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The Journal of Pain, Vol 8, No 2 (February), 2007: pp 152-160Available online at www.sciencedirect.com

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he EVMS Pain Education Initiative: A Multifaceted Approach toesident Education

an Chen,* Benjamin Goodman, III,* Marissa Galicia-Castillo,†

ntonio Quidgley-Nevares,‡ Marcia Krebs,� and Gayle Gliva-McConvey§

Division of General Internal Medicine,Division of Geriatrics,Department of Physical Medicine and Rehabilitation, andTheresa A. Thomas Professional Skills Teaching and Assessment Center, Eastern Virginia Medical School, Norfolk,irginia.

Shore Cancer Center, Nassawadox, Virginia.

Abstract: Chronic pain is a major health issue that causes significant patient morbidity as well aseconomic loss. Many studies have highlighted the lack of training in chronic pain management forresident physicians and the need to develop programs that address the challenges of providing careto chronic pain patients. We wanted to determine whether a workshop using a combination ofstandardized patients, small groups, and large group lectures addresses residents’ curricular needsregarding chronic pain management. We developed a 1-day workshop for residents at EasternVirginia Medical School, which has a nationally recognized professional skills center. After completingthe workshop, residents showed significant gains in knowledge (post-test vs pre-test overall mean�23.4%, P < .001). Significant gains in clinical skills were also seen (overall �5.9%, P < .001) withimprovements in the areas of pain assessment (�6.3%, P < .001), physical examination (�7.7%, P <.03), and pain management (�8%, P < .01). Physicians also reported increased comfort regardingchronic pain management. Almost all residents stated they would make specific practice changes inthe assessment and management of chronic pain patients. The results suggest our workshop is anovel model that is effective in teaching residents how to assess and manage chronic pain.Perspective: This article demonstrates that the use of standardized patients with other teachingmethods is an effective approach in teaching resident physicians regarding the assessment and man-agement of chronic pain patients. The findings have the potential to restructure our methods ofteaching in chronic pain education.

© 2007 by the American Pain Society
Key words: Chronic pain education, curriculum design, resident education, standardized patients.
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reating chronic pain has become a major healthissue owing to its widespread prevalence8 and bur-den on patients and society.17 It is well established

hat pain is often inadequately treated, and studies haveointed to possible causes such as lack of training in pain

eceived April 12, 2006; Revised June 28, 2006; Accepted June 30, 2006.upported by an educational grant towards the Pain Education Initiativerogram from Purdue, Inc., and by the Excellence in Primary Care Re-earch Training Grant D14-HP-00182 from the U.S. Department of Healthnd Human Services, Health Resources and Services AdministrationHRSA), to Dr. Chen.ddress reprint requests to Ian Chen, MD, MPH, Department of Internaledicine, Eastern Virginia Medical School, 825 Fairfax Avenue, Suite 410,orfolk, VA 23507. E-mail: [email protected]/$32.002007 by the American Pain Society

toi:10.1016/j.jpain.2006.06.008

52

anagement among physicians or socioeconomic dis-arities among patients.3,12,13,19,21 These findings are in-icative of a need for novel approaches to the educationnd evaluation of medical students and resident physi-ians in this area.4 Many previous studies suggest thateaching efforts should be directed toward improvinghysicians’ comfort, skills, and attitudes toward chronicain management.5,6,14,20

The content of a curriculum on chronic pain manage-ent for medical students has been investigated,18 but

here is a lack of literature on the process and content ofurricula directed toward resident physicians. We at-empted to address this deficiency by developing a mul-ifaceted approach toward chronic pain education cen-
ered around the use of standardized patients (SPs).

