) are most caring of patients who are willing to become part of the medical story they wish to tell and the therapeutic activities they hope to pursue. (Good et al., 2002, p. 596)

Pain may not be part of the “medical story” most physicians are interested in telling or learning about because they concentrate on other diseases and conditions.

People with pain, especially chronic pain, sometimes do find that physicians are poor listeners. In a study of physician communication with people with cancer pain, involving 17 oncologists and 84 patients, physicians were found to do most of the talking during patient visits and to interrupt most patients’ attempts to provide information or answer questions (Berry et al., 2003). The researchers concluded: “The nature of such communication may prevent the patient from sharing significant facts and experiences relevant to cancer pain and thus compromise the quality of pain management” (Berry et al., 2003, p. 374). A previous Institute of Medicine (IOM) study recommended additional training for medical students in subjects involving communication skills to “assist physicians in building therapeutic relationships with their patients and increase the likelihood that patients will follow their advice” (IOM, 2004, p. 4).

Inadequate training in pain is strongly implicated in insufficient treatment. An expert panel convened by the Mayday Fund reported:

. . . current systems of care do not adequately train or support internists, family physicians and pediatricians, [who are] the other health care providers who provide primary care in meeting the challenge of treating pain as a chronic illness. Primary care providers often receive little training in the assessment and treatment of complex chronic pain conditions. They tend to work under conditions that permit little time with each individual and few options for specialist referrals. (Mayday Fund, 2009, p. 3)

The Mayday panel recommended that every health professional be taught “the skills to assess and treat pain effectively, including chronic pain” (Mayday Fund, 2009, p. 9). Presumably, those skills would include the application of cognitive-behavioral therapy, which also can be useful in treating conditions other than pain and should be appropriately reimbursed (Chapter 3).

Medical schools’ inadequate attention to comprehensive pain education has been quantified. A recent study of 117 U.S. and Canadian medical schools found that only 4 U.S. schools offer a required course on pain (Mezei and Murinson, in press). Most schools incorporate pain into another required course. The study also found that over the 4-year course of U.S. medical school education

• the total number of pain sessions taught ranged from 1 to 28, with a mean of 9 and a median of 7; and
• the total number of pain teaching hours ranged from 1 to 31, with a mean of 11 and a median of 9.

Levels about twice as high were found at Canadian medical schools. The inadequacy of attention to pain in medical schools is reflected in students’ specialty preferences. In a questionnaire administered annually to graduating medical school students, the percentage of respondents indicating pain medicine as their preferred choice of specialty stood at a flat 0.0 from 2006 through 2010 (AAMC, 2010).

What do primary care physicians themselves think of their preparation in pain management? Results of a national survey of residents completing their training at U.S. academic health centers, including training in the primary care specialties for which pain management is an essential component (internal medicine, family medicine, and obstetrics-gynecology), found that

• half the primary care respondents felt only “somewhat prepared” to counsel patients about pain management;
• as many as 27 percent felt “somewhat unprepared” or “very unprepared”;
• only 21 to 26 percent felt “very prepared”; and
• in response to questions about treating specific common pain problems, only about half of the internal medicine residents rated themselves “very prepared” to diagnose and treat low back pain or headache, compared with about two-thirds of family medicine residents and a quarter or less of obstetrics-gynecology residents (Blumenthal et al., 2001).

The Association of American Medical Colleges has surveyed all medical graduates regarding whether their instruction in various areas was inadequate, appropriate, or excessive. In 2006, a quarter of graduates rated their instruction in pain management and palliative care as inadequate. The rating improved somewhat by 2010, with only 20 percent rating instruction in this area as inadequate (AAMC, 2010).

Likewise, in a survey of 1,236 practicing physicians, more than half said they felt poorly prepared to manage end-of-life or chronic pain care (Darer et al., 2004). However, physicians (and other clinical staff) working in a rehabilitation hospital appeared somewhat more confident of their competence in most pain management skills (Loder et al., 2003). In a survey in which 111 staff members participated, large majorities (between 63 and 89 percent) said they were comfortable with such tasks as engaging in basic pain assessment, providing psychological support, using thermal modalities for pain, managing pain in the elderly, and teaching relaxation techniques.

