Pain education in North American medical schools.

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Published in final edited form as: J Pain. 2011 Sep 25;12(12):1199–1208. doi: 10.1016/j.jpain.2011.06.006 Pain Education in North American Medical Schools Lina Mezei 1, # , Beth B Murinson 2, # ; the Johns Hopkins Pain Curriculum Development Team 3 Author information Article notes Copyright and License information 1 Department of Neurology, Johns Hopkins School of Medicine, Baltiore, Maryland 2 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland 3 Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland The Johns Hopkins Pain Curriculum Development Team: Dr. James N. Campbell, M.D. Dr. Jennifer A. Haythornthwaite, Ph.D. Mr. Richard A. Meyer, M.S. Dr. Gayle Page, Ph.D. Dr. Albert Wu, M.D. Dr. Myron Yaster, M.D. # Contributed equally. Issue date 2011 Dec. PMC Copyright notice PMCID: PMC13235945  NIHMSID: NIHMS329545  PMID: 21945594 The publisher's version of this article is available at J Pain Abstract Knowledgeable and compassionate care regarding pain is a core responsibility of health professionals associated with better medical outcomes, improved quality of life and lower healthcare costs. Education is an essen tial part of training healthcare providers to deliver conscientious pain care but little is known about whether medical school curricula meet educational needs. Using a novel systematic approach to assess educational content, we examined the curricula of Liaison Committee on Medical Education (LCME)-accredited medical schools between August 2009 to February 2010. Our intent was to establish important benchmark values regarding pain education of future physicians during primary professional training. External validation was performed. Inclusion criteria required evidence of substantive participation in the curriculum management database of the Association of American Medical Colleges (AAMC). A total of 117 U.S. and Canadian medical schools were included in the study. Approximately 80% of U.S. medical schools require one or more pain sessions. Among Canadian medical schools, 92% require pain sessions. Pain sessions are typically presented as part of general required courses. Median hours of instruction on pain topics for Canadian schools was twice the U.S. median. Many topics included in the IASP core curriculum received little or no coverage. There were no correlations between the types of pain education offered and school characteristics (e.g., private vs. public). We conclude that pain education for North American medical students is limited, variable, and often fragmentary. There is a need for innovative approaches and better integration of pain topics into medical school curricula. Keywords: Pain Education, Curriculum, Pain Knowledge, Curricular content, Teaching Introduction: Healthcare has undergone dramatic changes in the last 25 years, but inadequate treatment of pain has persisted 9 , 34 , 35 . Knowledgeable and compassionate care regarding pain is a core responsibility of health professionals 1 and is associated with better medical outcomes, improved quality of life and lower healthcare costs 14 , 27 . And although pain education was identified in 1988 as an important remedy for the under-treatment of pain, progress toward effective programs that educate future clinicians has been slow 29 . While all allied health professionals need education about pain, deficiencies are conspicuous in medical education 8 , 10 , 19 , 26 . It is increasingly evident that new approaches are needed as efforts at advocacy, legislation, regulation and influence have yielded few results 1 , 20 – 22 , 24 , 28 . Quality improvement is an important method for instigating change in healthcare 13 . A cornerstone of quality improvement is the development and application of meaningful metrics 11 . The most widely applied of these metrics are “process measures” which are specific, measurable elements of care that are linked to desired outcomes. They are often used because outcomes may be difficult to measure or difficult to act upon 41 . For example, outcome measures include a reduction in the number of heart attacks or the incidence of disabling migraine, while process measures include the measurement of blood pressure or the review of a pain medication usage at every clinic visit. Useful process measures are strongly associated with desired outcomes, are easily assessed and do not result in negative, unintended effects in their measurement 11 . Until now, pain education has not been evaluated using effective process measures. As recently as 2001, published studies describing pain education in medical school employed only presence or absence criteria 8 . The presence of ‘pain education’ could therefore mean one hour within a curriculum exceeding 3000 hours. There are many indications that meaningful progress will not be made until a more discerning approach to measuring the extent of pain education is adopted. The