Physician Acquisition of Cancer Pain Management Knowledge Thomas E. Elliott, MD and Barban. A. Elliott, PhD S&or, ofMedim1 oncolog)l and Hem.ztolo~. ‘The Lhduth Clinic, .Ud.(T.E.E.J: and Duluth FmdIy Fmtice Cemr (B.A.E.J: and Thz Uniwrsity o/Minnesota. School oJ MldLinr(T.E.E. and B.A.E.J. Lhdulh. Minnmto
pain management is a major international health problem. In the U.S.A. alone. it is estimated that 502,000 cancer deaths occurred in 1989.’ Of these. 60% to 80% will have had severe Dain in the terminal Dhhase of their illness.P’With pmper cancec pai’n management, 95% of these patients could have had complete or nearly complete relief of pain.g This reality has not been achieved in the U.S.A. or any Cancer
other country.’ Insufficient physician knowledge and education in cancer pain management has been cited as one of rhe maim factors contributing to inadequate pain r&f in cancer patients throuehout the worldP Even thowb the literature is&p& whb statements ab& lack of organized teaching of medical students and physicians in cancer pain management.“~’ there are little to no published data about how physicians have acquired the knowledge about cancer pain management they currently pasew or how they wish to further their knowledge. A review of the literature of the last 20 yr regarding physician acquisition of this knowledge revealed only three published R
p0m.8~~~‘~Two reports were surveys of medical snrdents and resident phvsicians in trainina. and one report was a su&y of practicing phisicians. These three studies cotdinned a lack of adequate knowledge at all levels of learning and suggested reeducation of physicians as a solutiorr to d3is problem.
M#WdS A survey of all physicians in direct patient care in Duluth. Minnesota, was conducted to determine where they had learned about cancer pain management (CPM) and how they would like to further their knowledge. Responses fmm 150 of 243 surveyed physicians were recc&d, obtaining a 62% response. The 150 responding physicians in this survey represented 47 different medical wbaols located in 31 states, Canada and England. Of the responding phy sicians, 46% were graduates of the University of Minnesota Medical School. The respondents also represented 51 different postgraduate training pmgtams located in 25 different states. No sin.& postgraduate tmhdng program represented tnore than 12% of the survey sample. The physicians who responded were divided follows: medical school graduates p&&x l-968 (expressed asolder physicians, N = 41, or 27%). medical school gnd“ates between 1968 and 1977 (expressed as middle-aged physicians, N = 53. or 35%). and medical school graduates after 1977 (expressed as younger phy&ians. N = 56. or Sj$). The physicians were also divided into four specialty pncdce groups as follmvs: cancer speaists (N = 8. or 5%). tximarv are swxialisrs (N = 96, oT 60%),&.ge0ns’(N = 28, br 19%). and medical subsoccialists IN = 24. or 16%). Variances these &e anri speci&y groups were analy;zed with chi-square. Levels of significance are expressed with p-values. The survey asked specific questions about how physicians have learned and want to learn more about CPM. They were asked if their medical school curriculum included a course on narcotic analgesics at the clinical level and il their postgraduate training included a didactic course or focused clinical experience in cancer pin management. Also, mognizing that physicians acquire knowledge and skills fmm multiple sour. they were asked to rank where or how they learned about narmtic use in cancrc pain using a scale of 0 through 4 (0 = poor re-
intothree aptmumas
betweeit
source, 4 = major resource). Seven wnmmn waya of acquiring CPM information were listed for them to rank order. and an open-ended op tion of “Other. please lii: ” was also on the list. The indicated items were: medical school, residency, continuing medical educadon pmgrams. wnsultations. literature. hospice and drug representatives. The survey continued with questions about where and how the pbysician would like to learn about new cura* in CPM in the future. Sii options were listed for the physicians to rank, which included staff conferences, outside CME, consultations. literature. hasvice and drug representatives. plus the op.&r&d op. tion of ‘Other. please list:_“. The physicians rankeci their preferences using the scale I = first choice. 2 = second choice. etc. Finally. the survey presented a series of attitudinal saatetnents to which they were asked to indicate the strength of their response (I = agree strongly to 4 = disagree strongly). The results of the attitude survey are reported separately. Copies of the survey questionnaire are available from the authors upon reqttest.
