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10 Articles in Volume 6, Issue #1
Bioethics
Do Topical Herbal Agents Provide Pain Relief?
Infusion Catheter Epidural
New Report of a High-Dose Morphine Metabolite
Pain Education and Pain Educators
Suspecting and Diagnosing Arachnoiditis
Tennant Blood Study — First Update
The Demise of Multidisciplinary Pain Management Clinics?
The Dimensions of Pain
The Role of Psychology in Pain Management

Pain Education and Pain Educators

With limited opportunities of pain management residencies, and fellowships, alternate means must be employed for practicing physicians to train in the basics of pain management.

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

USEFUL PAIN REFERENCES AND TEXTBOOKS

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.

Raj PP. Pain Medicine: A Comprehensive Review, Second Edition. C.V. Mosby. St. Louis, MO. 2003. ISBN: 0-3230-1470-4. This is one of the most practical books to get a quick overview of the field of pain medicine. While intended as a preparatory book for pain related examinations, it has practical information in a short, easy to read format. This is generally more clinically useful than Practical Management of Pain, Third Edition.

Raj PP. Practical Management of Pain, Third Edition. C.V. Mosby. St. Louis, MO. 2000. ISBN: 0-8151-2569-0. This has been one of the best books for preparation for the American Board of Anesthesia’s added qualification (subspecialty certification) examination in pain medicine. It is an excellent preparatory book for those who are new to the field of pain medicine, but is now becoming dated.

Simons DG, Travell JG, Simons LS, and Cummings BD. Travell & Simons’ Myofascial Pain and Dysfunction: The Trigger Point Manual (2-Volume Set), Second Edition. Lippincott Williams & Wilkins. Philadelphia, PA. 1999. ISBN: 0-6833-0771-1. This is the “bible” of myofascial pain and its management. You cannot be a pain practitioner and without having this book available when examining patients.

Wallace MS and Staats PS. Pain Medicine and Management: Just the Facts. McGraw Hill. New York, NY. 2005. ISBN: 0-0714-1182-8. Intended to be a concise review to prepare for certification and credentialing, this book has a standardized format from section to section and provides the reader with “fast take” information.

Warfield CA and Bajwa ZH. (Eds). Principles & Practice of Pain Management, Second Edition. McGraw Hill.: New York, NY. 2004. ISBN: 0-0714-4349-5. A grounding textbook on pain management for all medical practitioners.

Regardless of the intended audience, the pain educator must be aware of self, master the content being discussed, understand the various styles of learning, and appreciate the validity of the experiences of the listeners.9 In most situations, the listeners have immediate needs that must be satisfied. The educator’s goal is to make the learner comfortable and engaged in the process. To do this, the educator must make whatever is being presented useful and non-threatening. When possible, information should be made practical and applicable to something that occurs in the learner’s day-to-day experience. Feedback and opportunities for practice help increase understanding and application. Adult learners generally prefer to work at their own pace, have flexibility, and perhaps even have fun in the process.

To accomplish all of this, competent pain educators must assess the needs of their audience to set behaviorally achievable goals and use innovative techniques that motivate the learner.9 Whether through case presentations, chart reviews, formal lectures, dissemination of handouts and worksheets, use of videos, group discussion, newspaper articles, role play, or debates, pain educators must deliver factual information to peers, other professionals, and the patients served.

When presenting to lay people, language must be understandable and not presented in medical jargon. The pain practitioner must tell enough of whatever is necessary for a reasonable man or woman to make a decision when obtaining informed consent for procedures or even opioid therapy. Likewise, the pain educator must do this while defining the limits of what is known factually from what may be suspected or assumed since the purpose is to educate the patient about the condition, not to just obtain one time permission to do something procedurally or medically. Instead of using anatomical terms and concepts predicated on the understanding of human physiology, the competent pain educator knows to use textbook and atlas illustrations to say pictorially what might take pages of text to explain, will make use of computer animation and real anatomical models, as well as other tangible aids to facilitate mastery of the needed information. Sadly, most pain practitioners lack even the most basic teaching aids in their offices, and rely on imaging studies to explain what is wrong and what must be done to correct the problem.

There is no one best teaching strategy for all people under all circumstances, but there are learning theories providing a “blue print” for teaching success regardless of the audience listening. Pain management physicians must become familiar with common techniques for teaching their peers, other healthcare colleagues, and patients. Just being a good practitioner is not good enough if we are to fully embrace patient education.

Concepts of Learning Theory to Practical Teaching Methods

While the modern theory of learning has been centered around Bloom’s taxonomy since the late 1950s,10 others have contributed to the understanding of adaptations necessary for educating healthcare professionals and lay people. The key message for pain educators is to get beyond the definitions and theories to deliver information that is highly practical and relevant for the learner, regardless of the circumstances.