development of recommended standards for pain education dates back to 1983 when the International Association for the Study of Pain (IASP) published a consensus curriculum 29 . Since then, other standards for pain education have been published: the European Federation of IASP Chapters (EFIC) curriculum, pain medicine exam guidelines and implemented courses 16 , 30 , 43 . These sources exhibit agreement that major topics should include pain neurobiology, clinical assessment, and pharmacological pain management. Other topics are also widely acknowledged as important: geriatric pain, pediatric pain and substance abuse; cancer pain, acute pain and neuropathic pain 33 , 38 . Little is known about the extent to which these are covered in medical schools. The present study was designed to appraise current medical school education about pain in North America. In order to move beyond historical ‘presence-or-absence’ criterion used for gauging pain education, we developed an instrument that not only incorporated major topics in pain but also included important sub-topics within each of the major topic areas. This approach resulted in a more thorough and compelling assessment of pain education. By looking carefully at the details of pain education, we found that while some areas receive particular emphasis; important curricular pain content is essentially not addressed at present. We observed that the development of a more detailed process metric for the assessment of pain education was essential to reaching meaningful observations about the scope and scale of pain curricula in North America. Methods: Instrument Development Following recommended guidelines for curriculum evaluation 25 , we performed a systematic review of medical school pain education. Sources included the IASP pain curriculum 36 , the European Federation of IASP Chapters (EFIC) curriculum 16 and one published example of an implemented curriculum 43 . Published reports and licensing exam guidelines were reviewed 5 , 7 . An interdepartmental focus group of Johns Hopkins pain experts reviewed the curricular precedents and from these the major topic headings for the report template were established. One area of concern was the need for adequate training in clinical assessment of pain; this was explicitly included as a major topic area. Detailed learning objectives, where available, from each of the published sources were reviewed by the group and discussed in the context of the educational needs of medical students. The group used a modified Delphi process 38 to establish a list of detailed learning objectives felt to be most appropriate for medical students. From this list of 201 learning objectives [ Supplemental data 1 ], a consolidated list of pain sub-topics, about 4 within each of the major topic areas, 53 in all, was developed. This sub-topic list was tested for appropriateness in a pilot study. In the pilot study, a preliminary survey of CurrMIT pain content data was performed during July-August 2008 as described in detail below. All the CurrMIT content data found in this survey was then sorted into the categories based on the sub-topic list. The sub-topic ‘names’ were removed from the sorted data and a colleague unfamiliar with the protocol (E.N.) was asked to name the categories based on the content in each category alone. The uncategorized content data were also reviewed. It was found that the sub-topic names were highly appropriate for categorizing the data concisely. The major topic area previously referred to as ‘the meaning of pain’ or ‘the definition of pain’ was renamed to the ‘ontology of pain’ to more formally and accurately reflect the contents of the category. Other topic and sub-topic labels were unchanged. Data Collection and Validation The pain curricula in U.S. and Canadian medical schools were assessed using the Association of American Medical Colleges’ (AAMC) Curriculum Management and Information Tool (CurrMIT) 32 . CurrMIT is a centralized repository of curricular information that is accessed through a password-protected website. It is widely used by medical school administrators in order to meet the requirements for maintaining a repository of curricular information as specified by the Liason Committee on Medical Education (LCME). We included curricula that had been updated since 2005 or more recently. A pilot study was performed July-August 2008, with the goal of developing effective search strategies for use with the CurrMIT database. It was evident from the pilot study that pain content is taught using one of three main delivery mechanisms: 1) within another required course, 2) within a required course dedicated to pain, and 3) as sessions or topics within an elective course. The comprehensive analysis was conducted August 2009 - February 2010, with a final recheck of the data in March, 2010. Individual school participation in CurrMIT was ascertained by searching two terms that commonly appear within medical course/session titles: “med”, i.e., medicine, medical, medication, and “clinic”, i.e., clinic, clinical, clinician. Schools with ≥100 entries containing “med” or “clinic” were labeled as CurrMIT participants. Custom reports of pain content were generated alphabetically by medical school name. During the pilot study, various alternative search terms were employed, e.g. ‘analgesia’, ‘nociceptive’, these were not found to provide additional information. Separate searches were conducted to ascertain the pain content delivered within required pain courses, elective pain courses and in the context of required general courses. As a final check, all of the CurrMIT reports were re-run to account for all identified courses and sessions via the Quick Search option tab. This provided institution name, course name, graduating class year, academic year, session name, topics covered, and course option. External validation of the CurrMIT reports for all of the required pain courses was performed using medical school course catalogues and course management systems. Where this information was not publicly available, we corresponded directly with course directors. Data Handling and Statistical Analysis For every report, relevant raw data was extracted and archived. Pain content was categorized into topics and/or subtopics by one investigator (L.M.) creating a curriculum data spreadsheet. Any areas of uncertainty were discussed in detail. Most sessions were noted to be one hour in duration, where the session duration was not noted and information to the contrary was not provided, a session was presumed to be 1-hour in duration. In most cases, pain sessions contained multiple objectives, which were categorized into subtopics. A ‘unit-time equivalent’ was assigned to each objective reported for a session by dividing the session’s duration by the number of specified objectives. Published AAMC and U.S. government data were used to categorize each medical school based on the following characteristics: setting (urban or rural) 40 ; public or private status 4 ; and number of graduates 2 , 3 (or matriculated number for newly accredited schools). The percentage of graduates entering primary care was calculated as the sum of the number of family practice, pediatrics, and Ob/Gyn graduates and half of the internal medicine graduates 4 . The inclusion of Ob/Gyn as primary care was based on the Bureau of Labor Statistics’ Occupational Outlook Handbook 39 , describing Ob/Gyn physicians as being “responsible for women’s general medical care”. Halving the percentage of internal medical graduates was based on the American Board of Internal Medicine ‘Resident and Fellow Workforce Data’ showing that about 50% of internal medicine residents eventually pursue specialized training 6 . Statistical analyses were performed using a standard spreadsheet program. Descriptive statistics were computed, regression analysis was used for the comparison of school characteristics, and t-tests were used to compare CurrMIT participants and non-participants. U.S. and Canadian medical schools are described separately as there were differences. Results: The study population consisted of all 145 allopathic (M.D.-granting) medical schools within the U.S. and Canada. 24 U.S. and 4 Canadian medical schools did not meet criteria as ‘CurrMIT participants’ and were excluded. The remaining 117 schools (13 Canadian) comprised the study sample. In order to gauge whether CurrMIT participants comprised a representative sample, U.S. CurrMIT participants and nonparticipants were compared for tuition, Medical College Admissions Test (MCAT) score, and number of graduates, with no differences observed (p > 0.05). The major pain topics and pain sub-topics resulting from the pain curriculum assessment process and included in the survey are shown in Table 1 . This list was found to encompass 95% of the content data pertaining to pain curricula in North American medical schools. Table 1. Framework metric for pain curriculum assessment Major Topics in pain Sub-topics in pain Human and social costs of pain Pain incidence and causes World-wide problem of pain Pain, disability and pain economics Gender and Age related pain effects Basic science of pain Transduction of nociceptive stimuli Transmission: 1° and 2° nociceptor Perception: cortical and subcortical pain representation Modulation: inhibition and facilitation Clinical assessment of pain Pain/symptom focused interview (QRST approach) Examination of painful limb/joints Examination of spine Diagnostic testing and clinical decision making Pharmacological pain management NSAIDs/COX inhibitors Opioids Neuromodulating agents Analgesia and placebo Non-pharmacological pain management Counseling/Shared Decision Making Conservative pain treatments and Evidence-based CAM Clinical Psychology of pain Rehabilitation and pain Acute Pain Peri-operative pain care Pain in the setting of trauma and fracture Headache Pain emergencies Chronic pain, including types and forms of pain