Undergraduate pain curriculum: What needs to be included and what doesn’t?

One of the prominent themes in social media discussions about pain is that the subjects are not given sufficient attention at undergraduate level. The results of this omission are that many entry-level clinicians don’t have the necessary knowledge, skills or attitudes for working with people who experience pain. (As an aside, it also makes my job as a postgraduate Academic Leader much more difficult: where do I start when developing a programme?!)

Luckily there is an IASP Pain Curriculum. Actually there are many of them, for many disciplines, and they provide educators with great guidance. The problem is, however, there is so much that could be included in this kind of education – and we usually don’t have much room in a programme to include it all.

The main problems with the curriculum are: the content and levels of competency required at an undergraduate level aren’t specified; most research into this area targets postgraduates, with less attention for undergraduate pain education. Most curriculum for pain have been discipline-specific, and while a consensus on the content and desired competencies of an interprofessional pain curriculum at a pre-licence or undergraduate level has been discussed, an a-priori defined competency level across professions for the items in the IASP curriculum hasn’t been established. We need cross profession agreed competencies to allow for good collaboration. (see van Lankveld, Afram, Staal, van der Sande, 2020).

In my role as Academic Coordinator for Postgrad Programmes in Pain and Pain Management, one aspect of the interprofessional curriculum that is quite difficult to navigate is how to turn topic headings into knowledge, skills and attitudes. I’m wary of teaching directly to subject (knowledge) without accompanying this with appropriate skills and attitudes – particularly at postgraduate level, given knowledge (topics) are continuing to change over time. There’s clearly some material that is highly valued by one profession over other professions – and this is normal for every discipline! And I’m not sure we can ever hope to cover every single thing.

One consistent theme in research into attitudes and beliefs among musculoskeletal clinicians is that confidence to assess and then use information from the psychosocial domain is low (Alexanders, Anderson & Henderson, 2015; Buchbinder, Staples & Jolley, 2009; Miki, Kondo, Takebayashi & Takasaki, 2020; Singla, Jones, Edwards & Kumar, 2015). This problem is not isolated to physiotherapists, but cuts across all professions, including psychologists referred patients with “medically unexplained symptoms” (Brittni & Williams, 2020). I wondered if this area has been given sufficient emphasis in our curriculum, and most especially, whether opportunities to develop skills and attitudes that support equitable and effective pain management are developed.

van Lankveld, Afram, Staal, van der Sande (2020) used interprofessional expert panel groups, followed Delphi process, and incorporated a measure of competency (the Dublin Descriptors), to establish which of the many areas of the pain curriculum should be prioritised. This makes for interesting reading, as some of the areas considered integral to better pain management, such as the socio-political and ethical were not considered crucial, while those related to Epidemiology, Development of Pain Theories, and Mechanisms were all thought crucial. I find this interesting as stigma, equity of access to treatment, ethical use of analgesics are all areas of healthcare that directly influence what we do in treatment and in particular, what gets funded and what does not.

Developing a teaching programme from a list of topics considered important involves opinions, values, and an understanding of pedagogy. Given we live in an ever-changing information environment, I think skills and attitudes towards what is today considered “fact” need to be emphasised – how do we learn to think critically? At least part of critical thinking is reading around a topic to become familiar with current and historic models and knowledge. I also think that some of the more complex issues we need to deal with as societies are often those attitudes towards people who violate our assumptions about who is and isn’t “other”. Learning is not only about content, it’s about attitudes towards the subject matter. And some of these attitudes are buried deeply beneath community assumptions and values. To uncover these attitudes, then help people reflect critically on them and their clinical implications is, I think, one of the tasks educators need to address.

For that reason, in my 5th year undergraduate medical teaching, I ask students to undertake a case study where their job is to listen to the person with pain, identify risk factors and protective factors for recovery and return to optimal functioning and participation, and then offer individually tailored recommendations to the person, in language the person will understand. My hope is that these future medical practitioners will have developed some empathy and strategies for caring for and encouraging patients with pain to be less afraid of their pain, and more able to go on with their lives.

What should go in undergraduate training? I think we can weave all the content of these curriculum into our undergraduate training, but we should also leave students with the certain knowledge, skills and attitudes that this area of study is going to change. And that means lifelong learning about pain, people, science and self.

Alexanders, J., Anderson, A., & Henderson, S. (2015). Musculoskeletal physiotherapists’ use of psychological interventions: a systematic review of therapists’ perceptions and practice. Physiotherapy, 101(2), 95-102. doi: 10.1016/j.physio.2014.03.008

Buchbinder, R., Staples, M., & Jolley, D. (2009). Doctors with a special interest in back pain have poorer knowledge about how to treat back pain. Spine (Phila Pa 1976), 34(11), 1218-1226; discussion 1227. doi: 10.1097/BRS.0b013e318195d688

Crawford, C., Ryan, K., & Shipton, E. (2007). Exploring general practitioner identification and management of psychosocial Yellow Flags in acute low back pain. N Z Med J, 120(1254), U2536.

Cowell, I., O’Sullivan, P., O’Sullivan, K., Poyton, R., McGregor, A., & Murtagh, G. (2018). Perceptions of physiotherapists towards the management of non-specific chronic low back pain from a biopsychosocial perspective: A qualitative study. Musculoskelet Sci Pract, 38, 113-119. doi: 10.1016/j.msksp.2018.10.006

Jones, Brittni, & Williams, Amanda C. de C. (2020). Psychological therapists’ judgments of pain and treatment decisions: The impact of ‘medically unexplained symptoms’. Journal of Psychosomatic Research, 131, 109937. doi: https://doi.org/10.1016/j.jpsychores.2020.109937

Miki, T., Kondo, Y., Takebayashi, T., & Takasaki, H. (2020). Difference between physical therapist estimation and psychological patient-reported outcome measures in patients with low back pain. PLoS One, 15(1), e0227999. doi: 10.1371/journal.pone.0227999

Singla, Mukul, Jones, Mark, Edwards, Ian, & Kumar, Saravana. (2015). Physiotherapists’ assessment of patients’ psychosocial status: are we standing on thin ice? A qualitative descriptive study. Manual therapy, 20(2), 328-334.

van Lankveld, W., Afram, B., Staal, J. B., & van der Sande, R. (2020). The IASP pain curriculum for undergraduate allied health professionals: educators defining competence level using Dublin descriptors. BMC Med Educ, 20(1), 60. doi: 10.1186/s12909-020-1978-z