This requires educators to transcend the Sgt. Joe Friday philosophy of “just the facts ma’am, just the facts” and additionally employ the domains of the cognitive, psychomotor, and affective. This demands that the questions encountered on examinations do more than simply require the recall of information.

Cognitive

For most teaching, the cognitive domain is the most frequently utilized. It ranges from the least demanding level, the acquisition of raw knowledge (memorizing), but then progressively advances to comprehension (understanding), application (using), analysis (taking apart), synthesis (putting together), and evaluation (judging).11 We and our students (patients and peers) demonstrate basic knowledge by arranging, defining, labelling, listing, memorizing, naming, ordering, recognizing, recalling, repeating, reproducing, and stating. Knowledge acquisition is confirmed by regurgitating what has been learned. This is the easiest to assess via standard testing methods, but has little to do with what is needed to manipulate and utilize the information in most practical cases.

Comprehension

Comprehension involves someone being able to classify, describe, discuss, explain, express, identify, indicate, locate, recognize, report, restate, review, select, and translate the basic information.11 Comprehension is used whenever we are interpreting, describing in our own words, organizing and select facts and ideas, or retelling something we learned to another person. This is much more than reciting back data; some degree of integration of information is necessary for comprehension.

Application

When educators and those being taught are able to apply information, then even more data manipulation is required. The critical tasks for application involve applying, choosing, demonstrating, dramatizing, employing, illustrating, interpreting, operating, practicing, scheduling, sketching, solving, using, and writing.11 Through application we solve problems, produce some result and employ facts, rules and principles. In the end, we resolve questions about how one thing is an example of something larger, how two things are related, and what is it’s significance.

Analysis

Analysis takes acquired information to an even higher level and requires the ability to analyze, appraise, calculate, categorize, compare, contrast, criticize, differentiate, discriminate, distinguish, examine, experiment, question, and test hypotheses.11 When we analyze, we critically subdivide larger ideas or objects to show how each smaller aspect or component contributes to the whole, we identify underlying motives for an action, and we separate large groups into their individual constituents. To do this, we question each of the parts or features of something, outline the features, compare and contrast elements of the whole, and even list evidence for or against the thing being studied.

Synthesis

Synthesis, the creation of something new from what has been mastered, and involves being able to arrange, assemble, collect, compose, construct, create, design, develop, formulate, manage, organize, plan, prepare, propose, set up, and write.11 In synthesis, we create unique, original products that may be expressed verbally or manifested in physical form.

Questions resolved by synthesis deal with predictions and inferences going beyond what is presently known (prognosis), creating or developing a new form, seeing the possibilities from the combining of things, and suggesting solutions for problems at hand.

Evaluation

Lastly, we must evaluate through the use of appraisal, argument, assessment, comparison, defence, estimation, judgment, prediction, rating, selection, supporting, and valuing.11 To do evaluation we are making value decisions about issues (cost versus benefit, opportunity cost), resolve differences of opinion or position, and develop decisions, judgments or positions. To “test” evaluation, we ask about the learner’s agreement with something, how the learner would determine what is most important, require the learner to establish priorities, and develop criteria used for assessment.

Taking time to make challenging presentations using the system attributed to Bloom, whether to peers or patients, would do much to create the “buy in” that is needed. The person who has incorporated information to such a degree that by breaking it down and rearranging its components finds new uses, has meaningfully mastered it. By then observing changes that occur, forming judgments and making further refinements, what is initially just new information could become part of daily life. If the goal for health care education is to change attitudes, beliefs and behaviors, then the education provided must allow for these higher levels of learning, and educators must see the work done as highly collaborative instead of just the filling of empty heads.

The Affective Domain

The affective domain ranges from awareness to distinguishing implicit values via analysis.11 It addresses attitudes, interests, opinions, values, emotional sets and, if the teaching purpose is to change attitudes and behavior rather than to transmit information, the instruction should be structured to the affective domain.12 Teaching in the affective domain could require the determination of worth for a particular object, phenomenon, or behavior. This would then lead the learner to a comparison of competing ideas, methods or philosophies.

The importance of the affective domain is the appreciation of the emotional needs that occur in education. As educators we must work hard to make every educational experience relevant and manage the expectations of the learner. Education by shame or blame is not satisfying for the learner, and more likely reflects the failure of the educator to motivate the learner, rather than laziness or lack of interest in the subject on the learner’s part. How many of us were enthusiastic learners when physically and emotionally exhausted, much less when we were told how worthless and no good we were because we failed to have some result on morning rounds? While much is said about developing educational goals and objectives that usually address the cognitive needs of the audience, very little is mentioned about their emotional needs.

PAIN RELATED ATLASES

Waldman SD. Atlas of Common Pain Syndromes. W.B. Saunders Company. Philadelphia, PA. 2002. ISBN: 0-7216-9211-7.

