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Teaching Chronic Pain in the Family Medicine Clerkship: Influences of Experience and Beliefs About Treatment Effectiveness: A CERA Study

Kimberly Schiel Zoberi, MD; Kelly M. Everard, PhD; Jumana Antoun, MD

Background: Chronic pain is a common and important disease state in North America, but many medical students and practicing physicians feel poorly prepared to treat this condition.

Methods: Data were collected via the 2014 CERA Family Medicine Clerkship Director survey, which was electronically sent to 121 US and 16 Canadian clerkship directors. The authors sought to determine the quantity of chronic pain management instruction included in clerkship curricula and any characteristics of clerkship directors that correlated with the teaching of various pain topics. Survey items included the total amount of time spent teaching about chronic pain, various subtopics addressed, and personal characteristics of clerkship directors (years as clerkship director, number of years since graduation, amount of pain-related CME taken yearly, confidence in caring for patients with chronic pain, and belief in efficacy of various treatments).

Results: The response rate was 91%. Half of respondents indicated that they do not teach about chronic pain during the clerkship at all. The mean number of minutes spent teaching about chronic pain during the family medicine clerkship was 48 minutes (SD=65.). The majority of clerkship directors felt confident about their ability to treat chronic pain, and there was a positive correlation between confidence and time teaching about chronic pain during the family medicine clerkship. Confidence in treating chronic pain patients also correlated with the likelihood of covering several specific pain subtopics, including pain assessment, documentation skills, non-pharmacologic treatment, treatment with opioids, and treatment with non-opioids.

Conclusions: Chronic pain management is currently taught in only about half of family medicine clerkships. Confidence in caring for chronic pain patients is the only characteristic of clerkship directors that predicts whether the subject of chronic pain will be taught within the family medicine clerkship.

(Fam Med 2016;48(5):353-8.)

According to the Institute of Medicine report on the treatment of chronic pain in America, more than 100 million Americans are affected by chronic pain, and health care providers need a better understanding of pain to improve assessment and treatment of pain in their patients.1 As clinicians and educators, our responsibility incorporates both skillful treatment of patients and the education of learners regarding the knowledge, skills, and attitudes necessary for the compassionate care of chronic pain patients.

Pain management exists as a subspecialty, and primary care physicians show a desire to be supported by these specialists when needed.2 However, there are far too few board-certified pain management specialists to deliver care to each patient suffering from chronic pain.1 Most pain management encounters are conducted by primary care physicians, with only a small minority of patients receiving care from a specialist.3 Primary care providers express a lack of confidence in treating chronic pain patients.4 A 2007 survey of 500 primary care providers practicing at academic medical centers revealed that only 34% felt comfortable treating patients with chronic pain.5 Those practicing in community clinics fared no better.6 A survey of residents from various fields shows that confidence among trainees is even lower.7 Primary care providers cite a lack of formal training in pain management as one of several reasons for their discomfort.8

Medical student education about chronic pain management is inadequate, both in quantity and quality, with few medical schools requiring a course in pain management. A 2011 study showed that pain management is generally taught within various clerkships and electives for a mean of 11 hours in US schools and 27 hours in Canadian schools.9 This study did not specify what fraction of that instruction was conducted during the family medicine clerkship. With such heterogeneity among method of delivery and number of hours of pain management curriculum, there is little consensus about the ideal pain management curriculum. Although most graduating medical students consider their training in pain management to be adequate,10,11 experts in the field disagree.9,11 This lack of dedicated time and standardization of curriculum in pain management education translates to a workforce that is unprepared to address the growing pain management need.

As family physicians, we are uniquely qualified to educate students about the complex, multidimensional problem of pain management, which fits well into our care model.2 However, there is a dearth of data regarding the quantity or content of chronic pain education in family medicine clerkships and the factors that influence the decision to include this content within the family medicine clerkship. The clerkship director is the person who is ultimately responsible for the standard curriculum that is disseminated to all students taking the family medicine clerkship. We wished to examine whether the family medicine clerkship director’s characteristics influence the quantity and content of chronic pain education within the family medicine clerkship. Determining this relationship may help us understand the reasons behind embracing or avoiding this subject in the family medicine clerkship. The purpose of this study was to learn the quantity and content of the family medicine chronic pain management curriculum and determine which characteristics of the clerkship director influence this curriculum in the family medicine clerkship.

 

Methods

 
 

Data were collected for this study as part of the 2014 CERA Family Medicine Clerkship Director survey. CERA is a joint initiative of all four major US academic family medicine organizations: Society of Teachers of Family Medicine, North American Primary Care Research Group, Association of Departments of Family Medicine, and Association of Family Medicine Residency Directors.