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153ORIGINAL REPORT/Chen et al

tandardized patient–based assessments are perfor-ance-based evaluations used to assess competencies inedical interviewing, clinical reasoning, physical exami-ation, and application of clinical knowledge.2 They aresed in assessments at all levels of training, includingedical students (clerkship exams), graduating medical

tudents (National Board of Medical Examiners USMLEtep 2–Clinical Skills Assessment), international medicalraduates (ECFMG Clinical Skills Assessment), and for res-

dent and practicing physicians.1,15,22 The use of SP as-essments has been favored because they provide morenformation than standard subjective evaluations orests that only measure knowledge. Standardized pa-ients have been used to simulate a variety of patientcenarios. For example, SPs have been used to assess thekills of residents and students regarding domestic vio-ence, geriatric medicine, and psychiatric illness.9,10,16

We developed a full-day workshop using a combina-ion of SP assessments, small groups, and large groupectures to teach our resident physicians about chronicain management. The objective of this study was toetermine whether the SP approach could be success-ully used to meet some of the needs of our residents inhe realm of chronic pain education.

ethods

ubjects and SettingThe workshop was presented in March 2005 to resi-ents in internal medicine, family medicine, combined

nternal medicine/family medicine, and combined inter-al medicine/geriatrics residency programs at Easternirginia Medical School (EVMS), a university-based med-

cal school in southeastern Virginia. In the study year, thisepresented a total of 71 residents in the 4 programs: 33ategorical medicine, 10 preliminary medicine, 1 medi-ine/geriatrics, 11 medicine/family medicine, and 16 fam-ly medicine. All residents in these programs were askedo participate unless there were conflicts with clinicaluties or vacation.The Theresa A. Thomas Professional Skills Teaching

nd Assessment Center at EVMS provided the SPs used inhe study. The Center uses SPs ranging from ages 16 to8, representing diverse racial, ethnic, cultural, and so-ioeconomic backgrounds. The facility has 15 rooms thatan simultaneously record SP-learner interactions andas been nationally recognized with an award for theost outstanding live Continuing Medical Educationrogram from the American College of Physicians. Theenter works with resident physicians, medical students,nd other health and nonhealth related professionals atnumber of institutions. A previously developed Wom-

n’s Health Initiative program at the Center has beensed at multiple institutions throughout the countryJ. G. Dixon, MD, oral communication, March 2006).

ducational TheoryThe Pain Education Initiative (PEI) at EVMS was based
n the PRECEDE/PROCEED model of health education
rograms described by Green and Krueter.7 This multidi-ensional model recognizes that health and health be-

aviors have multiple causes that must be targeted forntervention. In the case of treating chronic pain, therere certain predisposing, enabling, and reinforcing fac-ors that affect physicians’ behavior and the environ-ent that they work in, and in turn, these behavioral and

nvironmental factors ultimately contribute to the qual-ty of patient outcomes. The educational program shouldherefore be designed to target the predisposing, en-bling, and reinforcing factors. Examples of predisposingactors include physician knowledge, attitudes, and be-iefs regarding chronic pain management and their pa-ients. Enabling factors include certain chronic pain man-gement skills or availability of training. Reinforcingactors consist of feedback from peers or teachers.

verall DesignThe PEI workshop was designed with multiple compo-ents to target the predisposing, enabling, and reinforc-

ng factors. Small group discussions and large group lec-ures were designed to provide the foundation ofnowledge and skills that residents need to adequatelyanage chronic pain. The SP sessions exposed residents

o patients with chronic pain problems and were alsoesigned to provide immediate feedback to the resi-ents regarding their competencies in interviewing, per-orming physical examinations, and communication. Are-test and post-test was designed to measure changes

n knowledge. Self-administered pre- and post-work-hop surveys allowed residents to reflect on their ownttitudes and beliefs about chronic pain managementnd patients. The workshop staff was a collaboration ofaculty from the Divisions of General Internal Medicinend Geriatrics in the Department of Internal Medicine,he Department of Physical Medicine and Rehabilitation,he Palliative Care and Pain Center at the Sentara Cancernstitute, and staff at the Professional Skills Center atVMS. The EVMS Institutional Review Board granted anxemption from review based on research of educa-ional practices in an educational setting, and formalonsent was not required.

ducational InterventionsThe PEI workshop used 2 pain-related SP cases, writteny the workshop faculty. The clinical content of the 2ases was chosen based on consensus opinion of theorkshop faculty and on the proposed curriculum items

uggested by Turner and Weiner.18 In the SP-learner ses-ions, residents’ history taking, physical examination,nd counseling behaviors were carefully noted by SPs onhecklists. The sessions were digitally recorded for fur-her review. The 2 cases focused on pain scenarios fairlyommon in a primary care office practice:

. Mr. Patrick Walker, who presents with low back pain,and a chief complaint of “I hurt so much, I can’t standthe pain. I need stronger pain meds.”