Some efforts are under way to improve pain education and training in medical schools in creative ways. For example, at the Johns Hopkins University School of Medicine, a new 4-day program in pain medicine for first-year students integrates core curriculum knowledge with emotional and reflective development (Murinson et al., 2011). Pain specialists provide instructional support, and the course emphasizes building “emotional skills.” Student performance on a variety of outcome measures has been encouraging.

In CME—the end of the medical education continuum for practicing physicians—attention to pain also has increased somewhat. In 2001, California enacted legislation requiring all physicians other than radiologists and pathologists to take 12 CME units in pain management or end-of-life care; this mandatory CME provision is implemented by the state’s Board of Medical Examiners through regulation (California Business and Professions Code, 2011, Sec. 2190.5). This is a one-time-only requirement, however, and so does not compel clinicians to stay abreast of developments in the field throughout their careers.

Another possible shortcoming of mandatory CME is that the relationship between CME and desired changes in practice patterns is somewhat limited. In a recent review of 105 studies, only 60 percent showed that CME produces changes in physician practice patterns (although the authors found this to be a persuasive reason to promote CME) (Davis et al., 2009). A targeted approach to CME in pain management would require it only of physicians who prescribe high levels of opioids.

One frontier of CME (and quality improvement) appears to offer promise for physicians seeking to improve their competence in pain management. Academic detailing, in which medical school professors or other nonindustry experts offer tailored instruction to clinicians, was offered by a drug and therapeutics information service to primary care physicians in Fayette County, Kentucky (May et al., 2009). Instruction, in the form of personal visits, was offered in two subjects: diabetes management and pain management. Nearly three in five physicians chose to accept visits dealing with pain management.

NURSE EDUCATION

Every patient is an individual pharmacological experiment; one size does not fit all.

—A nurse in a pain management clinic⁶

The experience of pain is an overwhelming, whole-person experience with devastating effects on the experiencing person, the family witness, and the nurse.

—Nurse educator Betty Ferrell (2005)

Nurses provide bedside care to people with pain in hospitals and nursing homes, in patients’ homes, at schools and workplaces, in physicians’ offices, in public health and patient education programs, and as advanced practice nurses (a category that includes nurse practitioners, clinical nurse specialists, certified nurse midwives, and nurse anesthetists). Nursing leaders emphasize their profession’s focus on the “whole patient,” a helpful perspective when one is considering the complex interplay of factors involved in caring for people with acute and chronic pain. Nurses are educated to take into account that the “human response to a health problem may be much more fluid and variable” than suggested by the medical diagnosis and a greater key to recovery than a single medical treatment (ANA, 2011, p. 1). Moreover, nurses are trained to be attentive to the needs of families, who play a vital role in the care of people with chronic pain.

More specifically, nurses with baccalaureate degrees are charged with responsibility for providing care that incorporates many components of high-quality pain care. A recent report of the American Association of Colleges of Nursing states:

Baccalaureate-prepared nurses provide patient-centered care that identifies, respects, and addresses patients’ differences, values, preferences, and expressed needs (IOM, 2003). Patient-centered care also involves the coordination of continuous care, listening to, communicating with, and educating patients and caregivers regarding health, wellness, and disease management and prevention. The generalist nurse provides the human link between the healthcare system and the patient by translating the plan of care to the patient. A broad-based skill set is required to fill this human interface role. (American Association of Colleges of Nursing, 2008, p. 8, citing IOM, 2003)

To the extent that such psychosocially oriented care is delivered to people with chronic pain early in their course of treatment, it may have a particularly salutary effect in preventing serious problems—such as the progression from acute to chronic pain—later on. The report also outlines expectations for students’ clinical experiences within baccalaureate programs. These clinical experiences should be “focused on developing and refining the knowledge and skills necessary to manage care as part of an inter-professional team” and should take place “across the range of practice settings” (American Association of Colleges of Nursing, 2008, pp. 4, 34).

