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PROMEDICA MONROE REGIONAL HOSPITAL
FAMILY MEDICINE RESIDENCY
PAIN MANAGEMENT CURRICULUM (PGY-2 & 3)
Description of Educational Experience
The Pain Management rotation is an elective experience for family medicine residents
that will provide a greater understanding of the fundamentals of treating painful
disorders in both the inpatient and ambulatory settings. Pain Medicine is concerned
with the prevention, evaluation, diagnosis, treatment, and rehabilitation of acute and
chronic pain disorders.
Residents will have the opportunity to develop assessment, diagnostic, and
management skills specific to pain syndromes, as well as, technical skills for pain
management procedures which may include therapeutic nerve blocks,
epidural/subarachnoid anesthetic blocks, continuous monitored drug infusions,
stimulation procedures, therapeutic heat and cold, manipulation and massage,
relaxation, biofeedback, casting & splinting or conditioning/exercise therapy.
Family medicine physicians should be able to effectively evaluate and manage the
immediate care of patients with common pain disorders and refer patients appropriately
for specialty care. This includes recognition and referral of patients with depression
and/or addiction disorders from chronic pain problems, and referrals for palliative or
hospice care at end-of-life.
Educational Goals:
The purpose of the Pain Management rotation is to provide residents the opportunity to
gain experience and competence in the management of patients with acute or chronic
pain, or palliative care for patients at end-of-life. Pain disorders may occur from a
discrete cause such as postoperative pain or pain associated with a malignancy, or it
may be part of a syndrome in which pain is a primary problem such as neuropathic
pain or migraine headaches.
The diagnosis and management of pain disorders is complicated in special patient
populations including culturally diverse groups, nonverbal patients including infants or
ventilator-dependent patients, altered consciousness or cognition, and age-dependent
factors for pediatric, pregnant, lactating, and geriatric patients.
Family Medicine physicians should develop an awareness of pain as a factor in quality
of life and activities of daily living. Psychosocial factors including family support,
finances, underlying depression, coping skills, and substance abuse are all
considerations for the physician providing longitudinal health care to continuity
patients experiencing pain.
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Patient Care
Goal
Residents must be able to provide patient care that is compassionate, appropriate, and
effective for the treatment of health problems and the promotion of health.
Competencies
Residents are expected to:
 Gather essential and accurate information about their patients
 Develop and carry out patient management plans
Objectives
The PGY2/PGY3 resident will be able to:
 Effectively evaluate diagnosis and:
1. Demonstrate competency in medical history and physical examination
skills when formulating a pain disorder diagnosis including:
a.
Review of historical data
b.
Interpretation of previous laboratory, imaging and electro
diagnostic studies
c.
Behavioral, social, occupational and vocational assessment
d.
Interview and physical examination
e.
Recognition of pain as 5th vital sign
f.
Use appropriate pain scales to assess pain based on
individual patient needs (non-verbal, age appropriate,
culturally sensitive)
2. Develop a diagnostic work-up and treatment plan for pain disorders
individualized to the patient
3. Provide longitudinal care by assessing and reassessing the patient’s pain
and quality of life throughout various treatments, episodic illnessrelated events and changes in prognosis
4. Perform common pain management procedures under supervision,
which may include:
a.
Therapeutic nerve blocks
b.
Anesthetic portals including spinal, epidural, Baer Blocks,
or pleural injections
c.
Casting & splinting
d.
Joint injections
e.
TENS units
5. Understand psychosocial effects of chronic pain syndromes or end-oflife pain and associated symptoms on the patient, family, and/or
caregivers
Medical Knowledge
Goal
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Residents must demonstrate knowledge of established and evolving biomedical,
clinical, epidemiological, and social-behavioral sciences, as well as, the application of
this knowledge to patient care.
Competencies
Residents are expected to:
 Demonstrate an investigatory and analytic thinking approach to clinical
situations
 Know and apply the basic and clinically supportive sciences which are
appropriate to their discipline
Objectives
The PGY2/PGY3 resident will be able to:
 Have the opportunity to develop knowledge and skills in the following areas:
1. Evaluation, differential diagnosis, treatment and management of pain
disorders that may include:
a.
Types of Pain
i. Neuropathic pain
ii. Nociceptive pain
b.
Complex regional pain syndromes
c.
Unrelenting pain
d.
Specific causes of pain
i. Trauma
ii. Post- amputation
iii. Spinal cord injury
iv.
Burns
v.