. Mr. Harry Profert, who presents with worsening neu-
ropathic pain, and a chief complaint of “My leg hurts

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154 Multifaceted Approach to Pain Education

all the time. I can’t stand it anymore. Why aren’t allthe pain meds working?”

In the morning session, half of the residents partici-ated in 2 of the 3 small group sessions—“Assessment ofain” and “Management of Pain”—while the other halfere involved with the first SP case. After completion of

heir respective assignments, the residents switched. Thefternoon sessions similarly consisted of the “’PEARLS’ ofain Management” small group and the second SP case.esidents were randomly assigned to 1 of 2 full days forhe workshop, to begin with either the small group or SPase and to begin with either the low back pain or theeuropathy case (Table 1). Each small group had specificctivities or topics to review during the session. For ex-mple, in the “Assessment of Pain” small group, samplectivities included: 1) review of the pathophysiology ofhronic pain; 2) review of the important elements of theistory and physical; and 3) review of the elements thatre often missed in the assessment of pain. For thePEARLS” small group, the topics included: 1) when toefer a patient to an outside provider; 2) how to dealith the “difficult patient,” and 3) documentation andrescription writing.The large group sessions were conducted with all of

he participants attending 2 lectures entitled “Pharma-ologic Indications and Principles” and “Managementtrategies for Specific Chronic Pain Conditions.” The lec-ures covered specific topics such as reviewing the differ-nt classes of pain medications, dose conversions, treat-ng side effects, urine drug screens, and factors toonsider in treating elderly patients, patients with HIV,r patients with sickle cell.

utcome EvaluationOur outcome evaluation for the workshop targeted

hanges in physician knowledge, attitudes, and behav-ors and acquisition of new skills during the sessions. Wesed 3 evaluation methods, developed through the con-

able 1. Overall Design/Outline of the Pain EduSESSION 1 SESSION 2

ay 1roup A Standardized Patient:

Low Back PainSmall Group:Assessment of PainManagement of Pain

Large GroPharmacoManagem

conditioroup B Small Group:

Assessment of PainManagement of Pain

Standardized Patient:Low Back Pain

ay 2roup A Small Group:

Assessment of PainManagement of Pain

Standardized Patient:Neuropathy Pain

Large GroPharmacoManagem

conditioroup B Standardized Patient:

Neuropathy PainSmall Group:Assessment of PainManagement of Pain

ensus opinion of the workshop faculty: p

. A 15-question pre-test repeated as a post-test wasused to evaluate changes in applicable knowledge ofpain assessment and management. The order of thequestions and possible answers were changed frompre-test to post-test, but the content of the questionsremained the same.

. The SP case checklist (Appendix 1) was used to evalu-ate changes in history, physical examination, andcounseling skills. Residents were evaluated with thechecklist for both the low back pain and the neurop-athy case.

. A questionnaire was administered to all participantsto evaluate the efficacy of the small groups, largegroups, SP cases, and workshop overall in changingtheir knowledge, attitudes, and skills regarding painmanagement.

tatistical AnalysisStatistical analyses were performed using Stata 7.0

Stata, College Station, TX). Descriptive statistics for theemographic variables were compiled. Survey questionsith Likert scale outcomes were dichotomized into aroup of Agree or Strongly Agree vs Strongly Disagree,isagree, or Neutral. The pre- and post-tests were scoreds percentage correct; each question was also analyzedndividually. Checklist items were equally weighted, andn overall percentage score was derived from the num-er of checklist items correctly performed out of all

tems. Subanalyses of the checklist items were also per-ormed for the 4 main areas of competency—pain assess-ent, physical examination, pain management, and