The physicians who returned the survey wem representative of the populadon. The overall response rate was 62%. Of the 72 surveyed physicians who graduated before 19668,518 returned the auestionnaire. Einhtv-fiw Dhvsicians practi&g in Duludt g&&d be&n 1968-1977: 57% of them reswnded to the survey. A majority (74%) of the 73 physicians surveyed who graduated after 1977 returned their questionnaires. Except for the cancer spedalists. the respondents also rcprewwd the specialty practice mows mwmrdonatelv. Sixtvfo.; &em .I? th; p;im& care piysti&, 55% of the surgeons. and 55% of the medial subrpzcialisxs returned the survey. Young phy. sicians are over-represented in these findings. Although we cannot know how the non~spon den& answen would differ fmm dmse we received. the consistency in training backgmunds between those who responded and those who did not, as well as their comparable ages and specialty choices (Table I), indicate that the sample is reprexntative of rhe medical community in Duluth. MN. which in private pm&ebased, nonuniversity and nongovernmental. This sample represented 23 diNerent special-
Grad"aio" &fore 1938 IWJ-1977 since 1977 spKialisu Primary Care SW-= Medical SubrpsialLts “WO-O”~0IOgy Numlxr of Medial Schools Number of Postgraduate Sites
41 53 36
35 37 21
76 90 77
90 28 24 8 47 51
51 23 19
141 51 43 8 79 102
ties and subspecialties who are practitioners of prbttaty. secondary, and tertiary care. One-half of the responding physicians directly cared for 10 or more cancer patients per yr, and 16 physicians (10.6%) managed or partly managed 100 or more cancer patients per yr. Hmu Physic&
Have Lmmed
CPM
In the survey, physicians were first asked how they learned about cancer pain managerttent (Tables 2 and 3). Of the respondents. 32% reparted that their medial school cuniculum contained a cliiical course on narcotic analgesic use. Twenty-sewn percent of the physicians reported that their postgraduate training included a didactic course or focused clinical experience in the use of nxcodcs for control of chronic cancer pain. Only 16% tanked the medical school course as a major source of information. Younger physicians reported learning more in medical schools than okler physicians (23% compared to 8% x2 = 19.8, df- 8, p = 0.01).
Medical School Postgraduate (Ftesidency) training CME C.xtstdutions Literature Drug Reps Hwpice
8% 27% 4’1% 39% 34% 1% 31% N-41
z 51
the tnost si&ficant-b&~ng resource for most ohvsiciatts: 53% of all ohvsicians indicated mihe;lcy trait& was tb& t&or learnina source. This.may bfa rerent t&J: 82% of-younger physicians, 44% of middle-aged pbyskktns, and 27% of older physicians stated that residency training pmgrams were a major xsnurce (xp = 36.6, d/= 8, $I = .09001). when analyzed by specialty groups. there were no significant differences. Cancer spe&list training ptqrams were reported to have no greater etnphasis on CPM learning than other residency training programs. Continuing medical education was tanked a major resource for 32% of all physicians. Older physicians repotted learning signiiicattdy more about CPM from continuina medical education than younger physicians ?47% compared to 13%. xz = 19.4.4 = 8.P = 0.01). There were no significant differences in the anwunt learned from continuing medial education when analyzed by specialty groups. Laming about CPM through consultation
15% 44% 41% 47% 31% I% 26% 53
23% 82% 13% 23% 31% 1% 15% 56
16%; z
.
z 2% 23% 150
Ptimaty
care
t-kme-onc
12% 56% 25%
Medkal School Postgraduate (Residency) training CME Co”~“hltiMl~ LitClXUre J’w =pr Hospice
,=
17% 56% 27% 30% 23% 1% 27% 96
6% 12% N= 6
Medical
Sub-Srmialirt S”mwnS 17% 44% 41% 5036 43% 1% 22% 24
11% 54% 40% 54% 46% I:: 2s
Total
16% 55% 32% S6v 32w 2’s: 150
01
The community hospice program was ranked as a tnqor resource for 23% of all physicians. When analyzed by age. 31% of older physicians and 26% of middle-aged physicians repotted the hospice pqmtn as a major resource for information about CPM; only 15% of younger physicians reported the rante. These differences, and those meaaared among the four specialty grottoups,were not statistically significant. Learning abottt CPM from drug company representatives has teen a tesottrce for only 2.2% of all physicians.