Waldman SD. Atlas of Uncommon Pain Syndromes. W.B. Saunders Company. Philadelphia, PA. 2002. ISBN: 0-7216-9372-5.

Waldman SD. Atlas of Interventional Pain Management, Second Edition. W.B. Saunders Company. Philadelphia, PA. 2003. ISBN: 0-7216-0108-1.

Waldman SD. Atlas of Pain Management Injection Techniques. W.B. Saunders Company. Philadelphia, PA. 2000. ISBN: 0-7216-8504-8.

Waldman SD. Physical Diagnosis of Pain: An Atlas of Signs and Symptoms. Elsevier Saunders. Philadelphia, PA. 2006. ISBN: 1-4160-0112-3.



PATIENT RESOURCES

Caudill M. Managing Pain Before it Manages You, Revised Edition. Guilford Press. New York, NY. 2001. ISBN: 1-57230-178-8. This is a very good self-help workbook for patients to better understand their pain, and the factors that contribute to pain interference with activities of daily living.

The Psychomotor Domain

The psychomotor domain evolves from imitation to manipulation, precision, articulation and naturalization.11 To develop competence in this domain first requires the acquisition of skills and then developing consistency through time. There is always “beginners luck” when trying a new skill, but patients and colleagues expect skillful practitioners to always be able to do the task. Performance itself takes the place of discussion or questioning when we examine in the psychomotor domain. The operator can pass the needle successfully into the site of the procedure. The pain physician can correctly interpret the imaging study. Mastery in the psychomotor domain requires a blending of reflex movements with basic fundamental movements, perceptual abilities, physical capacity (endurance, strength, flexibility, agility) and, finally, the acquisition of complex skilled movements.

Probably more so for the psychomotor domain, issues of innate ability, artistry and talent come into play. While most can be taught the skills necessary for simple tasks (drawing blood, placing bandages), issues of craftsmanship are likely to involve the refinement of talents already possessed. The challenge for educators is in the shaping of skills through hands on practice and the building upon movements already mastered to move to more complex tasks. Through approximation, learners develop skill sets that take them closer to the final goal.

PROFESSIONAL ORGANIZATIONS PROVIDING PAIN EDUCATION FOR PHYSICIANS

American Academy of Pain Management (AAPMan)

The American Academy of Pain Management (www.aapain manage.org), started in 1988 and was the first multidisciplinary clinical organization in the U.S., working to support the needs of clinicians. Over the years, the AAPManagement created the first credentialing process in pain management, developed the National Pain Data Bank (an outcome measurement system for establishing what works and what does not), initiated the Pain Program Accreditation service (a voluntary compliance program), published its own textbook (Weiner’s Pain Management: A Practical Guide for Clinicians, 7th Ed), and ultimately set many of the standards that other pain groups emulated. More controversial than the other groups because of its inclusionary, multidisciplinary philosophy, it was the only group for a decade with a codified Pain Patient Bill of Rights and Code of Ethics for the practice of pain management. Their quarterly peer-reviewed publication is the American Journal of Pain Management and their expanded quarterly news magazine is The Pain Practitioner.

American Academy of Pain Medicine (AAPMed)

The American Academy of Pain Medicine (www.painmed.org) was created by a group of physicians who felt that the American Pain Society did not meet the needs of practicing physicians. They started a more clinically focused organization in the early 1980s and addressed the needs of pain physicians, especially concerns related to billing and payment. They are the “guild” organization for pain physicians and have a seat in the AMA’s House of Delegates. Unlike IASP and APS, they are only open to MDs and DOs who trained in allopathic residency programs. In the mid-1990s, they spun off the American Board of Pain Medicine to be the testing and credentialing arm for their organization. Their bimonthly professional publication is Pain Medicine and their quarterly newsletter is the Pain Medicine Network.

American Pain Society (APS)

The American affiliate of the IASP is the American Pain Society (www.ampainsoc.org). It spun off from the IASP to give American members of the IASP an opportunity to have an organization with an eye on pain management in the USA. It too, had a strong association with the research and academic interests in pain management and, for many years, always met in conjunction with the national meeting of neuroscientists. Over the years, it too became more clinical and took the lead in the publishing guidelines about managing pain. Today, the APS is one of the more openly political pain organizations and has close ties with the Pain Policy Study Group at the University of Wisconsin (Madison) run by David Joranson. The official professional publications of the APS are the monthly The Journal of Pain and the quarterly APS Bulletin newsletter.

American Society of Interventional Pain Physicians (ASIPP)

The American Society of Interventional Pain Physicians (www.asipp.org) is one of the newer organizations. It is focused on the needs of pain physicians who are working primarily as interventionalists, but some members are interested in the role of politics in pain management. ASIPP has more recently become the most effective lobbying group and has been able to introduce and pass legislation in the U.S. Congress. ASIPP has written guidelines related to interventional pain medicine and to the use of long-term prescription opioids. The official publication is the bimonthly Pain Physician.