ommunication.We applied paired t tests to each individual’s checklist

cores from the first case to the second case, as well as the5-question pre-test and post-test. We performed biva-iate analyses of the demographic variables vs thehange in pre-test and post-test scores and the change inhecklist scores to determine whether there were any

on InitiativeSSION 3 SESSION 4 SESSION 5

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esults

emographicsForty-three residents (27 women, 16 men) participated

n the PEI workshop over the 2-day period. The distribu-ion of the residents closely mirrored the resident popu-ation at EVMS with 24 categorical medicine, 10 familyractice, 8 combined medicine/family, and 1 preliminaryedicine participating in the program. All levels of train-

ng were represented with 15 interns and 11 second-ear, 15 third-year, and 2 fourth-year residents partici-ating. Residents’ self-reported race was predominantlyhite (58%), Asian (20%), or African-American (12%).wo residents (5%) reported a personal history ofhronic pain.Participants rated their initial knowledge and skills on1 (minimal) to 10 (expert) scale that demonstrated aean of 5.03 (�1.3). Thirty percent of residents felt that

heir formal education had effectively prepared them toanage chronic pain, and most residents (72%) felt thatost of their knowledge and skills were acquired “on

he job through observation or trial and error.” The mostcknowledged deficiencies were: 1) confidence in ad-ressing aberrant drug-taking behavior; 2) confidence inhysical exam abilities to detect when a patient might bexaggerating symptoms; and 3) converting between in-ravenous and oral doses of opioid analgesics.Participants rated their comfort in pain managementn a 1 (uncomfortable) to 10 (comfortable) scale thatemonstrated a mean of 5.13 ( � 1.4). Sixty-five percentf residents reported frustration with chronic pain pa-ients and 79% of residents reported low satisfaction inaking care of chronic pain patients. The concerns mostften cited were: 1) whether chronic pain patients get

able 2. Results From Pre-Test and Post-TestTOPIC PRE-

1: Description of pain experience2: Pain pathophysiology3: Best indicator of pain intensity4: Treatment principles for opioid side-effects5: Nociceptive versus neuropathic pain6: Changing oral to intravenous morphine7: Appropriate rescue dosing8: Characteristics of opioids9: Side effects of opioids10: Tolerance versus worsening prostate cancer11: Pseudoaddiction versus tolerance12: Opioids in older patients13: Opioids in substance abuse14: Definition of physical dependence15: Changing short acting to long acting opioids

P � .05.

P � .001.

etter; 2) that “ethnic groups vary in their expression of m

eeds regarding chronic pain treatment”; and 3) thatopioid medications cause dependency among my pa-ients with chronic pain.”Only 23% of participants reported confidence in the

bilities of their colleagues to effectively manage pain,nd 79% of residents felt that patients with chronic painook more of their time than other patients. Residentselt that physical therapy (70%) and referral to a painlinic (49%) were effective measures in the treatment ofhronic pain, and only 18% of residents reported “Myhronic pain patients are satisfied with my care.”

re- and Post-TestThe mean overall score on the pre-test was 57.3% (Ta-le 2). The questions with the fewest correct answersere: 1) changing short-acting opioids to long-actingpioids (Q15), 7% correct; 2) differentiating pseudoad-iction from tolerance, dependence, and addictionQ11), 21% correct; 3) selecting the appropriate rescueose of opioid medications (Q7), 21% correct; and 4)ifferentiating nociceptive pain from other types of painQ5), 35% correct. The mean overall score on the post-est was 80.7%, which was significantly higher than there-test (P � .0001). Not surprisingly, significant im-rovements were seen regarding the 4 questions above,ith improvements ranging from a 45% to a 55% in-

rease in the number of correct answers (P � .0001 for all). Residents had the highest percentage of correct an-wers (90%) and showed the least change from pre- toost-test on questions regarding pain pathophysiologyQ2) (P � .74) and strategies on treating chronic pain inatients with substance abuse (Q13) (P � 1.0). Residentender, age, year of training, specialty, and self-ratednowledge of pain management did not predict scores.ronbach’s alpha for the pre-test and post-test were .48nd .52, respectively, suggesting that the tests measured