with onco:o&ts ‘wtb reported as a major resource by 35% of physicians. Older physicians and middle-aged phy&atts tanked this melhod mo@z often than youn)~ physicians; this represents a statistical trend 09%. 47% and 23%. respectively; x* = 15.4, dj = i, ) = 0.05). When analyzed by specialty gmups. signifxmt diierewes were observed. Tbe eight cancer specklists (five medical oncologists and three radiotherapists) were excluded from the ana& sis since they provide ttte majority of the cat&r pain management catsultations in our cotnmunity. Fifty-four percent of surgeons and 50% of medical subspecialists reported that consultation provided a maior resczurce for kaming CPM: only 30% oiprimary care physiciani agreed (2 = 25.0, df = 12, p = 0.01). The literature was reported al a modest resource for leaminn CPM. Of all ohvsicians. 32% reponed that &e literature has&at& jar resource for them. Tltere were no significam differences among the physicians by age, but rzmcer specialists and medical subspecialists have used the literature to gain information more than surgeons and primary care physicians.
How
Piqsicicms wouldLiketoLearnCPM
The study then
focused on how physicians
would like & kam more about CPbf’in.the fttture (Tables 4 and 5). The most popttkr method tanked by physicians in this study was local medical staff conferences. Of all ohvsicians, 84% reported this as their p&&i method, and there was a statistical trend indicaring that younger physicians were strongest in this preference cp < 0.65). Tbe diffetatces among specialty groups were not statistically significant. However, it is remarkable that 100% of the surgeons ranked local statfconferencesas T&Q
Rfenwl
Sources Pa Physieiuu’ *cquisition OFCPM Skilb
Order Ph”&ii”~ StaffCnnfermcel outside CME ca”s”ltatio”l Literature Dwt Reps HOSpiCe $4.05
81% 27% 65% 35% 3% 64%
N = 4,
72% 37% 64% 46% SE 53
96% 94% 66% 48% 54% 56
84%’ z 45% 2% 49%
150
cepts in CPM. Thirty-three pawn: of physicians indicated they wotdd prefer toattend regional or national continuing medical education meetings to learn abx: CPM. There were no signifxan: differences when analyzed by age groups. Further analvsh revealed that 88% of the cancer racialists&dd travel to condnuing medical ;ducation mnferences for nwre information about CPM. Only 33% of primary care physicians, 24% of surgeons. and 26% of medical subspeCialisB rewned the same willinettess, (x2 = 25.7.3 = 12, p = 0.01). Phvsicians also wan: IO learn about CPM d&gh consultations. Regardless of age, 65% of all physicians ranked mnsulradon as a prefared medmd. When analyzed by specialty group, surgeons reported greatest imeres! in leaminn in this ww. medical subst&alis:s were also ve& buerested, and primary care physicians wwe less so (88%. 78%. and 56%. resp tively. xp = 25.0, df = 12, p = 0.017). Less than half of all physicians wanted to learn about CPM thmugh the literature. However, there were significant differences when analyzed by age and specialty groups. Younger and middle-aged physicians wanted IO learn more from ihe literature than older physicians, although these differaces were no: sratisdcally signifi&:. Cancer specialists and medical subspecialists reported wanting to learn more from tbt literature than primary care physicians and surgeons. These differences documented a statistical trend, 88%. 65%. 40%. and 28%. respeclively, (x2 = 23.6, d/ = 12, p = 0.02). Nearly half of the physicians wanted to learn fmin ihe local harp& program. There were no significant differences when analyzed by age or speckay groups.
80% 98% 56%
41%
_ 46% 90
Few physicians wanted to learn cancer pain management from drug company represent+ tives. Surgeons were more likely to indicate this as a method of choice.
