Pain Education and Pain Educators
Despite the issuance of the World Health Association guidelines for the treatment of cancer pain in 1986,1,2 the U.S. Agency for Health Care Policy and Research guidelines for Acute Pain in 19923 and for Cancer Pain in 1994,4 and the International Association for the Study of Pain’s latest version of the Core Curriculum in Pain in 2005,5 the majority of healthcare professionals still leave their training programs inadequately prepared to treat people with pain. California has felt this to be such a significant problem that, with two pieces of legislation, it first established a December 31, 2006 requirement for all license holders other than those in pathology and radiology to obtain 12 hours of pain management and end of life care education (AB 487),6 and fixed the “pipeline” so that all graduates of California medical schools must have similar instruction (AB 791).7 While some have argued that these requirements are insignificant or unreasonable, most acknowledge that this is at best an “eye opener” for most physicians and medical students and will not develop much more than a basic understanding of pain care.
Is it unreasonable for patients to expect that those caring for them are minimally competent in pain management? Is it appropriate for patients to expect their elective procedures to be done in painless conditions? Should failure to relieve pain be considered professional negligence or grounds for civil litigation (on the grounds of child or elder abuse for those under 18 and over 60, respectively)? These are no longer questions for discussion in classes on professional ethics, they are the grounding principles in the current medical literature, patient information briefings, and used as the arguments for actual lawsuits.
Today, healthcare practitioners may feel “damned if you do and damned if you don’t” when it comes to managing pain. However, it does now come down to personal philosophy patterned after the baseball batters dilemma when facing a challenging pitcher, “do you want to go down swinging or watch them go by and try to walk?” For most physicians, doing something good, relieving pain, and eliminating suffering for their patients usually beats doing nothing at all. Education is the remedy for the knowledge deficit regarding pain management. The competent pain educator must know where to locate and how to access the major sources for pain related information, professional organizations providing pain education, differences required when giving information to other professionals versus patients and the public at large, and challenges associated with moving from concepts of learning theory to practical teaching.
Educating Other Professionals vs Patients and the Public at Large
While most healthcare professionals have few opportunities to teach, most do so in some capacity every day. By teaching each other, our interns, residents and fellows, as well as our patients, many of us are now pain educators—whether formally trained or not. Each day we get by with our natural abilities to clarify and explain, with our compelling personalities, and with the hope that the structure imposed by PowerPoint will make what we are saying seem clear to others.
There are obviously differences that impact the way information is transmitted between teachers and students when the teacher is an adult and the student is a child. The teacher determines the agenda and the child-student learns what is presented. The child-student is passive in the educational process, and has no real say about the content presented, has little practical experience to contribute to the learning process, and clearly is the “empty vessel” waiting to be filled.8 At some point, the child-learner is tested to establish mastery of the content. Sadly, there may be little or no apparent utility for the material being taught, and the task of the child-student is to “get through” and move on.
The adult learner is very different from the child-student. The adult learner elects to receive training (or at least accepts the required training as part of a job), and so comes to the “classroom” with more of a personal agenda. Rather than being “filled” with ideas, the adult learner engages in the educational process and becomes an active partner with rich life experiences that may directly apply to the lessons being taught. The adult learner expects to participate in the learning process.
Having said this, there are big differences between educating other healthcare professionals versus our patients and their family members. Fellow physicians, especially in one’s own area of specialization, clearly have a very similar training background and base of practical experience. Whole ideas can often be described in terms of a single descriptive word or phrase. A single picture, even without any additional information— whether an imaging study or pathological microphotograph—can communicate a diagnosis, lead to a mutually agreed upon course of action, and much more. However, when professionals differ in their areas of specialization or disciplines, then a more common approach that shows respect for the learner is necessary. When trying to communicate the complexities of diagnosis, the resolution of the differential diagnostic process, and the implications for providing treatment options to patients, it is even more complicated. Without a common framework of knowledge and the obvious difference in education and experience, there is no possible way for information to be effectively provided to patients and lay people in the same way that it is given to other healthcare professionals or members of our own area of specialization.9
Ballantyne JC. (Ed). The Massachusetts General Hospital Handbook of Pain Management, Third Edition. Lippincott Williams & Wilkins. Philadelphia, PA. 2006. ISBN: 0-7817-6224-3. An outstanding pocket sized paperback book that is very useful for healthcare students, primary care practitioners, residents and fellows in anesthesia, pain management and other specialties.
Boswell MV and Cole BE. (Eds). Weiner’s Pain Management: A Practical Guide For Clinicians, Seventh Edition. CRC Press. Boca Raton, FL. 2006. ISBN: 0-8493-2262-6. Very thorough, comprehensive, clinically oriented textbook intended for pain professionals and others interested in learning more about multidisciplinary pain management.
Loeser JD, Butler SH, Chapman CR, and Turk DC. (Eds). Bonica’s Management of Pain, Third Edition. Lippincott Williams & Wilkins. Philadelphia, PA. 2001. ISBN: 0-6833-0462-3. A “gold standard” textbook, carrying on the legacy started by John Bonica and the University of Washington pain service.
McMahon S and Koltzenburg M. (Eds). Wall And Melzack’s Textbook of Pain, Fifth Edition. Churchill Livingstone. New York, NY. 2006. ISBN: 0-4430-6791-0. The “original” pain textbook, now considered the cornerstone in the field for academicians and researchers in pain.