CORRECT POST-TEST % CORRECT P VALUE

% 93% .02*% 85% .74% 98% .001*% 80% .11% 80% �.001†% 73% .006*% 75% �.001†% 78% .006*% 93% .003*% 53% .11% 68% �.001†% 87% .26% 90% 1.00% 95% .006*% 62% �.001†

TEST %

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hecklist ScoresChecklist scores (Table 3) were calculated for both the

ow back pain session and the neuropathy session. Asoted before, residents were randomized to participate

n either the low back pain or neuropathy standardizedatient scenario first. The mean overall score for the firstession (combining low back pain and neuropathycores) was 74.9%, with scores of 81.3% for pain assess-ent, 47.6% for physical examination, 80.9% for man-

gement, and 89.7% for communication. The meanverall score for the second session (combining low backain and neuropathy scores) were 80.7%, with scores of7.6% for pain assessment, 55.3% for physical examina-ion, 88.9% for management, and 91.2% for communi-ation. Significant increases from the first SP session tohe second SP session were seen in overall score (�5.9%,� .001) and for each component except communica-

ion.There were no differences in the mean overall scoreetween the low back pain case and the neuropathy case78% vs 77.6%, P � .82), and scores by case type were alsoimilar for the 4 major components. There were no sig-ificant relationships between the checklist scores anday of the PEI session, order of the case, or resident gen-er, age, race, or specialty. Senior residents scored better

able 3. Results from Checklist by Session and

SUBSECTION

FIRST SESSION

(LBP � 22, NEURO � 20)SECOND

(LBP � 19.

ssessment 81.3% 87hysical examination 47.6% 55anagement 80.9% 88ommunication 89.7% 91verall score 74.9% 80

bbreviations: LBP, low back pain; Neuro, neuropathy pain.

Three total sessions were not completed: 1 low back in first session, 1 low bac

P � .05.

able 4. Written Evaluations of Small Groups, LSESSION OVERALL (1–10)

ain assessment small group 8.4 1: Imppat

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n the low back pain case than interns (Kruskal-Wallis, P.04), but performed similarly to others on the neurop-

thy case. Cronbach’s alphas for the assessment sectionere, respectively, .62 and .63 and for the physical exam-

nation section .82 and .91. For the management section,ronbach’s alphas were, respectively, .56 and .58 and forhe communication section .48 and .76.

ritten EvaluationsEach small group, large group, and SP session was also

ated on a Likert scale from 1 (not very helpful) to 10very helpful) and from strongly disagree to stronglygree in meeting session objectives. The large group ses-ion on pharmacology was highest rated followed by themall groups on pain management “PEARLS,” pain as-essment, and pain management. The large group onifferent pain conditions and the standardized patientessions were also rated favorably. The pharmacologyecture was rated significantly higher than all other ses-ions (P � .002) except the “PEARLS” lecture. The stan-ardized patient session rating was statistically similar tohe pain management and pain conditions sessions. Ta-le 4 presents the topics that were rated highest in eachession. Cronbach’s alpha for each section of the ques-ionnaire instrument ranged from .85 to .95.

Case*ION

O � 22) PLOW BACK PAIN

(N � 41)NEUROPATHY

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�.001† 84.6% 84.3% .87�.03† 51.9% 50.9% .78�.01† 84.8% 84.9% .96

.5 90.7% 90.2% .83�.001† 78.0% 77.6% .82

econd session, and 1 neuropathy in second session.

e Groups, and Standardized PatientTOPICS RATED HIGHEST

g resident’s confidence in assessing the true impact of pain on aactivities of daily livingg history taking skills regarding elements that are often missed inssmentg my focus on the goals of chronic pain managementg my skills in determining how much to increase and decreaseopioid medicationsnding appropriate prescription writingg my ability in documenting the chronic pain patient encounterng between different routes of administration for a certain

nding how to change from one class of medication to anotherg chronic pain patients with neuropathyg chronic pain patients with low back paindardized patient providing feedback on the checklist

