Development of a comprehensive e-learning resource in pain management.

OBJECTIVE: The prevalence of chronic nonmalignant pain (CNMP), the lack of confidence and reward among trainees and providers caring for patients with CNMP, and the lack of a comprehensive curriculum in pain management prompted the creation of the Virginia Commonwealth University (VCU) Chronic Nonmalignant Pain Management curriculum, an innovative e-learning resource. This article describes the development of the curriculum and presents initial evaluation data. DESIGN: The curriculum is organized into six modules that cover 20 specific Accreditation Council of Graduate Medical Education competency-based objectives. Broad content and effective instructional design elements promote its utility among a range of learner levels in a variety of medical disciplines. RESULTS: Twenty-four physician reviewers and over 430 trainees (medical students and graduate medical residents) have evaluated the curriculum. Of the respondents to course evaluation questions, 85.7% (366/427) stated that they would access the practice resources again, 86.3% (366/424) agreed that the treatment of CNMP was more important to them after completing the curriculum, 73.9% (312/422) stated that they would make changes in their behavior or practice, and 92.3% (386/418) stated that they would recommend the curriculum to their colleagues. Qualitative data are uniformly positive. Results of pretest and posttest scores and item analyses have been used to make content changes. CONCLUSIONS: The VCU Chronic Nonmalignant Pain Management curriculum is an e-learning resource that has the potential to fill a significant training void. Design and content changes have been made as a result of initial evaluation data. Data from ongoing evaluation will allow curricular refinement.

A shot in the dark: failing to recognize the link between physical and mental illness.

A 74-year-old widowed white man with chronic rheumatoid arthritis presented with nausea and weight loss. He was diagnosed with failure to thrive and admitted for hydration. Misoprostol was determined to be the etiology of his symptoms and he was discharged home. Three days later, he killed himself with a gunshot to the head. Clinicians often fail to recognize those at high risk for suicide. Suicidal risk is increased in both psychiatric and physical illness, and particularly when both are present. Psychiatric illness, particularly depression, often underlies chronic medical illness. The purpose of this case report is to remind health care providers of the strong association between depression and chronic medical illness, and to consider this in all patients, including those who present solely with physical symptoms. Recognizing this association and screening for it, as recommended by the U.S. Preventive Services Task Force, may prevent the unnecessary tragedy of suicide.

Preparation, confidence, and attitudes about chronic noncancer pain in graduate medical education.

BACKGROUND: Physicians report they feel ill-prepared to manage chronic noncancer pain (CNCP), in part because of inadequate training. Published studies and clinical observation demonstrate that trainees lack confidence and reflect negative attitudes about CNCP. Overall, there is minimal published guidance on specific specialty roles and responsibilities in CNCP management. OBJECTIVE: The purpose of this study was to assess resident preparation, confidence, and attitudes about CNCP across graduate medical education programs and to assess resident perception of roles and responsibilities in CNCP management. METHODS: In 2006 we surveyed residents from 13 graduate medical education programs in 3 institutions about CNCP and report quantitative and qualitative analyses of survey responses from 246 respondents. RESULTS: A total of 59% of respondents rated their medical school preparation and 36% rated their residency preparation as "fair" or "poor"; only 17% reported being "confident" or "very confident" in assessing patients with CNCP; and 30% used negative or derogatory terms (eg, manipulative, irritable, needy) to describe patients with CNCP. Respondents from postgraduate years 3-6 were more than twice as likely as postgraduate year 1 or postgraduate year 2 respondents (44% versus 21% and 20%, respectively) to use negative or derogatory terms (P  =  .0007). Respondents were significantly more likely to report that pain specialists are "good" or "excellent" in managing CNCP compared with generalists (73% versus 6%; P < .0001). CONCLUSION: Education in pain management should begin in medical school and continue through graduate medical education, regardless of specialty. Early and sustained training interventions are needed to foster empathy in caring for patients with pain. Residency and fellowhip training should impart a clear understanding of each specialty's role and responsibilities in pain management to better foster patient-centered pain care.

Fibromyalgia: diagnosis and management for the primary healthcare provider.

Fibromyalgia is a disorder of chronic generalized musculoskeletal pain affecting 2% of the general population, with an increased frequency in women. Clinical diagnosis relies on history and research-supported tender point criteria. As in other chronic pain syndromes, a multidimensional approach optimizes treatment response. Empirical data and consensus support the use of nonpharmacological modalities, such as education, aerobic exercise, and cognitive behavioral therapy, in the management of fibromyalgia. Evidence-supported pharmacological interventions include tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, alpha-2-delta ligands, and other serotonergic-noradrenergic analgesic agents, such as tramadol. This paper offers the primary healthcare provider a systematic approach to the diagnosis of fibromyalgia and management strategies based on available evidence, consensus, and empirical data.

Management of chronic nonmalignant pain: a needs assessment in an internal medicine resident continuity clinic.

INTRODUCTION: The authors hypothesized that Internal Medicine (IM) residents experience a lack of preparation, confidence, and reward when managing patients with chronic nonmalignant pain (CNMP) in their continuity clinic and that they exhibit deficiencies in CNMP management practices, particularly when opioids are prescribed. METHODS: As part of a quality improvement project in the IM resident continuity clinic, the authors performed a needs assessment through a self-administered resident questionnaire and a retrospective chart review. RESULTS: Fifty-seven percent of respondents rated their CNMP preparation as "fair" or "poor," 89 percent reported that their experience was "much less" or "somewhat less" rewarding than managing patients with other chronic conditions, and 58 percent reported that CNMP management "negatively" or "very negatively" affected their view of primary care as a career. Twenty-eight charts of patients receiving opioids during a 1-year study period were reviewed. Although residents were likely to document pain diagnoses (93 percent) and pain scores (82 percent) as well as utilize medication agreements (82 percent), they were less likely to document illicit substance use (39 percent), document legal history (32 percent), or obtain prior medical records (39 percent). Few urine drug screens were ordered (18 percent) and 25 percent of patients had fewer than four face-to-face visits during the year. DISCUSSION: The questionnaire indicated that IM residents lack preparation in managing CNMP, which results in lack of confidence and reward. The chart review revealed management practice deficiencies in risk assessment and prescription drug misuse monitoring. As a result, the authors have implemented curricular interventions, integrated a pain clinic within the continuity clinic, optimized residency program clinic scheduling, and developed tools for consistency in management practices.