Nociceptive pain Inflammatory pain Neuropathic pain Other pain syndromes: FM, HIV, DM Pediatric pain Pain in pediatric patients (infants, todddlers, adolescence) Peri-procedure pain assessment, prevention and management Geriatric pain Pain processing in older adults Major causes of pain in aging Adjustments to pain treatments with age Pain assessment in nonverbal and demented patients Cancer pain/Palliative care Pain assessment in cancer Pain management in palliative care Communication about pain in cancer Impact of cancer pain on quality of life Pain ontology (Culture and ethnicity) Interpretation of pain (the meaning of pain) Pain definitions and taxonomy Perspectives on the physician’s duty to relieve pain Communicating about culturally defined treatment alternatives Interventional approaches to pain care Injections Neurosurgery for pain Orthopedic interventions Stimulator techniques Medicolegal Substance abuse Pain contracts, risk assessment and documentation standards Process of medico-legal complaints Case law on pain management Visceral, pelvic, and abdominal pain Gynecologic and obstetric pain problems Miscellaneous Open in a new tab Pain is taught most often in the context of a more general required course that is not focused on pain per se (required general course). Eighty-three (79.8%) U.S. medical schools included one or more pain sessions within required general courses. In all, 738 total pain sessions and topics were found in CurrMIT. The total number of pain sessions taught at a single school ranged 1–28, with a mean of 9 [SD ± 6.] and a median of 7. Most schools incorporated pain sessions into multiple required general courses with a total of 416 courses including pain sessions and/or topics. The ratio of the total number of pain sessions to the number of courses incorporating pain sessions was 1.77 and the median number of courses incorporating pain at any given medical school was 4 indicating curricular fragmentation. Those schools that did teach about pain within the context of a required course that focused explicitly on pain (required pain course), had a higher number of hours devoted to teaching about pain (median 18.5). By comparison, 12 (92.3%) Canadian medical schools included pain sessions within at least one required course. 224 Canadian pain sessions and topics were found. The total number of pain sessions taught at a single school ranged 1 to 60, with a mean of 19 [SD ± 17] and a median of 12. 86 courses incorporated pain sessions and topics. The ratio of pain sessions to courses was 2.60 and the median number of courses incorporating pain was 6 indicating curricular fragmentation. Analysis of the pain topics covered in Canadian and U.S. medical schools is provided below and shown in Table 2 . Table 2. 30 Most frequently reported sub-topics in pain medicine by frequency and placement in curriculum Sub-Topic in Pain # with sub-topic as a required topic (U.S.) 1 # with sub-topic in a required pain course (U.S.) # with sub-topic in an elective pain course (U.S.) # with sub-topic in a general required course (U.S.) # with sub-topic as a required topic (Canada) Visceral and abdominal pain 57 1 1 56 9 Examination of the spine/back pain 54 1 2 54 8 Transmission: 1° and 2° nociceptor 53 3 5 53 8 Neuropathic pain 33 3 1 32 5 Transduction of nociceptive stimuli 32 3 2 32 8 Modulation: inhibition and facilitation 31 3 1 31 8 NSAIDs/COX inhibitors 31 3 4 28 8 Pain/symptom focused interview 31 3 12 29 5 Opioids 30 3 2 29 9 Examination of painful limb/joints 29 1 1 28 8 Other pain syndromes 28 2 5 26 6 Nociceptive pain 27 3 10 26 3 Gynecologic and obstetric pain 27 1 2 26 8 Clinical psychological approaches to care 27 3 5 25 5 Pain management in palliative care 24 1 3 23 5 Pain definitions and taxonomy 22 3 1 19 5 Analgesia and placebo 22 3 3 19 9 Inflammatory pain 21 2 0 20 4 Peri-operative pain care 19 3 11 17 5 Diagnostic testing and clinical decision making 18 2 7 17 2 Headache 17 0 1 17 3 Pain incidence and causes 17 3 1 14 3 Perception: cortical and subcortical pain representation 17 3 2 17 8 Pain in pediatric patients 16 1 3 15 9 Conservative treatments and evidence- based complimentary and alternative medicine 13 2 0 12 4 Substance abuse and addiction 10 2 3 8 9 Pain assessment in cancer 9 2 8 7 5 Interpretation of pain/meaning of pain 8 2 1 6 4 Neuromodulating agents 8 3 0 5 6 Pain, disability, and economics 6 2 3 4 3 Open in a new tab Of the 104 U.S. medical schools, 4 (3.8%) reported having a required pain course; 3 of these were private institutions. The duration of required pain courses ranged from 1.5–13 days. Course titles illustrated a focus on pain and included: “Perioperative Medicine and Pain Therapy”; “Principles of Pain and Pain Management”; “Pain and Suffering”; and “Pain Intersession”. The topics covered in these required pain courses are shown in Table 2 . An additional 17 (16.3%) U.S. medical schools offer a designated pain elective and 8 of these offer more than one elective in pain education. Thirteen of these schools were public institutions. A total of 25 pain electives were found, ranging from 1–4 weeks. A majority of the electives are administered by anesthesiology departments. The topics covered in these elective pain courses are shown in Table 2 . The cumulative number of pain teaching hours for U.S. CurrMIT participating medical schools ranged from 1–31, with a mean of 11.13 (± 8.23) hours, a median of 9 hours, and a mode of 4 hours (see Figure 1 ). In Canada, the cumulative number of pain teaching hours per school ranged from 3–76 , with a mean of 27.56 (± 22.02) hours, and a median of 19.5 hours. 