This study reports how physicians have acquired the knowledge about cancer pain management they currendy pmsess, and how they wish to further their knowledge. These data do not assess the quality or validity of the physicians’ cancer pain management knowledge or skills, nor do they address whether physicians wan: to gain additional information. Numerous published reports have already documented a general ofpbysichn knowledge and skills in CPW5 and the resultant lack of pain relief for the majority of cancer pade~~ts.~ As with all surveys. this study is limited by the sample size, the respondents characteristics, and the self-report nature of the survey. The information reported by older physicians about medical school and postgraduate training may be limited hy their memories of thme years. Also, the recognized cancer specialists (5 medical oncologis:s and 3 radiotherapists) in this survey represen: only eight respondents out of :hc 150: any conduaions drawn fmm this subset are tentative and very limited. Very few ph&ians. only 16%. reported leaminz about CPM in medical school. The pre&s:udy suggests, howwer. that since 1978 medical schools have begun to increase this information. Tbeze findinns are consistent with previous literature indic&g that ux of opioids in CPM was no: iaunh: in m&l schools in the pas:.’ Even :oday,‘;his source of learning remains a: a low level as reponed by recen: physician graduates in thii survey. A survey of
lack
78% 26%
loo% 24%
65% 4% 48% 28
26% 6% 66% 24
7a%
88%
64% 59%’
66aB
4vz.b 2% 49% 156
medical school curricula is needed to determine the type of trabdng currently olfered. Residency and fellowship programs have become the major resource for physician knowledge of CPM. This study documents that since 1978 there has been a significant increase in this leaming resource. However, this study also documents that no specialty training program is enhancing this knowledge better than another. The oncok~gy trabdng pmgram graduates in this study represent a small sample size: however, they completed onmlogy fellowships at five different institutions over the last I5 yr. These oncologists reported no greater learning fmm their fellowships in CPM than the nononc&gists in dds survey. B&d on the resp&es in this survey. enbaxement of physician knowledge of CPM can be designed. G&e local medical staff conferences on cancer pain management are needed. Of the physicians. 84% indicated this as the most desired method to learn. Laal and regional cancer specialists can present these conferences effectively. The &ferences will need to be s&d&d remdarlv and reinforced with other fomts of co&& medical education. Consultations are the~second mmt desired way to learn CPM according to this study. esp ckdly for surgeons and medical subspecialists. The consubtions add to the rrhvsicians’ knowledge, especially if rhe specialist who provide these consultations have bad intensive reeducation at regional and national conferences. Consultations must be based on current CPM knowledge. Hospice programs can participate effecdvely in the continuing education and in the consultations as well. Intensive education and adequate tale models in all postgraduate training programs involved in the care of patients with cancer are needed. However, special attention in oncology training programs is necessary, Y) that they can provide the role models, leadership, and adequate consultation for other physicians participating in the management of cancer patients.= The literaxe i8 a modest reanuce as reported in tbis study. but should be targeted to younger physicians, cancer specialists, and medical subspecialists. These physicians indicxed a preference to learn CPM from the literature. Future studies are needed to expand the data
provided by this study in order to validate iu conclusions and extend them beyond a single medical community. Studies are needed in mntinuing medical education to document the amount and quality of CPM educatimt. Perhaps, statewide or multiple state studies could be done through state cancer pain initiatives or cooperative cancer study groups. Studies are also needed to assess CPM in medical school curricula. Likewise, similar studies are needed at the postgraduate training level. National surveys dll h; required to c&in this daa. Most importantly, these studies need to be designed to determine iF these educational efforts are changing physician skills and behavior in management of cancer pain.
The authors wish to thank the physicians of their community who participated in this study. They wish to thank Colleen Renicr for stadsdcal and data analysis. and Hospice Duluth for its assistance in this study.
R&?tWS 1. Silvderg
E.
Cancer
statisdcs. 1989.
CA
t989:3~1):3-20.
