Pain, 50 (1992) 249-250 © 1992 Elsevier Science Publishers B.V. All rights reserved 0304-3959/92/$05.00

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PAIN 02096

Guest Editorial

What should medical students learn about pain? Mitchell B. Max Neurobiology and Anesthesiology Branch, National Institute of Dental Research, National Institnt'es of Health, Bethesda, MD 20892 (USA) (Received and accepted 27 February 1992)

A decade or two ago, pain experts were a rare breed and had relatively little clout in medical schools. We observed the dismaying shortcomings in the treatment of patients with pain and often blamed this on the lack of medical school teaching. With the growth of the field of pain research and management, many medical schools now have a dozen or more basic science and clinical faculty members expert in pain, and there is some consensus on the relevant subject matter (Fields 1991). Given these resources, it should be possible to influence many medical schools' curricula. The questions have now become practical and immediate: what should be the design and timing of students' educational experience related to pain? Those who teach health professionals about pain will welcome this issue's delightful and inspiring paper by Wilson et al. (1992) describing the results of a 6-h course on pain for first-year medical students at the University of Kentucky. Ninety-five students reviewed a brief text describing the scientific !~,asis of pain and analgesia, social and behavioral aspects of pain treatment, and shortcomings of current pain treatment practices. Concurrently, they met with members of the acute and chronic pain management services, observed their rounds and patient management conferences, and wrote a 1-page essay describing the experience. To assess the impact of the course, a brief questionnaire was given before the course and 5 months after its completion. This included questions about the incidence of acute and chronic pain and the frequency of undertreatment, and the open-ended sentence completion items, "People in pain are . . . " and "Working with patients in pain will be ...". Not suprisingly, students' answers about the inci-

Correspondence to: Mitchell Max, M.D., N I D R / N I H Pain Research Clinic, National Institutes of Health, Building 10, Room 3C-405, Bethesda, MD 20892, USA. Tel.: (301) 496-5483 or -6695; FAX: (301) 496-2443.

dence of pain moved in the desired direction after the course; if anything, students tended to overestimate the frequency of unrelieved pain. Unfortunately, knowing these 'right answers' does not assure adequate treatment of pain once the student gets on the wards. In the clinical situation, the practices of other clinicians (Soumerai and Avorn 1984; Morgan 1989) and the lack of formal accountability for good pain rehef may be more influential, and pain may be relatively ignored. The most striking finding of Wilson et al. was that 5 months after the course, 30% of the students responded that working with pain patients will be worthwhile or rewarding, compared to 15% prior to the course. This occurred notwithstanding the students' realization that treating patients with chronic pain is often difficult or unsuccessful. The authors point out that this 'realistic enthusiasm' for the treatment of pain problems has a greater chance of lasting into clinical practice than naive and optimistic views drawn from more didactic approaches to pain education. Although the authors characterize this report as preliminary, I was impressed by their data and by the moving quotes from the students' essays. Something more occurred here than what the paper's title calls a change in "medical students' attitudes towards pain". Many of the students discovered possibilities about themselves: who they might aspire to be as physicians. A crucial function of professional education is to let students realize that they can contribute something to their discipline that was previously missing. Such a realization can generate the passion and persistence that characterize the leaders in any field. Particularly because treating pain and suffering has not been central in the discourse of modern medicine (Max 1990) and because our educational traditions have focused on teaching bodies of facts and procedures (Gardner 1991), we must take special care that our curricula nurture the possibility of this self-discovery. This has been a central concern, for example, of Weissman and his colleagues in the Wisconsin Cancer Pain Initiative (1991), who have designed their educational programs

