Outline Curriculum on Pain for Medical Schools

Pilowsky, I. An outline curriculum on pain for medical schools.  PAIN 1988;33:1-2.

IASP Ad hoc Subcommittee on Medical School Courses and Curriculum

Although most formal decisions as to the management of pain are made by doctors, it has been obvious for a long time that medical undergraduate teaching on the subject of pain leaves much to be desired. Many medical schools teach very little about pain at either the preclinical or clinical levels and information is poorly integrated.

Changing medical undergraduate curricula is never an easy task. It is one which needs to be catalysed and facilitated in a variety of ways. As part of its aim to increase educational standards in the field of pain IASP® set up an Ad Hoc Sub-committee on Medical School Courses and Curriculum in November 1985. The members of the committee represent the entire range of disciplines with and interest in pain and include the people listed above.

The committee set itself the task of producing an outline model pain course which would indicate in the form of a list of topics, the issues which should be covered in a medical undergraduate curriculum. Each member of the committee was asked to provide a list of subjects. These were combined into a single list which was circulated to all members and after revision an agreed version was submitted to Council at its August 1987 meeting where it was accepted.

The chief purpose of this editorial is to make the Pain Curriculum Outline available to a wide audience in the hope that it might stimulate comments, criticisms and suggestions. The committee hopes that those involved in Medical School Curriculum planning might use the Outline to draw the attention of their colleagues to the areas which ought to be covered if medical graduates are to be adequately prepared for the management of pain. We realize, of course, that there are as many ways of covering the topics in the Outline as there are medical schools. We hope, however, that the Model Curriculum we have proposed will provide useful guidelines and we have purposely avoided offering suggestions on how these might be put into practice in terms of hours or location in the curriculum.

Outline Summary
Introduction and overview
Definition of pain
Ethical issues
Basic sciences
Clinical sciences
The clinical presentation of pain

Management
1. General principles
2. Clinical pharmacology
3. Neurostimulation techniques
4. Nerve blocks
5. Surgical techniques
6. Psychotherapeutic and behavioral approaches
7. Physical therapy

Pain in special contexts
The evaluation of methods for treating pain

Proposed Curriculum on Pain for Medical Undergraduates

1. Introduction and overview
Pain as a public health problem
Epidemiology: societal consequences
Economic impact
Medico-legal and compensation issues

2. Definition of pain
Relationship between acute and chronic pain
Philosophical issues
Historical aspects of the study of pain
Biological significance of pain (survival value) (should also be interwoven into all appropriate topics)

3. Ethical issues
Pain research in humans and animals
Pain disability and litigation
Pain in children
Pain and opiate dependence

4. Basic sciences
Neuroanatomy
Neurophysiology
Biochemistry
Pharmacology
Psychology, sociology, anthropology

Topics
Peripheral receptors, afferent fibers, spinal terminations and spinal processing of nociceptive information, ascending tracts, transmitters (peptides and amino acids), supraspinal sites of termination of ascending tracts, descending control of nociceptive information and pain modulation.

Affective, cognitive, behavioral, and developmental aspects. Pain attribution. Self-esteem, self-efficacy, and perceived self-control.

Interpersonal issues, sick role, illness behavior (normal and abnormal), the influence of political, governmental, and social welfare programs, the role of the family.

Cultural differences in pain meanings and treatment approaches.

5. Clinical sciences
Pathology (somatic and psychosocial)
Trauma and injury (compressed or severed nerve)
Deafferentation pain
Musculoskeletal pain
Visceral and referred pain
Migraine, muscle contraction headache
Temporomandibular pain
Psychiatric disorders
Herpes zoster
Pain in neurological disease
Pain and cancer

6. The clinical presentation of pain
Descriptions of major syndromes (acute and chronic)
Illness behaviors associated with pain (denial and amplification)
Pain as a coded message of psychosocial distress

7. Management
a. General principles
The measurement, quantification and recording of pain
The multiperspective approach (multidisciplinary pain clinics)
The clinician-patient relationship
b. Clinical pharmacology
Nonsteroidal anti-inflammatory drugs
Systemic and spinal opioids, endorphins
Local anesthetics
Other drugs (anticonvulsants, antidepressants, agents influencing 5-HT and endorphins)
c. Neurostimulation techniques
Transcutaneous nerve stimulation
Epidural stimulation
Brain and spinal cord stimulation
Acupuncture
d. Nerve blocks
Local anesthetics
Neurolytic solutions
e. Surgical techniques
Nerve decompression
Neurosurgical techniques
Orthopedic techniques
f. Psychotherapeutic and behavioral approaches
Individual, family, and group psychotherapy
Cognitive-behavioral therapy
Relaxation techniques (biofeedback, etc.)
Hypnotherapy, operant approach, stress management
g. Physical therapy
Exercise, massage, heat, hydrotherapy, etc.

8. Pain in special contexts
Postoperative (including prophylaxis)
Children and infants (signs of pain, evaluation and management, physiology, acute and chronic pain)
Cancer-related pain (death and dying, palliative care)
Aged
Intellectually retarded
Pregnancy and childbirth
Occupational issues (e.g., overuse syndromes, posttraumatic stress disorders)

9. The evaluation of methods for treating pain
The measurement of pain, disability, associated distress and suffering
Choice of outcome measures
The evaluation of analgesic therapy
Assessment of pain relief