Electronic surveys were sent to 121 US and 16 Canadian clerkship directors at allopathic medical schools accredited by LCME/CACMS (Committee on Accreditation of Canadian Medical Schools) in September and October 2014. Three reminder emails were sent to non-respondents after the initial email, which included a personalized greeting, a letter signed by the presidents of each of the four participating organizations urging participation, and a link to the survey through the online program SurveyMonkey.® Non-respondents were also contacted through personal email and telephone calls, to verify status as clerkship director and accuracy of email address and to encourage participation. The study was approved by the American Academy of Family Physicians Institutional Review Board.

Survey Questions

Respondents were asked basic demographic information about their schools and clerkships and how many students are in each medical school graduating class. They were also queried about when they graduated from residency and how many years they have served as clerkship director. Additional items asked about the amount of time spent teaching about chronic pain in total and amount of time spent teaching pain assessment, documentation skills, risk assessment, non-pharmacological treatment, use of adjuvant pain medications, use of nonopioids, and use of opioids. Clerkship directors were asked how many pain patients they typically see in a week, their confidence in taking care of pain patients (1 to 5 scale where 1 is least confident and 5 is most confident), how much chronic pain CME they did, and how effective they believed different treatments were (1 to 5 scale where 1 is not at all effective and 5 is very effective).

Analyses

Frequencies summarized demographic variables, descriptions of schools and clerkships, number of minutes chronic pain was taught in the clerkship, number of pain patients seen, confidence in caring for patients with chronic pain, and effectiveness of pain treatments. Nonparametric correlations using Spearman’s rho were used, because our data were not normally distributed, to determine correlations between amount of time chronic pain was taught in the clerkship and clerkship director characteristics, including number of chronic pain patients they see per week, confidence in treating chronic pain patients, amount of time spent in CME on chronic pain, years since residency graduation, and years as clerkship director. Spearman’s rho was also used to determine correlations between amount of time specific pain topics were taught and the clerkship director characteristics. Finally, we tested whether there were correlations between beliefs in the effectiveness of a particular treatment and teaching about that treatment in the clerkship.

 

 

Results

The survey was sent to 121 US and 16 Canadian clerkship directors. The overall response rate to the whole survey was 91%, with 124 of 137 clerkship directors responding. The subset of respondents who answered the question regarding whether they taught about chronic pain during the clerkship (n=104) was used for analysis. Descriptive statistics for study variables are summarized in Table 1.

 
table1

 

Half of the clerkships did not cover the topic of chronic pain at all. The mean number of minutes that clerkships taught chronic pain was 48.2 (SD=65.0). Excluding those clerkships that did not teach about chronic pain, the mean number of minutes for those that taught about chronic pain was 96.4 (SD=61.8). Table 2 lists the frequencies of the different chronic pain topics taught in the clerkships and the amount of time spent teaching each topic.

 

table2
 

Nonparametric correlations using Spearman’s rho showed that the amount of time spent teaching about chronic pain was positively associated with confidence in caring for patients with chronic pain (rs=.201, P=.046) but not the other clerkship director characteristics (Table 3). Confidence in caring for patients with chronic pain also was the only clerkship director characteristic correlated with any of the chronic pain topics: pain assessment (rs=.269, P=.049), non-pharmachological treatment (rs=.338, P=.011), non-opioids (rs=.378, P=.008), and opioids (rs=.420, P=.003) (Table 4).

table3
 
table4

Beliefs in effectiveness of opioids, non-opioid medications, non-pharmacologic treatments, and adjuvant pain medications for treating chronic pain were not correlated with teaching about that type of treatment (rs=-.21,-.15, -.11, and .06, respectively; all P values greater than .05).

 

Discussion

The most important finding of this survey is that half of family medicine clerkships are not teaching the topic of chronic pain management at all. Despite the large number of patients affected by chronic pain, and chronic pain’s importance in physical, psychological, and social well-
being,1 family medicine clerkships are not consistently including this topic in their curriculum.

In this study, we proposed several characteristics of the clerkship director that may be related to whether chronic pain management is included in the curriculum. We found that confidence in caring for a patient with chronic pain was the only factor associated with teaching chronic pain during the clerkship. Factors that were not associated included years as clerkship director, years since residency graduation, number of chronic pain patients per week, and total minutes of CME activity regarding chronic pain in the last year. Confidence also correlated with time teaching several specific subtopics of chronic pain, including pain assessment, documentation skills, non-pharmacologic treatment, non-opioid treatment, and opioid treatment.

The percentage of respondents reporting feeling confident about treating chronic pain was much higher among our survey of clerkship directors in 2014 than previous surveys of practicing physicians or residents.5,7,12 This may be due to the fact that our study included only clerkship directors, a group of academic physicians who are likely to follow latest guidelines and developments in pain management. Other studies of academic family medicine physicians’ confidence in treating chronic pain patients have found a similarly high level of confidence among their respondents.13

One might speculate that the decision to “take on” this complex and controversial subject is multifactorial, and confidence alone is just one small aspect of that decision. Other factors might include a desire to avoid subjects that are negatively viewed by students, a perception that this is better taught by other specialties such as anesthesia or a healthy appreciation for the difficulty of teaching this subject in a limited amount of time. There is ample evidence that most physicians do not enjoy taking care of chronic pain patients4 and that this negative attitude is shared by students.14

The number of minutes a clerkship director spent engaged in CME activities regarding chronic pain positively correlated with the number of chronic pain patients seen per week and with confidence in caring for patients with chronic pain. Although causation cannot be determined, recent CME activity may increase a physician’s confidence in treating chronic pain patients and willingness to manage these patients in primary care.