2. Ronica JJ Caper pain:A major nadmd problem. Cancer Nursing L978;1:31&SL6.
health
3. Twycrmr RG. Lack SA. Symptom control in far advanced cancer: Pain relief. London: Pitman. 1984. 4. AnSell M. The quality of mercy. N Engl J Med 19S2:506:9S-93. 5. Marks RM. Sachchar E,. “ndertreatment of medkal ispatients with narcotic analgesics. Ann lntem Med 1979;78:17~181. 6. Weiwman DE. Cancer pin educxition: A call Lr role models. J Clin Oncal 1988:6:179s-,794. 7. Eng~mm PF. Cancer pain manrgemcnt. cwlcept. in Oncol 1979:1:*xX
Curr
8. &eland CS. &eland LM. et al. Fwaon infiuencing phy&iin management of cancer pain. Cancer 1986;58:796-S66. 9. Grossman SA. Sheidler VR. Skills of medical nu. dents ad house offtcers in presrribing narcotic med. ications. J Med Educ 1985:66:552-557. 10. Champ AD. The knowledge, attitudes, and ex. periencc of medical pemmmel treating pain in the terminally ill. MI SinaiJ of Med 197&45(4):561ds0.
pain management is a major international health problem. In the U.S.A. alone. it is estimated that 502,000 cancer deaths occurred in 1989.’ Of these. 60% to 80% will have had severe Dain in the terminal Dhhase of their illness.P’With pmper cancec pai’n management, 95% of these patients could have had complete or nearly complete relief of pain.g This reality has not been achieved in the U.S.A. or any Cancer
other country.’ Insufficient physician knowledge and education in cancer pain management has been cited as one of rhe maim factors contributing to inadequate pain r&f in cancer patients throuehout the worldP Even thowb the literature is&p& whb statements ab& lack of organized teaching of medical students and physicians in cancer pain management.“~’ there are little to no published data about how physicians have acquired the knowledge about cancer pain management they currently pasew or how they wish to further their knowledge. A review of the literature of the last 20 yr regarding physician acquisition of this knowledge revealed only three published R
p0m.8~~~‘~Two reports were surveys of medical snrdents and resident phvsicians in trainina. and one report was a su&y of practicing phisicians. These three studies cotdinned a lack of adequate knowledge at all levels of learning and suggested reeducation of physicians as a solutiorr to d3is problem.
M#WdS A survey of all physicians in direct patient care in Duluth. Minnesota, was conducted to determine where they had learned about cancer pain management (CPM) and how they would like to further their knowledge. Responses fmm 150 of 243 surveyed physicians were recc&d, obtaining a 62% response. The 150 responding physicians in this survey represented 47 different medical wbaols located in 31 states, Canada and England. Of the responding phy sicians, 46% were graduates of the University of Minnesota Medical School. The respondents also represented 51 different postgraduate training pmgtams located in 25 different states. No sin.& postgraduate tmhdng program represented tnore than 12% of the survey sample. The physicians who responded were divided follows: medical school graduates p&&x l-968 (expressed asolder physicians, N = 41, or 27%). medical school gnd“ates between 1968 and 1977 (expressed as middle-aged physicians, N = 53. or 35%). and medical school graduates after 1977 (expressed as younger phy&ians. N = 56. or Sj$). The physicians were also divided into four specialty pncdce groups as follmvs: cancer speaists (N = 8. or 5%). tximarv are swxialisrs (N = 96, oT 60%),&.ge0ns’(N = 28, br 19%). and medical subsoccialists IN = 24. or 16%). Variances these &e anri speci&y groups were analy;zed with chi-square. Levels of significance are expressed with p-values. The survey asked specific questions about how physicians have learned and want to learn more about CPM. They were asked if their medical school curriculum included a course on narcotic analgesics at the clinical level and il their postgraduate training included a didactic course or focused clinical experience in cancer pin management. Also, mognizing that physicians acquire knowledge and skills fmm multiple sour. they were asked to rank where or how they learned about narmtic use in cancrc pain using a scale of 0 through 4 (0 = poor re-
intothree aptmumas
betweeit
source, 4 = major resource). Seven wnmmn waya of acquiring CPM information were listed for them to rank order. and an open-ended op tion of “Other. please lii: ” was also on the list. The indicated items were: medical school, residency, continuing medical educadon pmgrams. wnsultations. literature. hospice and drug representatives. The survey continued with questions about where and how the pbysician would like to learn about new cura* in CPM in the future. Sii options were listed for the physicians to rank, which included staff conferences, outside CME, consultations. literature. hasvice and drug representatives. plus the op.&r&d op. tion of ‘Other. please list:_“. The physicians rankeci their preferences using the scale I = first choice. 2 = second choice. etc. Finally. the survey presented a series of attitudinal saatetnents to which they were asked to indicate the strength of their response (I = agree strongly to 4 = disagree strongly). The results of the attitude survey are reported separately. Copies of the survey questionnaire are available from the authors upon reqttest.