10 Canadian schools incorporated ≥14 cumulative pain teaching hours. Figure 1. Open in a new tab Frequency histogram, Pain teaching hours by school. Main figure shows schools teaching 0–5 hours, 5–10 hours and so on. U.S. medical schools are shown as dark gray bars, Canadian schools as light gray. Inset shows expanded x-axis for 0 to 10 hours, U.S. schools only. The pain sub-topics most commonly covered by North American medical schools are listed in Table 2 , and in the supplemental data ( supplemental data 2 ). In this analysis, all of the pain content documented by participant medical schools in the CurrMIT database was categorized into one of 53 sub-topics. The sub-topics are listed in order of decreasing frequency of representation in medical school curricula. The pain sub-topics most commonly included in medical school curricula include: Visceral and abdominal pain, Examination of the spine/back pain, Transmission: 1° and 2° nociceptor, Transduction of nociceptive stimuli, Neuropathic pain, Modulation: inhibition and facilitation, NSAIDs/COX inhibitors, Pain/symptom focused interview, and Opioids. These clearly important sub-topics fall under the broad topics of Visceral pain, Pain neurobiology, Clinical assessment, and Pharmacology. The 30 most commonly represented sub-topics are included in the table. The less frequently represented sub-topics are included in supplemental data. To assess the scope of content included in pain education, the coverage of major topics and sub-topics was assessed; the results are shown in Table 3 . Certain major topics received heavier emphasis. The major topics of pain neurobiology, clinical assessment, chronic pain and pharmacological management are covered by the majority of medical schools. Many U.S. medical schools cover the topic of visceral pain, devoting an average of 2.5 hours to this topic, while Canadian schools document over 6 hours of education on this topic. By contrast, only 22 (27%)U.S. schools document coverage of pain definitions. Pediatric pain is covered by 16 U.S. medical school schools, and 9 Canadian programs. Geriatric pain coverage is documented for 10 (12%) U.S. schools and no Canadian programs. Substance abuse and addiction (medico-legal aspects of pain care) are covered by 10 U.S. medical schools and 3 Canadian programs. Topics taught at less than five schools are provided as supplementary data ( supplemental data 2 ). A “miscellaneous pain session” topic was included in the analysis for those sessions with ambiguous titles and no listed objectives. There were a total of 48 sessions (less than 5% of the total) that were placed into the miscellaneous category (data not shown). Table 3. Major Topics and Subtopics in Pain Taught by US and Canadian Curriculum Management and Information Tool (CurrMIT)-Participant Medical Schools M ajor T opic # S chools W ith M ajor T opic R equired A verage T eaching H ours P er M ajor T opic S ubtopic # O F S chools W ith S ub -T opic R equired US C an US C an US C an Clinical assessment ‡ 68 11 1.4 3.0 Examination of spine/back pain § 54 8 Pain/symptom focused interview § 31 5 Examination of painfullimb/joints § 29 8 Diagnostic testing and clinical decision making § 18 2 Basic Science ‡ 58 8 0.8 0.6 Transmission: 1° and 2° nociceptor § 53 8 Transduction of nociceptive stimuli § 32 8 Modulation: Inhibition and facilitation § 31 8 Perception: Cortical and subcortical pain representation 17 8 Visceral and abdominal pain * 57 9 2.5 6.3 Types and forms of pain (chronic pain) 48 7 0.5 1.3 Neuropathic pain § Nociceptive pain § Other pain syndromes § Inflammatory pain § 33 27 28 21 5 3 6 4 Pharmacological management 44 9 0.7 1 NSAIDs/COX inhibitors § 31 8 Opioids § 30 9 Analgesia and placebox 22 9 Neuromodulating agents 8 6 Nonpharmacological Management * 37 7 1.1 0.9 Clinical psychological approaches to care § 27 5 Conservative treatments and evidence-based CAM 13 4 Acute pain * 33 9 0.9 1.2 Peri-operative pain care § 19 5 Headache 17 3 Pain emergencies 5 1 Cancer pain/palliative care * 31 8 1 1.7 Pain management in palliative care § 24 5 Pain assessment in cancer 9 5 Obstetric and gynecologic pain ‡ * 27 8 1.6 2.2 Pain ontology † 26 7 0.6 0.8 Pain definitions and taxonomy § 22 5 Interpretation of pain/meaning of pain 8 4 Perspectives on physician’s duty to relieve pain 6 4 Human & social