Inevitably, at some point during our careers, we physicians have all heard the often-impractical adage “See one. Do one. Teach one.” During the advent of medical education, when apprenticeship was the predominant form of learning, this first step made sense.

Over the years, this style of teaching was replaced by the lecture hall and “see one” in the teaching paradigm turned to “hearing” one or more plainly didactic learning. As this proverb suggests, to treat patients and teach future generations, we must first be taught about the topic.

When it comes to pain management, however, oftentimes in medical school, this teaching is brief, inadequate, or worse yet, dangerously outdated or completely absent from the curricula. This lack of education and training in pain management that physicians receive during their early formative years raises grave concerns, especially given the widespread prevalence of pain. It is estimated that 1.5 billion people worldwide suffer from chronic pain.¹ In Europe, chronic pain is one of the most common reasons that patients see their primary care physician.² In the United States, total costs for treating chronic pain have surpassed those estimated for heart disease, cancer, and diabetes.³ In addition, it has been reported that pain is not adequately treated in 65% of nursing home residents.⁴ Thus as the population ages, the impact associated with chronic pain may grow even bigger. Given the high degree of suffering and costs to society, health care providers must be equipped to treat pain appropriately. And yet, medical trainees, the physicians of the future, receive limited education in the field.

In 2009, at the First National Pain Medicine Summit, the panel came to the conclusion that medical training in pain management was of low quality and did not lead to competency.⁴ This poor training was evident in every specialty, even in oncology where pain management should have been an integral part of cancer care.⁴ Furthermore, Menzi et al investigated the presence, content, and time dedicated to pain medicine education in a total of 117 United States and Canadian medical schools. Although neither country uniformly incorporated pain into their curricula at the time of the study (2011), American schools paled in comparison to their northern counterparts with merely 11 hours of pain teaching on average. In addition, less than 4% of medical schools had a mandatory dedicated course on pain education.⁵ The European Advancing the Provision of Pain Education and Learning (APPEAL) study⁶ found a similar situation across the ocean where pain education consisted mainly of intermittent and sporadic pain topics amidst general required coursework, with less frequent specific courses in the participating European medical schools. This was coupled with inconsistent training across countries. Even with an optimistic assumption of improvement across these metrics in the past 6 years, subpar pain education is a global problem that is evident in American medical training.

“When it comes to pain management, oftentimes in medical school, this teaching is brief, inadequate, or worse yet, dangerously outdated or completely absent from the curricula.”

Unsurprisingly, for newly graduated interns, a sense of dread supersedes clinical knowledge when paged in the middle of the night to prescribe an analgesic regimen to a patient in pain. In a brief voluntary survey of our institutions’ pain specialists, over 60% reported minimal or next-to-no confidence in their pain treatment readiness level when entering internship. Fortunately, anesthesiology is among the few specialties whose faculty coach house staff on pain treatment options in different clinical scenarios during residency. Pain education across other residency programs does not routinely include dedicated and thorough analgesia treatment guidelines. Therefore, in the clinical setting, managing patients’ pain as a trainee can become reflexive, based on peers’ experience at an institution. Treatment may be delegated, mismanaged, avoided, or ignored at the patient’s expense.

While many institutions do have an inpatient pain service to help design multimodal analgesic regimen in difficult-to-treat patients, it is not feasible to delegate all treatment of pain to pain specialists. There are reported fewer than 4,000 pain specialists in the country, which is an insufficient number to treat all patients with acute, subacute, chronic, or persistent pain in inpatient wards and in the outpatient setting.⁴

Based on these facts, perhaps we should all agree that pain management needs better emphasis in trainee’s education across the medical school, internship, residency, and fellowship.

This is especially important in the current opioid epidemic crisis. As opioid usage has been increasingly scrutinized and highly publicized and critiqued, we cannot help wondering if physicians’ roles in this opioid epidemic, while controversial, have certainly been affected by our training or lack thereof on this complex topic. In a recent survey, over 50% of primary care physicians felt only “somewhat prepared” to educate patients about their pain, while 27% felt “somewhat unprepared” or “very unprepared.”⁴ This leaves less than 25% of primary care physicians feeling prepared to treat pain. It is unfair, however, to criticize these physicians without providing proper tools and education to counteract the issue.

A nationwide call to address the opioid epidemic was recently laid forth by former President Barack Obama in March 2016. This prompted a pledge from nearly 75 United States medical schools to incorporate the prescribing guidelines at the Centers for Disease Control and Prevention (CDC) safe into requisite coursework. The International Association for the Study of Pain, in collaboration with various pain management societies, including ASRA, has drafted a comprehensive recommended pain medicine curriculum that lays the groundwork for improved pain education. Pain-related proficiencies are increasingly being incorporated into resident evaluations for progression and graduation.

Overall increased awareness regarding risks of opioids and bolstered training paradigms, while well intended, are not set up for success without up-to-date, unbiased evidence-based resources. Building on those points, through the Resident and Medical Student Pain Education Special Interest Group (SIG), we are attempting to put training and teaching of our trainees into the hands of those that may be best fit for it. Thus, even highly specialized pain subspecialty practitioners, while mastering their own realm of pain and staying abreast of new research developments in a field like headache, may be called upon to give in-depth lectures on peripheral neuropathies or other aspects of pain outside of their wheelhouse. This is part of the motivation for our creation of the Resident and Medical Student Pain Education SIG: to distill down the immense pain medicine knowledge and treatment experience in the members of ASRA.

Optimal pain management of patients, superimposed on the current opioid epidemic, requires a new approach. Perhaps in this subspecialized era of medicine “Teach one. See one. Do One” is more appropriate when initiated by expert guidance and supported with significant evidence-based research and novel ways of teaching such as simulation and virtual reality. By utilizing the teaching prowess of this society and our members, we can help facilitate this transition by creating teaching tools and mentoring opportunities to educate our future colleagues, striving to ultimately teach everyone.

References

1. Global Industry Analysts, Inc. Global pain management market to reach US$60 billion by 2015, according to a new report by Global Industry Analysts, Inc. [press release]. January 10, 2011. Available at: http://www.prweb.com/ pdfdownload/8052240.pdf. Accessed June 2017.

2. Friessem C, Willweber-Strumpf A, Zenz MW. Chronic pain in primary care. German figures from 1991 and 2006. BMC Public Health. 2009;9:299.

3. Gaskin DJ, Richard P. The economic costs of pain in the United States. J Pain. 2012;13:715–724.

4. Pizzo P, Clark N. Alleviating suffering 101 – pain relief in the United States. N Engl J Med. 2012;366:197–199.

5. Mezei L, Murinson B, Johns Hopkins Pain Curriculum Development Team. Pain education in North American medical schools. J Pain. 2011;12(12):1199–1208.

6. Briggs EV, Battelli D, Gordon D, et al. Current pain education within undergraduate medical studies across Europe: Advancing the Provision of Pain Education and Learning (APPEAL) study. BMJ. 2015;5(8):e006984.