The physicians who returned the survey wem representative of the populadon. The overall response rate was 62%. Of the 72 surveyed physicians who graduated before 19668,518 returned the auestionnaire. Einhtv-fiw Dhvsicians practi&g in Duludt g&&d be&n 1968-1977: 57% of them reswnded to the survey. A majority (74%) of the 73 physicians surveyed who graduated after 1977 returned their questionnaires. Except for the cancer spedalists. the respondents also rcprewwd the specialty practice mows mwmrdonatelv. Sixtvfo.; &em .I? th; p;im& care piysti&, 55% of the surgeons. and 55% of the medial subrpzcialisxs returned the survey. Young phy. sicians are over-represented in these findings. Although we cannot know how the non~spon den& answen would differ fmm dmse we received. the consistency in training backgmunds between those who responded and those who did not, as well as their comparable ages and specialty choices (Table I), indicate that the sample is reprexntative of rhe medical community in Duluth. MN. which in private pm&ebased, nonuniversity and nongovernmental. This sample represented 23 diNerent special-
Grad"aio" &fore 1938 IWJ-1977 since 1977 spKialisu Primary Care SW-= Medical SubrpsialLts “WO-O”~0IOgy Numlxr of Medial Schools Number of Postgraduate Sites
41 53 36
35 37 21
76 90 77
90 28 24 8 47 51
51 23 19
141 51 43 8 79 102
ties and subspecialties who are practitioners of prbttaty. secondary, and tertiary care. One-half of the responding physicians directly cared for 10 or more cancer patients per yr, and 16 physicians (10.6%) managed or partly managed 100 or more cancer patients per yr. Hmu Physic&
Have Lmmed
CPM
In the survey, physicians were first asked how they learned about cancer pain managerttent (Tables 2 and 3). Of the respondents. 32% reparted that their medial school cuniculum contained a cliiical course on narcotic analgesic use. Twenty-sewn percent of the physicians reported that their postgraduate training included a didactic course or focused clinical experience in the use of nxcodcs for control of chronic cancer pain. Only 16% tanked the medical school course as a major source of information. Younger physicians reported learning more in medical schools than okler physicians (23% compared to 8% x2 = 19.8, df- 8, p = 0.01).
Medical School Postgraduate (Ftesidency) training CME C.xtstdutions Literature Drug Reps Hwpice
8% 27% 4’1% 39% 34% 1% 31% N-41
z 51
the tnost si&ficant-b&~ng resource for most ohvsiciatts: 53% of all ohvsicians indicated mihe;lcy trait& was tb& t&or learnina source. This.may bfa rerent t&J: 82% of-younger physicians, 44% of middle-aged pbyskktns, and 27% of older physicians stated that residency training pmgrams were a major xsnurce (xp = 36.6, d/= 8, $I = .09001). when analyzed by specialty groups. there were no significant differences. Cancer spe&list training ptqrams were reported to have no greater etnphasis on CPM learning than other residency training programs. Continuing medical education was tanked a major resource for 32% of all physicians. Older physicians repotted learning signiiicattdy more about CPM from continuina medical education than younger physicians ?47% compared to 13%. xz = 19.4.4 = 8.P = 0.01). There were no significant differences in the anwunt learned from continuing medial education when analyzed by specialty groups. Laming about CPM through consultation
15% 44% 41% 47% 31% I% 26% 53
23% 82% 13% 23% 31% 1% 15% 56
16%; z
.