costs of pain † 20 5 0.4 1.1 Pain incidence and causes 17 3 Pain, disability, and economics 6 3 Pediatric pain 16 9 1.3 1.7 Medicolegal † 14 4 0.9 0.9 Substance abuse and addiction 10 3 Geriatric pain † 8 0 1.1 0 Pain processing in older adults 5 0 Interventional approaches to pain † 8 3 0.2 0.5 Injections 5 3 Open in a new tab Abbreviations: CAM, complementary and alternative medicine; NSAIDs, nonsteroidal anti-inflammatory drugs. * No subtopics were identified. † Additional subtopics were identified, but fewer than 5 U.S. schools covered the subtopic. ‡ Major topics are taught by the majority of U.S. medical schools. § Subtopics are taught by 20 or more U.S. medical schools. The characteristics of U.S. medical schools were compared between schools that did not document pain educational content, schools that deliver pain content through required general courses, elective pain courses and required pain courses ( Table 4 ). Although the number of medical schools with required pain courses is quite small, as a group they appear to be private, moderate-sized, urban medical schools with high-achieving students. There were no apparent differences between schools not teaching about pain and those incorporating pain content into required general courses. Table 4. Characteristics of U.S. CurrMIT participant medical schools, by mode of pain content delivery Characteristic: Schools with designated pain course (n=4) Schools with pain elective (n=17) Schools with pain sessions within another required course (n=83) Schools not documenting pain content (n=21) No. (%) No. (%) No. (%) No. (%) Public 1 (25%) 13 (76%) 56 (67%) 11 (52%) Private 4 (75%) 4 (24%) 27 (33%) 10 (48%) Urban 4 (100%) 15 (88%) 75 (90%) 20 (95%) Rural 1 0 (0%) 2 (12%) 8 (10%) 1 (5%) Graduates (≤100) 2 0 (0%) 5 (29%) 26 (31%) 3 (14%) Graduates (101–150) 4 (100%) 5 (29%) 29 (35%) 8 (38%) Graduates (151–250) 0 (0%) 5 (29%) 24 (29%) 10 (48%) Graduates (251–350) 0 (0%) 2 (12%) 4 (5%) 0 (0%) % primary care (≤25) 3 1 (25%) 0 (0%) 4 (5%) 3 (14%) % primary care (26–36) 3 (75%) 8 (47%) 47 (57%) 10 (48%) % primary care (37–47) 0 (0%) 9 (53%) 32 (38%) 8 (38%) Average MCAT (≤30) 0 (0%) 7 (41%) 29 (35%) 5 (24%) Average MCAT (31–33) 1 (25%) 8 (47%) 36 (43%) 10 (48%) Average MCAT (34–38) 3 (75%) 2 (12%) 18 (22%) 6 (28%) Tuition (≤$15k) 0 (0%) 2 (12%) 12 (14%) 3 (14%) Tuition ($16–32k) 1 (25%) 10 (59%) 44 (53%) 8 (38%) Tuition ($33–49k) 3 (75%) 5 (29%) 27 (33%) 10 (48%) school also offers pain elective(s) 0 17 (100%) 16 (19%) 0 school has pain session(s) in non-pain courses 4 (100%) 16 (94%) 83 (100%) 0 Open in a new tab 1 Rural setting characterized by having a population less than 250,000 in metro counties. Data source: Rural-urban continuum codes from the USDA Economic Research Service: The economics of Food, Farming, Natural Resources, and Rural America. (Population densities from 2000 Census). 2 Data source: AAMC Data Warehouse. Table 27: Total Graduates by U.S. Medical School and Sex, 2002–2009. Matriculation number was used for newly accredited schools which came from AAMC Data Warehouse Table 1 : U.S. Medical School Applications and Matriculates by School, State of Legal Residence, and Sex, 2009. 3 Data source: AAMC Medical School Admission Requirements 2010–2011. Calculated number was determined by taking the total % of graduates going into family practice, obstetrics/gynecology, pediatrics, and adding 50 % of graduates in internal medicine (the others going on to specialty training). There were no significant associations between the number of pain sessions offered and medical school characteristics, including the average MCAT score for accepted students (−0.009, N.S.), the percentage of primary care graduates (−0.008, N.S.), or tuition (−0.060, N.S.). Discussion: Although a majority of medical schools are teaching one or more core topics in pain, a large number of U.S. medical schools are not reporting any pain teaching and an equally large number devote fewer than 5 hours to the topic; essential topics in pain are under-represented. As a whole, Canadian medical schools demonstrate more extensive pain education than their U.S. counterparts. And even though the importance of integrated pain courses is widely recognized 43 , only 4% of U.S. medical schools currently report having such courses. This study provides an important benchmark for the current state of pain education in North America. Given the recent advances in pain science, it is perplexing that pain education in medical schools remains so limited. Some possible explanations include intrinsic barriers to curricular reform and a lack of resources specific to the education of medical trainees. Despite the establishment of consensus recommendations nearly 30 years ago 29 , we find that subjects intrinsic to those recommendations, specifically pediatric pain, medico-legal aspects of pain care and geriatric pain are addressed by a small minority of medical schools. In this study, we adopted quality improvement