American Society of Pain Educators (ASPE)

The American Society of Pain Educators (www.paineducators.org) is the most recently established, non-profit professional organization, whose mission is to improve the standards of clinical pain practice by providing training in pain management education and helping to establish credentialed pain educators (CPEs) as standing resources within pain practices, hospitals, healthcare systems, and long-term care facilities. The ASPE, through the American Board of Pain Educators, intends to be the sole credentialing agency for pain educators in the United States. It’s quarterly newsletter is the Pain View and it’s Pain Educators Journal will begin in 2006.

American Society of Regional Anesthesia and Pain Medicine (ASRAPM)

The American Society of Regional Anesthesia and Pain Management (www.asra.org) is the largest pain society in the U.S. It is an anesthesia-based organization that promotes the use of regional anesthesia techniques for the management of pain. While it does allow non-anesthesiologists to be members, its clinical meetings are focused on the needs of anesthesiologists doing pain management. For many years, ASRAPM provided very good review courses to prepare anesthesiologists for their pain management “added qualifications.” Since the American Board of Medical Specialties began allowing neurology, psychiatry, and physiatry to take the American Board of Anesthesia’s Pain Medicine examination, the ASRAPM has not been as active in preparatory courses. Their official publication is the bimonthly Regional Anesthesia and Pain Medicine.

International Association for the Study of Pain (IASP)

The original pain society was the International Association for the Study of Pain (www.iasp-pain.org)). This was the original group of neuroscientists who “started” the field of modern pain management. They were mostly interested in the underlying causes and mechanisms for pain, so they always had a greater research rather than clinical focus. Over the years, more clinicians became members and the organization evolved to include direct linkages between research and clinical. Today, the IASP is the largest multidisciplinary organization with 6,700 members. Their official publication is the monthly journal Pain.

Society for Pain Practice Management (SPPM)

The Society for Pain Practice Management (www.sppm.org) is a smaller group with a mission to educate specialists in the area of pain treatment and practice management, and to promote the health and wellness of mankind by advancing the art and science of the specialty of pain management. It addresses the traditionally business-related aspects of pain practice. It offers training in invasive techniques much like ASIPP and ASRAPM, but it also helps new pain physicians open their practices and become financially stable.

Where Does the Pain Educator Turn Today?

As previously mentioned, the American Society of Pain Educators (ASPE) is the only U.S. organization solely focused on the needs of the person committed to pain-related education. Whether developing a better teacher for healthcare organizations and schools by providing basic training in teaching methods, or by helping skilled clinicians cross over from day-to-day practice to being effective communicators and explainers of what is being done, the ASPE provides meaningful learning opportunities through annual live meetings, enduring materials, electronic communication and web based materials.

It is no longer true that “those who can’t do, teach.” When it comes to pain education in the U.S., there are now 500 members of the ASPE who see themselves as enthusiastically committed people who can be fixed assets for institutions, brokers and translators of pain related information, managers for people in pain who must negotiate the medical system, and much more. Rather than being “burned out” or semi-retired, pain educators are working hard to bring the message to medical, nursing and pharmacy schools that pain is treatable, and to patients that they can learn to live with it and manage it using the many medications, methods, and skills available.

The pain educator is now poised to be the hub in the wheel. Pain educators can simultaneously raise the knowledge and skill levels for those who are lacking, determine the institutional needs, and implement the care plans developed, as well as insure their success through treatment adherence. Much can be done to control pain, and much more will be done during this Decade of Pain Control and Research to end the misery that comes from pain. Knowledge is about empowerment, and pain educators are the “go to” people. In the end it is not what you teach, but what they learn, that matters.

Sources for Pain Related Information

Twenty years ago there were only a couple of significant pain organizations, a couple of annual meetings, and not one major comprehensive textbook on the subject of pain management. Early adopters and clinicians in the field of pain management came to realize that much needed to be developed to promote the new discipline, and for that discipline to be recognized. While a “unified voice” never occurred, the number of pain organizations increased with each having some unique focus. There was also a significant expansion in what was written and disseminated regarding pain and its management in books, magazines, websites and monographs. Ultimately several major textbooks on pain, pain-themed journals, and newsletters were published; a multitude of meetings were held; dozens of position statements were written; and many groups staked out distinct perspectives on pain research, management and education.

To obtain relevant pain-related information, the pain educator must look to a number of core books, textbooks, atlases, journals, and other publications. While not intended to be entirely comprehensive, the tables of resources (pages 43and 45) are a “short list” of what is popularly available and easily obtained from online vendors today. Also, refer to page 49 for a listing of professional organizations providing pain education for physicians.

Last updated on: December 20, 2011
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