z 2% 23% 150
Ptimaty
care
t-kme-onc
12% 56% 25%
Medkal School Postgraduate (Residency) training CME Co”~“hltiMl~ LitClXUre J’w =pr Hospice
,=
17% 56% 27% 30% 23% 1% 27% 96
6% 12% N= 6
Medical
Sub-Srmialirt S”mwnS 17% 44% 41% 5036 43% 1% 22% 24
11% 54% 40% 54% 46% I:: 2s
Total
16% 55% 32% S6v 32w 2’s: 150
01
The community hospice program was ranked as a tnqor resource for 23% of all physicians. When analyzed by age. 31% of older physicians and 26% of middle-aged physicians repotted the hospice pqmtn as a major resource for information about CPM; only 15% of younger physicians reported the rante. These differences, and those meaaared among the four specialty grottoups,were not statistically significant. Learning abottt CPM from drug company representatives has teen a tesottrce for only 2.2% of all physicians.
with onco:o&ts ‘wtb reported as a major resource by 35% of physicians. Older physicians and middle-aged phy&atts tanked this melhod mo@z often than youn)~ physicians; this represents a statistical trend 09%. 47% and 23%. respectively; x* = 15.4, dj = i, ) = 0.05). When analyzed by specialty gmups. signifxmt diierewes were observed. Tbe eight cancer specklists (five medical oncologists and three radiotherapists) were excluded from the ana& sis since they provide ttte majority of the cat&r pain management catsultations in our cotnmunity. Fifty-four percent of surgeons and 50% of medical subspecialists reported that consultation provided a maior resczurce for kaming CPM: only 30% oiprimary care physiciani agreed (2 = 25.0, df = 12, p = 0.01). The literature was reported al a modest resource for leaminn CPM. Of all ohvsicians. 32% reponed that &e literature has&at& jar resource for them. Tltere were no significam differences among the physicians by age, but rzmcer specialists and medical subspecialists have used the literature to gain information more than surgeons and primary care physicians.
How
Piqsicicms wouldLiketoLearnCPM
The study then
focused on how physicians
would like & kam more about CPbf’in.the fttture (Tables 4 and 5). The most popttkr method tanked by physicians in this study was local medical staff conferences. Of all ohvsicians, 84% reported this as their p&&i method, and there was a statistical trend indicaring that younger physicians were strongest in this preference cp < 0.65). Tbe diffetatces among specialty groups were not statistically significant. However, it is remarkable that 100% of the surgeons ranked local statfconferencesas T&Q
Rfenwl
Sources Pa Physieiuu’ *cquisition OFCPM Skilb
Order Ph”&ii”~ StaffCnnfermcel outside CME ca”s”ltatio”l Literature Dwt Reps HOSpiCe $4.05
81% 27% 65% 35% 3% 64%
N = 4,
72% 37% 64% 46% SE 53
96% 94% 66% 48% 54% 56
84%’ z 45% 2% 49%
150
cepts in CPM. Thirty-three pawn: of physicians indicated they wotdd prefer toattend regional or national continuing medical education meetings to learn abx: CPM. There were no signifxan: differences when analyzed by age groups. Further analvsh revealed that 88% of the cancer racialists&dd travel to condnuing medical ;ducation mnferences for nwre information about CPM. Only 33% of primary care physicians, 24% of surgeons. and 26% of medical subspeCialisB rewned the same willinettess, (x2 = 25.7.3 = 12, p = 0.01). Phvsicians also wan: IO learn about CPM d&gh consultations. Regardless of age, 65% of all physicians ranked mnsulradon as a prefared medmd. When analyzed by specialty group, surgeons reported greatest imeres! in leaminn in this ww. medical subst&alis:s were also ve& buerested, and primary care physicians wwe less so (88%. 78%. and 56%. resp tively. xp = 25.0, df = 12, p = 0.017). Less than half of all physicians wanted to learn about CPM thmugh the literature. However, there were significant differences when analyzed by age and specialty groups. Younger and middle-aged physicians wanted IO learn more from ihe literature than older physicians, although these differaces were no: sratisdcally signifi&:. Cancer specialists and medical subspecialists reported wanting to learn more from tbt literature than primary care physicians and surgeons. These differences documented a statistical trend, 88%. 65%. 40%. and 28%. respeclively, (x2 = 23.6, d/ = 12, p = 0.02). Nearly half of the physicians wanted to learn fmin ihe local harp& program. There were no significant differences when analyzed by age or speckay groups.