Pain management now is considered an essential responsibility for nurses, and nursing organizations acknowledge the need for “prompt, safe, and effective pain management.” The nursing profession views pain as a complex and multidimensional experience (Lewis et al., 2011) that responds subjectively to both physical and psychological stressors (LeMone et al., 2011). In a joint position statement, the American College of Emergency Physicians, American Pain Society, Emergency Nurses Association, and American Society for Pain Management Nursing enunciated 14 core principles regarding pain management (American College of Emergency Physicians et al., 2010). Two of these principles refer to educational issues:

• Clinician education and resources [should] support optimal pain management.
• Research and education are encouraged to support widespread dissemination of evidence-based analgesic practices.

Elsewhere among these principles, the need to rely on evidence-based practices is reinforced. Despite these well-articulated goals for nursing education, however, shortfalls persist. A survey of 111 nurse practitioners and physician assistants working in community clinics, surveyed about the adequacy of their training for pain management, rated it 0.5 on a scale of 0 to 4 (Upshur et al., 2006).

Numerous actions demonstrate the nursing profession’s commitment to high-quality pain care. In 2006, the house of delegates of the American Nurses Association passed an “Improving Pain Management” resolution (Trossman, 2006). And in 2005, the American Nurses Credentialing Center began administering a certification examination in pain management for generalist nurses (ANA, 2005).

Recognition of the need to sensitize and educate nursing students about pain management has been based on evidence and expert opinion. College students surveyed were found to have “many misconceptions” about pain management that must be addressed before education specific to pain management is attempted (McCaffery and Ferrell, 1996), although efforts to overcome personal biases and opinions are not universally successful. For example, nurses’ personal opinions about patients’ pain levels have been shown to affect their clinical behavior ( McCaffery et al., 2000).

One important construct, interprofessional education, is intended to increase the effectiveness of the care received from both physicians and nurses. An example of an initiative intended to foster improved interdisciplinary teamwork is that of the Centers of Excellence in Primary Care Education program of the Department of Veterans Affairs, which recently awarded grants to five of the department’s medical centers and collaborating organizations (Department of Veterans Affairs, 2011). The funded centers will “develop and test innovative approaches to prepare physician residents and students, advanced practice nurse and undergraduate nursing students, and associated health trainees for primary care practice in the 21st Century.” The projects are designed to promote shared decision making; interprofessional collaboration; quality improvement; and longitudinal relationships among students, patients, and teachers. These projects may well contribute to enhancing pain care, a central focus of veterans’ services (Chapter 3).

In other, nonfederal settings, state laws that restrict the scope of practice of nurse practitioners and other advanced practice nurses may impede the delivery of primary care (IOM, 2010). Given that responsibility for most pain care falls heavily on primary care practitioners, and too few primary care physicians exist to shoulder that burden, nurse practitioners are likely to play an increasingly important role.

One innovation in nursing pain education consists of pain resource nurse (PRN) programs. Initially developed at the City of Hope National Medical Center, PRN programs are intended to create a cadre of well-trained nurse coaches and mentors to promote nurses’ use of best-practice pain strategies. PRN training includes in-person coursework, regular follow-up in-service training, news letters, ongoing peer support, and other forms of education. This approach has been found to produce significant improvements in nurses’ knowledge and attitudes about pain care, as well as improved patient satisfaction with pain control and a reduction in the prevalence of pain (Paice et al., 2006). However, some participants in PRN programs have expressed frustration with “the slow pace of change and improvement, the lack of visible signs of their success, and the ongoing nature of the work” (McCleary et al., 2004, p. 34). Institutional support is considered key to the success of the PRN initiative.

OTHER HEALTH PROFESSIONS EDUCATION

If dentists couldn’t offer “pain-free” dentistry, no one would go to them!