methodologies to make an appraisal of pain education. Although the ultimate goal is to hold physicians, and others, accountable for pain knowledge acquisition through the application of this knowledge in clinical practice, clearly, assessing medical school pain education sessions is an appropriate process measure. By taking a more careful look at what is being taught in medical schools, we establish an important baseline for future improvements. This was made possible by formulating a novel assessment instrument that demonstrated sufficient but not excessive granularity. In addition to ensuring that teaching institutions implement pain management training within their curriculum, it is important to tailor licensing examinations and regulatory requirements to include the assessment of clinical pain care knowledge. Assessment of knowledge, emotional development and technical skills relating to pain management would further enhance the seriousness and importance of pain education. At present, the most prevalent method of instructing medical students about pain is through the inclusion of selected pain topics as sessions within other required courses. Unfortunately, this manner of teaching tends to produce a fragmentary, ineffectual understanding of pain 30 . As Hauser noted, “Multiple opportunities for training do not necessarily lead to quality instruction…when something has a bunch of different homes, in fact, it sometimes has no home” 37 . We assert that increasing the number of integrated, pain-focused courses required by medical schools is the best way forward. In large measure this is because, to be effective, pain education must extend beyond the cognitive realm 18 , 25 , 27 . In particular, formative learning for adept physicians needs to include intellectual, emotional, technical, and ethical dimensions 15 . When pain is restricted to delivery as an isolated session topic, it is unrealistic to expect medical students to acquire competence in multiple dimensions. Comprehensive pain education will require curricular content delivered in part as lectures, workshops, learning labs, multidisciplinary panels, small group discussions, and expert guest speakers 46 . This would provide students with a rich framework, fostering cognitive, emotional and reflective growth 12 . The current approaches to professional training in pain, both necessitates and benefits from multidisciplinary contributions. Recruiting anesthesiologists, neurologists, physiatrists, family medicine doctors and others as teachers is valuable 38 , 43 . Beyond this, interprofessional collaboration in education further stimulates both an appreciation and skillfulness within the budding physician for multiprofessional teamwork 23 . There has been a persistent debate in the nursing literature about the ‘theory-practice gap’ that arises when pre-clinical faculty develop on a career path that does not include direct clinical care 17 . This divide has been less evident in medical schools but for this reason, it is essential to maintain an educational orientation that explicitly invites clinicians into the classroom and is distinctly flavored by clinical realities. Because medical schools have various amounts of time that can be dedicated to pain content and will want to emphasize particular pain topics to meet local needs, a flexible, modular approach to building pain courses may be more effective than exhaustive pain syllabi. Providing educators with multiple alternative scenarios illustrating the introduction of integrated short pain courses may be the most productive way to foster change. Importantly, these pain course modules must include not only a list of learning objectives (syllabus), but also classroom-ready teaching materials and assessment activities calibrated to meet pre-specified learning objectives. These materials must be free of commercial bias, real or perceived. It is neither necessary nor desirable for each school to invest the manpower required to create their own materials. An important mechanism for peer-review and dissemination of medical school teaching materials has been created by the AAMC in the form of the MedEdPortal. A recent informal survey of MedEdPortal indicated that the currently available teaching materials focused on ‘pain’ are few. At last check, no materials describing an integrated approach to pain were available. One limitation to this study is the difficulty in obtaining detailed information about medical school curricula. Many schools view curriculum details as privileged information and do not make this publicly available. We used a highly-developed and widely-used database created by the AAMC, an umbrella organization incorporating all North American medical schools as members. In its ideal form, a database like CurrMIT would be a compulsory, comprehensive database, like Pubmed, for medical curricula. One advantage of this database approach is that most medical schools provide fairly detailed information, as