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Overall, 100% of residents felt that the PEI programmproved their knowledge regarding chronic pain man-gement, and almost all (�97%) of the residents statedhey would make specific changes in their assessmentnd management of chronic pain patients. About 75%f residents felt the SP was an essential part of the PEIrogram, and about half of the residents felt that usingPs was a more effective way to learn than lectures. Overhree-fourths of the residents felt the PEI program im-roved their attitudes toward chronic pain managementnd chronic pain patients. Forty percent of the residentselt that the time spent during the PEI program was tooong. The majority of residents (83%) thought the pro-ram was worthwhile and would participate in the pro-ram again, and 97% of residents would recommend therogram to colleagues who might need to learn morebout chronic pain management.

iscussionThis study suggests that the use of standardized pa-

ients to teach resident physicians chronic pain manage-ent is effective. Our search of the literature revealed no

tudies that used SPs in a formal pain management cur-iculum.As expected, resident performance on the pre-test ob-

ectively demonstrated a knowledge deficit in pain man-gement. Similar to previous studies, our residents alsoeported frustration, low satisfaction, and discomfort inreating chronic pain patients.6,21 Notably, level of train-ng did not predict scores on the tests. This appears tondicate that current educational strategies in chronicain are inadequate. If current training was effective inhis realm, one would expect scores to differ by years inraining. As noted previously, even though the contentf the pre- and post-test questions were similar to facil-

tate comparisons, the order of the questions, possiblenswers, and numerical calculations were changed. It isncouraging that the residents showed significant im-rovements from pre-test to post-test in fundamentalain management concepts such as differentiating theype of pain and in medication dosing. Interestingly, self-eported and objective deficiencies among residents alsoppeared to be centered on pharmacology issues. Givenhis finding, and the fact that most primary care physi-ians practice noninvasive pain management, it seemshat a larger focus on pharmacology issues when teach-ng residents and students pain management is war-anted.Checklist scores for the residents improved signifi-

antly from the first to the second SP case in severalategories, and the type or order of the SP case had nonfluence on the scores. The trend among senior resi-ents scoring better in the low back pain checklist mayeflect the high frequency of low back pain in the pri-ary care setting.11,17 This frequency may reflect the

enior residents’ experience and “on the job” training inssessing or managing low back pain. Even though these of SPs was rated slightly lower than the use of small
roups and large group lectures, our results show that e
he residents felt that the use of SPs was an effectiveorm of learning. The lower scores may reflect some res-dents’ discomfort with SPs or lack of experience withPs. Interestingly, communication between the residenthysician and the SP was almost universally rated highly,ut basic skills such as history taking and physical exam-

nation were rated lower. We believe that this reflects aack of assessment skills in general among residents inraining, particularly in the psychosocial and chronic dis-ase aspects of pain. For example, standard history ques-ions such as onset, frequency, and duration of pain wereniversally assessed by our residents, but questions re-arding patient sleep, lifestyle changes, functioning, andatient feelings were addressed more sporadically. Fur-her research and education focusing on these importantspects uniquely associated with chronic pain areeeded. Most importantly, the residents felt that SPsere especially helpful in providing performance-based

eedback in the different competency areas. Buy-in fromhe residents is certainly essential in the implementationf any educational venture.This program used an approach that looked at painanagement from a variety of perspectives. First, tradi-

ional small group and lectures improved knowledge ofhe mechanics of pain (pharmacology, pathophysiology,anagement skills). The workshop overall changed resi-

ents’ personal feelings toward patients with chronicain. Finally, residents showed improved performance inain assessment and management when evaluated byPs. This method of learning not only helps to grasp theontent of the material but also personalizes it.The PEI addresses multiple areas of the ACGME Coreompetencies, including: Patient Care, Medicalnowledge, Practice-Based Learning, Communica-ions/Interpersonal Skills, and Professionalism. The SPomponent of this intervention allows a much moreobust environment in which to evaluate the residentsn their core knowledge and skills.Our study has some limitations. The study was per-