—A dental educator⁷

Many health professions are involved in pain care. Although a comprehensive survey of the pain-related educational preparation of all health professions is beyond the scope of this report, the committee identified a few particularly noteworthy efforts.

CONCLUSION

Curricula for all health professions are full, and advocates of many important causes compete for a greater share of students’ and clinicians’ valuable educational time. Yet despite the large role that care of patients with pain will play in their daily practice, many health professionals, especially physicians, appear underprepared for and uncomfortable with carrying out this aspect of their work. These professionals need and deserve greater knowledge and skills so they can contribute to the necessary cultural transformation in the perception and treatment of people with pain.

FINDING AND RECOMMENDATIONS

Finding 4-1. Education is a central part of the necessary cultural transformation of the approach to pain. The committee finds that the federal government is in a position to contribute to substantial improvements in patient and professional education about pain.

Recommendation 4-1. Expand and redesign education programs to transform the understanding of pain. Federal agencies and other relevant stakeholders should expand education programs to transform patient and public understanding of pain. In concert with Recommendation 2-2, federal agencies, in partnership with health professions associations, payers, pain advocacy and awareness organizations, and other relevant stakeholders, should develop education programs for patients, the public, and health care providers that are designed to promote a transformation in their expectations, beliefs, and understanding about pain, its consequences, its management, and its prevention. Programs should

• be endorsed by expert pain health professions organizations;
• strive to increase awareness of the significance of pain, its prevention, the need to address acute and chronic pain in timely and effective ways, the biological and psychosocial aspects of pain, and the need for comprehensive assessment of pain, as well as to instill a balanced understanding of available treatments;
• incorporate materials such as fact sheets and information that can be made widely available, including on the Internet; and
• be specifically and appropriately targeted to patients, the public, and providers to ensure understanding of the concepts being imparted.

Recommendation 4-2. Improve curriculum and education for health care professionals. The Centers for Medicare and Medicaid Services, the Health Resources and Services Administration, accrediting organizations, and undergraduate and graduate health professions training programs should improve pain education curricula for health care professionals.

• Accrediting organizations, such as the Liaison Committee on Medical Education and American Psychological Association Committee on Accreditation, should establish specifically identifiable standardized curriculum requirements for pain education.
• The Centers for Medicare and Medicaid Services should provide financial support for advanced training in pain management.
• The Bureau of Health Professions should provide financial support for training grants for the education of practitioners in pain assessment and management.
• Undergraduate and graduate health professions training in programs whose graduates will participate in pain care should include pain education.
• Relevant accrediting organizations (such as residency review committees and the Accreditation Council for Graduate Medical Education) should establish specifically identifiable and standardized curriculum requirements for pain education in graduate training programs, such as primary care programs.
• Training should include education in interprofessional settings.
• Assessment of pain knowledge should be included in examinations for licensure (e.g., the U.S. Medical Licensing Examination), certification (the American Board of Medical Specialties), and recertification.
• Health care professionals should engage in ongoing pain education through postgraduate continuing education programs.

Recommendation 4-3. Increase the number of health professionals with advanced expertise in pain care. Educational programs for medical, dental, nursing, mental health, physical therapy, pharmacy, and other health professionals who will participate in the delivery of pain care should have increased capacity to train providers who can offer advanced pain care.

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Footnotes

1

Quotation from response to committee survey.

2

Quotation from testimony to the committee, November 2010.

3

Quotation from testimony to the committee, November 2010.

4

Quotation from response to committee survey.

5

A completely different model is that used in the United Kingdom under its system of “specialization in general practice” (Jones, 2006). Preliminary findings in a headache service suggested that, for patients with comparable severity of illness, outcomes from care by generalists with special training in headache management were similar to those from care by a traditional neurology service, while patient satisfaction was higher and costs were lower (Ridsdale, 2008).

6

Quotation from response to committee survey.

7

Quotation from committee member.