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around clinician role models and bedside clinical rounds. Much work (that is, virtually everything) remains to be done. The fragile enthusiasm created in a first-year course will wither if the student does not feel competent to handle the challenges of pain patients in the clinical years. Just as Wilson and Hafferty (1983) drew on existing expertise in behavioral science and the teaching of gerontology, teachers of pain management would do well to examine educational strategies, teaching aids, and assessment methods developed by other clinical specialties or by other institutions. For example, primary care clinicians have developed approaches to teaching student competence in interviewing skills (Roter 1990)which might be adapted to meet the challenges of treating patients with chronic pain. The use of a computer program for calculating opioid analgesic doses (Grossman and Sheidler 1985, 1989) has been shown to reliably increase physicians' competence in that domain. Assessment of the outcome of medical school courses in pain is crucial, particularly because in a new field, unforeseen phenomena and challenges are often revealed. For example, Cherkin et al. (1991a,b) recently showed that a brief course in physicians' offices significantly improved physicians' perceived knowledge, confidence, and patient-reassuring behavior in managing patients with low back pain. To the investigators' surprise, however, patients treated after the intervention were no more satisfied than those treated earlier. Cherkin et al. speculate that years of negative reactions to patients with back pain cannot be reversed by a brief course, and suggest that such training should begin before the physician enters practice. i hope that the paper by Wilson et al., one of the first to appear on the subject, stimulates many other innovative approaches to teaching about pain management. If such courses can help students to discover their commitment to the art of caring for the patient,

the benefit to medicine will be felt far beyond the pain clinic.

References Cherkin, D., Deyo, R.A., Berg, A.O., Bergman, J.J. and Lishner, D.M., Evaluation of a physician education intervention to improve primary care for low-back pain I. Impact on physicians, Spine, 16 (1991a) 1168-1172. Cherkin, D., Deyo, R.A. and Berg, A.O., Evaluation of a physician education intervention to improve primary care for low-back pain. II. Impact on patients, Spine, 16 (1991b) 1173-1178. Fields, H.L. (Ed.), Core Curriculum for Professional Education in Pain, International Association of the Study of Pain Publications, Seattle, WA, 1991. Gardner, H., The Unschooled Mind, Basic Books, New York, 1991. Grossman, S.A. and Sheidler, V.R., Skills e~" medical students and house officers in prescribing narcotic medications, J. Med. Educ., 60 (1985) 552-557. Grossman, S.A. and Sheidler, V.R., The Johns Hopkins Oncology Centers, Narcotic Conversion Program (on disk), Lea & Febiger, Philadelphia, PA, 1989. Max, M.B., Improving outcomes of analgesic treatment: is education enough?, Ann. Intern. Med., 113 (1990) 885-889. Morgan, J.P., American opioiphobia: customary underutilization of opioid analgesics. In: C.S. Hill, Jr. and W.S. Fields (Eds.), Drug Treatment of Cancer Pain in a Drug-Oriented Society, Adv. Pain Res. Ther., Vol. 11, Raven, New York, 1989, pp. 181-190. Roter, D.L., Cole, K.A., Kern, D.E., Barker, L.R. and Grayson, M., An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice, J. Gen. Intern. Med., 5 (1990) 347-354. Soumerai, S.B,, and Avorn, J., Efficacy and cost-containment in hospital pharmacotherapy: state of the art and future directions, Milbank Memorial Fund Quarterly: Health and Society, 62 (1984) 447-474. Weissman, D.E., Gutmann, M. and Dahl, J.L., Physician cancer pain education: a report from the Wisconsin Cancer Pain Initiative, J. Pain Sympt. Manag., 6 (1991) 445-448. Wilson, J.F., Brockopp, G.W., Kryst, S., Steger, H. and Witt, W.O., Medical students' attitudes toward pain before and after a brief course on pain, Pain, 50 (1992) 251. Wilson, J.F. and Hafferty, F.W., Long-term effects of a seminar on aging and health for first-year medical students, Gerontologist, 23 (1983) 319-324.

What should medical students learn about pain?

Pain, 50 (1992) 249-250 © 1992 Elsevier Science Publishers B.V. All rights reserved 0304-3959/92/$05.00 249 PAIN 02096 Guest Editorial What should...
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