ormed at a single site, but SPs are used in many insti-utions across the nation, so it is feasible that the sameype of program could be easily replicated at othernstitutions to evaluate its generalizability. Also, ow-ng to time and resources, we did not perform re-eated observations by the SPs in order to calculate

nterrater reliability. However, previous projects andraining at the Center have demonstrated interratereliability over 90%. Even though SPs have been usedn a variety of settings, including medical education,uality assessment, and research, their use can be atrength or a weakness depending on other factors. Ifhe portrayal of the patient by the SP is “poor,” if thehysician has low interest in the encounter, or if thehysician is unfamiliar with the use of SPs, differentesults might be seen. Lastly, we are only able to eval-ate the short-term changes seen in the program andannot infer the long-term outcomes that may be di-ectly or indirectly a result of the sessions. This studyas not designed to track long-term changes in knowl-
dge, skills, or behaviors or institution-wide changes

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n prescribing habits, leaving fertile ground for theontinued exploration of improved methodologies,ontent, and outcome measures of this educationalndeavor to improve physicians’ skills in the manage-ent of chronic pain.

onclusionChronic pain management in the primary care set-

ing is a challenge for which many physicians feel un-repared. The challenge is amplified by the lack ofighly developed instructional methods. Our study
uggests that the Pain Education Initiative model is an i
hysician survey. Pain Res Manage 8:189-194, 2003

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ffective and innovative way to educate our residentsbout this common and important topic.

cknowledgmentsWe would like to acknowledge all the staff at the

heresa A. Thomas Professional Skills Teaching andssessment Center and all the standardized patientsho participated in the Pain Education Initiative. Weould like to thank John Ullian, PhD, for his assistance

n reviewing the manuscript. The authors will providehe pain education materials (cases, checklists, lec-ures, tests, slides, and surveys) to any clerkship or res-
dency directors requesting the materials.
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ppendix 1Checklist for Low Back Pain Case and Neuropathyase

hecklist Items: Case #1 Low Back Pain

ssessmentResident able to confirm patient’s symptoms and chief

omplaint of low back pain

OnsetFrequencyDurationCourseLocation (topography)Able to describe quality of pain (dull, ache, etc) (qual-

ity)Quantifies pain on scale of 1-10 at worst, best

(intensity)

Inquires about past history of symptoms, if previousnjury or exacerbating factor involved (temporal pattern)

Inquires if recent factors have aggravated injuryAggravatingRelieving factors (temporal pattern)Rules out any neuropathic quality (such as burning,umbness) (quality)Able to pick up on any warning signs (such as nerveamage, impingement)

bowel/bladder functionfeverweaknessnumbness

Able to describe limitations on current activities ofaily living and functioning (function). (Inquires aboutatient’s previous work or school and now on leave be-ause of pain.)Inquires about sleep habitsInquires about lifestyle changes

sexual activityexercisewalkingInquires regarding patient Beliefs (FIFE)

FeelingsIdeasFunctionExpectations

Inquires about current medication use (treatments)Inquires regarding medication side effects (treat-ents)Inquires about total Tylenol usage (treatments)Inquires about previous treatments used and effect

PMH)Inquires about running out of medicines early and rea-

ons (treatments) n

Inquires about aberrant drug-taking behaviors (multi-le pharmacies, any other doctors, do you feel like you’rebusing drugs)Inquires about PMH possibly related to back disease

such as pertinent negatives—diabetes or previous diag-ostic tests (MRI))Inquires about FH of arthritis or diseases related toack pain (FH)Able to describe relationship with significant other/

pouse (relationships)Inquires regarding alcohol

Use, Frequency, Amount, dependency screening ques-tions

Insert CAGE and dependency alternative questionsInquires regarding tobacco

Use, Frequency, Amount, dependency screeningquestions

Inquires regarding drug use

Use, Frequency, Amount, dependency screeningquestions

hysicalLumbar Spine:

nspect / Palpate / Percuss

CT IT NDŒ Œ Œ PosteriorŒ Œ Œ LateralŒ Œ Œ Palpate and/or compare extensor musclesŒ Œ Œ Palpate and/or percuss each spinous