Limitations of this study include a failure to query the half of respondents who do not teach about chronic pain about their reasons for not including this topic in their curriculum. This survey focused on relationships between clerkship directors’ personal characteristics (confidence, enrollment in CME, beliefs about treatment efficacy) and curriculum design. It is likely that other factors affect the content of the curriculum as well, including expertise of various teaching faculty and response to student feedback. It should be noted that this survey focused only on teaching about chronic pain management in the family medicine clerkship, not across the total undergraduate medical curriculum. It is possible that this subject is covered elsewhere, either in other clerkships or longitudinally.

Future research may focus on other predictors of whether chronic pain management is covered during the family medicine clerkship and how it is taught. Possible factors include support from colleagues across disciplines, the availability of a multidisciplinary curriculum, likelihood of pain-related content on board exams, and medical students’ attitude toward the subject. Because this survey was regarding didactic (classroom) teaching, and not clinical modeling, we did not analyze the data by type of clinical site (rural or urban, community or academic.)

Surveying residency directors about their pain management curricula would clarify how this important subject is being covered during a family physician’s postgraduate training. Currently, neither the Family Medicine Core Content Curriculum nor the ACGME Program Requirements for Graduate Medical Education in Family Medicine explicitly require training in chronic pain management for medical students or residents, respectively.15,16 Making chronic pain managment a required element of the training and/or creating a unified curriculum that can be used by all medical schools would promote education on this important topic.

 

Corresponding Author: Address correspondence to Dr Zoberi, Saint Louis Univerity, Department of Family and Community Medicine, 1402 S. Grand Blvd., St. Louis, MO 63104. 314-977-8480. Fax: 314-977-5268. Zoberika@slu.edu.

 

References

 
  1. Institute of Medicine. Relieving pain in America: a blueprint for transforming prevention, care, education, and research. Washington, DC: National Academies Press, 2011.
  2. Murinson BB, Gordin V, Flynn S, et al. Recommendations for a new curriculum in pain medicine for medical students: toward a career distinguished by competence and compassion. Pain Med 2013;14(3):345-50.
  3. Breuer B, Cruciani R, Portenoy RK. Pain management by primary care physicians, pain physicians, chiropractors, and acupuncturists: a national survey. South Med J 2010;103(8): 738-47.
  4. Potter M, Schafer S, Gonzalez-Mendez E, et al. Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract 2001;50(2):145-51.
  5. O’Rorke JE, Chen I, Genao I, Panda M, Cykert S. Physicians’ comfort in caring for patients with chronic nonmalignant pain. Am J Med Sci 2007;333(2):93-100.
  6. Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006;21(6): 652-5.
  7. Yanni LM, McKinney-Ketchum JL, Harrington SB, et al. Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education. J Grad Med Educ 2010;2(2): 260-8.
  8. Olsen Y, Daumit GL. Chronic pain and narcotics: a dilemma for primary care. J Gen Intern Med 2002;17(3):238-40.
  9. Mezei L, Murinson BB, T. Johns Hopkins pain curriculum development, pain education in North American medical schools. J Pain 2011;12(12):1199-208.
  10. GQ Medical School Graduation Questionnaire. Washington, DC: Association of American Medical Colleges, 2010.
  11. Darer JD, Hwang W, Pham HH, Bass EB, Anderson G. More training needed in chronic care: a survey of US physicians. Acad Med 2004;79(6):541-8.
  12. Fox AD, Kunins HV, Starrels JL. Which skills are associated with residents’ sense of preparedness to manage chronic pain? J Opioid Manag 2012;8(5):328-36.
  13. Macerollo AA, Mack DO, Oza R, Bennett IM, Wallace LS. Academic family medicine physicians’ confidence and comfort with opioid analgesic prescribing for patients with chronic nonmalignant pain. J Opioid Manag 2014;10(4): 255-61.
  14. Corrigan C, Desnick L, Marshall S, Bentov N, Rosenblatt RA. What can we learn from first-year medical students’ perceptions of pain in the primary care setting? Pain Med 2011;12(8): 1216-22.
  15. Chumley H. The family medicine clerkship core content curriculum. Ann Fam Med 2009;7(3): 281-2.
  16. ACGME Program Requirements for Graduate Medical Education in Family Medicine. August 26, 2015. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/120_family_medicine_07012014.pdf.

From the Department of Family and Community Medicine, Saint Louis University (Drs Zoberi and Everard); and Family Medicine Department, American University of Beirut (Dr Antoun).


Copyright 2018 by Society of Teachers of Family Medicine