CurrMIT is an important mechanism by which to address licensing requirements. A second advantage of this approach is the minimization of bias intrinsic to inclusion in a ‘hot topics’ survey 31 or topic-specific survey 44 , where there will be a tendency towards over-representation of the queried topic. By contrast, CurrMIT data is a comprehensive representation of a school’s entire curriculum and to the extent that a school utilizes the database, the information therein is likely to be proportionately represented. To ensure accuracy, we conducted external validation for all required pain courses and found that, for participating schools, CurrMIT does represent a robust source of medical school curricular emphasis. A recent study of pain curricula in health science pre-licensure programs at selected Canadian universities lends additional external validity to our study 44 . Nine out of the 10 schools selected for study completed the survey. The average total hours spent on formal pain content was found to be 16 hours with a standard deviation of 11 44 . This corresponds well with our findings. And although a direct survey might appear to be more accurate, the inherent challenges were on par with those of our own study. A large majority of the university faculty responders reported that it was very challenging to assign pain content hours and to identify pain-specific categories; especially since in most cases, pain content was interspersed among many different courses 44 . Evidently, there is a need for better coordination, stronger leadership, unbiased support for education and peer-reviewed teaching resources sufficient to endure the incorporation of new knowledge into medical school curricula, a long and typically arduous process 45 . With this study, we have documented many deficits in pain education, thereby illuminating multiple areas of great need. We find that cancer pain, pediatric pain and geriatric pain are essentially unaddressed by the vast majority of medical schools. The risks of opioid treatment and the medico-legal implications of pain treatment are distinctly under-represented in medical curricula today. Taken as a whole, these data bring to light glaring discrepancies between the prevalence of pain in society and the time dedicated to educating future physicians about pain in medical school. Given that the twin dangers of pain under-treatment and the abuse of pain-active medications are among our society’s deepest public health concerns, pain medicine does not receive the attention that it deserves in medical education. There are inarguable links between the under-treatment and the mal-treatment of pain and the lackluster state of pain education in medicine. It is likely that unless opinion-leaders and the next generation of physicians become aware both of the importance of conscientious pain management and the dangerous deficits in pain education, the crisis in pain care and resultant deaths from opioid abuse will only spiral upwards 42 . A more organized and formal delivery of pain education is likely to be a principal catalyst in the sea-change required to rectify the current shortcomings of pain care. Supplementary Material 01 NIHMS329545-supplement-01.pdf (37.9KB, pdf) 02 NIHMS329545-supplement-02.pdf (44KB, pdf) Perspective: This study assessed the scope and scale of pain education programs in U.S. and Canadian medical schools. Significant gaps between recommended pain curricula and documented educational content were identified. In short, pain education was limited and fragmentary. Innovative and integrated education about pain in primary medical education is needed. Acknowledgements The members of the Johns Hopkins Pain Curriculum Development Team contributed to the construction of the ‘pain education process metric’ for this study. These included: Drs. James N. Campbell, Myron Yaster, Gayle Page, Jennifer Haythornthwaite, Albert W. Wu, and Richard Meyer. Special thanks to Elizabeth Nenortas for assisting in validating the appropriateness of the sub-topic categories. Thanks to Drs. Scott Fishman, Christina Spellman, and Rollin Gallagher for helpful discussions of this work. This work was supported in part by grants from The Mayday Fund and The Milbank Foundation for Rehabilitation Research. Dr. Murinson was the recipient of a NINDS Mentored Career Development Award Grant number NS048146. Footnotes Disclosures: There are no conflicts of interest. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. 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Medical education: revolution, devolution and evolution in curriculum philosophy and design. Med J Aust 191:35–37, 2009. [ DOI ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Supplementary Materials 01 NIHMS329545-supplement-01.pdf (37.9KB, pdf) 02 NIHMS329545-supplement-02.pdf (44KB, pdf) ACTIONS View on publisher site PDF (167.1 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

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