process

ROMŒ Œ Œ FlexionŒ Œ Œ ExtensionŒ Œ Œ Lateral bendingŒ Œ Œ Rotation

pecial Screening Techniques: Alternativeaneuvers to exacerbate possible disc

ymptoms/malingeringSLR—Straight Leg Raises—supine, raise leg passively,

lso dorsiflex footFemoral Nerve Traction Test— lying on side, passivelyyperextend hip, then flex kneeFABER Test/Patrick Test—flexion, abduction, external

otation of hip. Apply downward pressure to flexed kneeSchober Test— measure flexibility of lumbar spine

rom standing to maximum flexionPsoas Sign— hip flexion against resistance reproducesain responseObturator Sign—painful internal rotation of the hiphile hip and knee are flexed

Neuromuscular Function (may be covered with the
eurologic exam)

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Œ Œ Œ Test strength of hipŒ Œ Œ Test strength of kneeŒ Œ Œ Test strength of ankleŒ Œ Œ Test strength of toes

eflexesDeep Tendon Reflexes—test symmetrically

Œ Œ Œ Patellar reflexŒ Œ Œ Achilles reflexŒ Œ Œ Plantar reflex

erebellar FunctionŒ Œ Œ Rapid alternating movements—lower extremi-

tiesŒ Œ Œ Heel-to-shin bilaterally (knee extended, just pt.

heel)Sensory Status

Œ Œ Œ Sensation: lower extremitiesŒ Œ Œ Monofilament testing: legs for sensation with

monofilamentŒ Œ Œ Sensation: trunkŒ Œ Œ Test position sense at least in toes/feetŒ Œ Œ Test vibration sense in toes/ankles bilaterally

eurologic Screening Exams

Œ Œ Œ Observe gait, patient swings arms fully.Œ Œ Œ Have patient walk on toes.Œ Œ Œ Have patient walk on heels.Œ Œ Œ Observe tandem gait.Œ Œ Œ Have patient climb stairs or hop on each foot or

deep knee bend or duck walkŒ Œ Œ Perform Romberg Test

anagementDiscusses diagnostic impressions with patientEducates patient regarding pain and natural history ofainResident discusses how to deal with adverse reactionsResident discusses issues regarding addiction, toler-

nce, and dependenceTherapy is changed to: _____________________ (fill inlank)Discusses other alternatives such as PT, Steroids,iofeedback, Topical medsIf made, referral made to: _________________________

fill in blank)Discusses follow-up and is made for: __________________

fill in blank)Discusses contingencies and what to do if current ther-

py doesn’t work v

ommunication (scored 1:low to 5:high)Negotiates priorities and sets agendaVerification of informationLack of jargonEmpathy, encouragement and acknowledging patient

uesTransitional statements

hecklist Items: Case #2 Neuropathy—tems in addition to Case #1ssessmentResident able to confirm patient’s symptoms and chief

omplaint of left lower leg painInquires regarding patient diabetic control: Testingethods: type, frequency, results

hysicalInspectionYes NoCT IT NDŒ Œ Œ Lower extremities (verbalize observations)

alpate pulses bilaterallyŒ Œ Œ Femoral pulseŒ Œ Œ Popliteal pulseŒ Œ Œ Posterior tibial pulseŒ Œ Œ Dorsalis pedis pulseŒ Œ Œ Check for peripheral pitting edema

ipsROM—stabilize torso

Œ Œ Œ ExtensionŒ Œ Œ FlexionŒ Œ Œ Internal RotationŒ Œ Œ External RotationŒ Œ Œ AdductionŒ Œ Œ Abduction

euromuscular FunctionŒ Œ Œ Test strength of hipŒ Œ Œ Test tone of hip

anagementEducates patient regarding neuropathic pain and need

or important diabetic controlResident discusses the use of acetaminophen and usef �4 grams/dayDiscusses other alternatives such as Topical meds, adju-

ant meds, alternative meds

Documents

The EVMS Pain Education Initiative: A Multifaceted Approach to Resident Education