80% 98% 56%
41%
_ 46% 90
Few physicians wanted to learn cancer pain management from drug company represent+ tives. Surgeons were more likely to indicate this as a method of choice.
This study reports how physicians have acquired the knowledge about cancer pain management they currendy pmsess, and how they wish to further their knowledge. These data do not assess the quality or validity of the physicians’ cancer pain management knowledge or skills, nor do they address whether physicians wan: to gain additional information. Numerous published reports have already documented a general ofpbysichn knowledge and skills in CPW5 and the resultant lack of pain relief for the majority of cancer pade~~ts.~ As with all surveys. this study is limited by the sample size, the respondents characteristics, and the self-report nature of the survey. The information reported by older physicians about medical school and postgraduate training may be limited hy their memories of thme years. Also, the recognized cancer specialists (5 medical oncologis:s and 3 radiotherapists) in this survey represen: only eight respondents out of :hc 150: any conduaions drawn fmm this subset are tentative and very limited. Very few ph&ians. only 16%. reported leaminz about CPM in medical school. The pre&s:udy suggests, howwer. that since 1978 medical schools have begun to increase this information. Tbeze findinns are consistent with previous literature indic&g that ux of opioids in CPM was no: iaunh: in m&l schools in the pas:.’ Even :oday,‘;his source of learning remains a: a low level as reponed by recen: physician graduates in thii survey. A survey of
lack
78% 26%
loo% 24%
65% 4% 48% 28
26% 6% 66% 24
7a%
88%
64% 59%’
66aB
4vz.b 2% 49% 156
medical school curricula is needed to determine the type of trabdng currently olfered. Residency and fellowship programs have become the major resource for physician knowledge of CPM. This study documents that since 1978 there has been a significant increase in this leaming resource. However, this study also documents that no specialty training program is enhancing this knowledge better than another. The oncok~gy trabdng pmgram graduates in this study represent a small sample size: however, they completed onmlogy fellowships at five different institutions over the last I5 yr. These oncologists reported no greater learning fmm their fellowships in CPM than the nononc&gists in dds survey. B&d on the resp&es in this survey. enbaxement of physician knowledge of CPM can be designed. G&e local medical staff conferences on cancer pain management are needed. Of the physicians. 84% indicated this as the most desired method to learn. Laal and regional cancer specialists can present these conferences effectively. The &ferences will need to be s&d&d remdarlv and reinforced with other fomts of co&& medical education. Consultations are the~second mmt desired way to learn CPM according to this study. esp ckdly for surgeons and medical subspecialists. The consubtions add to the rrhvsicians’ knowledge, especially if rhe specialist who provide these consultations have bad intensive reeducation at regional and national conferences. Consultations must be based on current CPM knowledge. Hospice programs can participate effecdvely in the continuing education and in the consultations as well. Intensive education and adequate tale models in all postgraduate training programs involved in the care of patients with cancer are needed. However, special attention in oncology training programs is necessary, Y) that they can provide the role models, leadership, and adequate consultation for other physicians participating in the management of cancer patients.= The literaxe i8 a modest reanuce as reported in tbis study. but should be targeted to younger physicians, cancer specialists, and medical subspecialists. These physicians indicxed a preference to learn CPM from the literature. Future studies are needed to expand the data
provided by this study in order to validate iu conclusions and extend them beyond a single medical community. Studies are needed in mntinuing medical education to document the amount and quality of CPM educatimt. Perhaps, statewide or multiple state studies could be done through state cancer pain initiatives or cooperative cancer study groups. Studies are also needed to assess CPM in medical school curricula. Likewise, similar studies are needed at the postgraduate training level. National surveys dll h; required to c&in this daa. Most importantly, these studies need to be designed to determine iF these educational efforts are changing physician skills and behavior in management of cancer pain.
The authors wish to thank the physicians of their community who participated in this study. They wish to thank Colleen Renicr for stadsdcal and data analysis. and Hospice Duluth for its assistance in this study.
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