Cancer
vi.
Vascular/ischemic
vii.
Hematological – Sickle cell, AIDS/HIV
viii. Rheumatologic/myofascial pain syndrome
ix. Diabetic neuropathies
x. Herpes zoster/postherpetic neuralgia
xi. Peripheral nerve pain
xii. Radiculopathy (cervical, thoracic, lumbar)
xiii. Pain in children
xiv. Pain in the elderly
xv. Pain in pregnant or lactating women
e.
Pain assessment
2. Understand the pharmacological management of acute and chronic
pain, including opioid and non-opioid analgesics, and current
pharmacological interventions including:
a.
Patient controlled analgesia (PCA)
b.
Indications, doses, side effects and contraindications for
various pain medications
c.
Equigesic dosing for IV/PO narcotics
d.
Methadone
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e.
Alternate routes of medication administration including:
i. Parental and IV routes
ii. Implanted ports for continuous infusions
iii. Rectal
iv.
Inhaled
v.
Oral
vi.
Nerve blocks
f.
Opioid pharmacology and management of opioid-related
side effects
i. Principles of addiction medicine
ii. Tolerance and physical dependency
iii. Detoxification and withdrawal syndromes
g.
Role of other pharmacological agents:
i. Anxiolytics
ii. Antidepressants
iii. Antipsychotics
iv.
Anticonvulsants
v.
Antispasmodics
vi.
Stimulants
vii.
Steroids
viii. Autonomic and cardiovascular drugs
ix. Neurolytics
x. Local anesthetics
xi. NSAIDS and acetaminophen
3. Knowledge of associated pain management issues such as:
a.
Ethical, moral, religious and legal aspects of pain control,
including the principle of “Double Effect” and terminal
sedation for unrelenting pain/symptoms
b.
Appreciation of dignity of life and issues related to death
and dying – includes hospice and palliative care
c.
Do not resuscitate – comfort care only orders
4. Understand legal issues surrounding the prescribing and use of
controlled medications for acute and chronic pain management
including:
a.
Use of patient contracts for scheduled narcotics
b.
Documentation
c.
State specific practice guidelines for prescribing scheduled
drugs
d.
Disposal of unused drugs
e.
Termination of physician-patient relationship for
noncompliance, malingering, diversion of controlled
substances
5. Understand the surgical management of acute and chronic pain,
including:
a.
Decompressive surgical procedures
b.
Central nervous system ablative techniques
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c.
Neurolytic techniques (chemical, cryogenic,
radiofrequency)
d.
Device implantation
e.
Palliation therapy
6. Complimentary/alternative medicine management of acute and chronic
pain including:
a.
Stimulation procedures
b.
Counseling and behavioral therapy
c.
Guided imagery
d.
Hypnosis
e.
Relaxation techniques
f.
Physical therapy
g.
Biofeedback
h.
Therapeutic heat and cold
i.
Manipulation and massage
j.
Nutrition
k.
Acupuncture
Practice-based Learning and Improvement
Goal
Residents must demonstrate the ability to investigate and evaluate their care of
patients, to appraise and assimilate scientific evidence, and to continuously improve
patient care based on constant self-evaluation and lifelong learning.
Competencies
Residents are expected to:
 Identify strengths, deficiencies and limits in one’s knowledge and expertise
 Set learning and improvement goals
 Identify and perform appropriate learning activities
Objectives
The PGY2/PGY3 resident will be able to:
 Appropriately identify gaps in knowledge
 Utilize available resources during the rotation to support and improve his/her
own learning (PDA, on-line resources etc.)
 Use computers for word processing, reference retrieval, statistical analysis,
graphic displays, database management and communication
Systems-based Practice
Goal
Residents must demonstrate an awareness of and responsiveness to the larger context
and system of health care, as well as, the ability to call effectively on other resources in
the system to provide optimal health care.
Competencies
Residents are expected to:
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
Utilize a multidisciplinary approach to pain management and collaborate with
the healthcare team and community resources to provide effective,
comprehensive patient care.
Objectives
The PGY2/PGY3 resident will be able to:
 Demonstrate ability to work with a team of health care professionals to improve
quality of care
 Develop an awareness of and responsiveness to the larger context and system of
health care, as well as, the ability to call effectively on other resources in the
system to provide optimal health care
 Identify elements key to patient safety such as the National Patient Safety Goals
for accuracy of identification and infection control
 Demonstrate appropriate use of referrals/consultations, including access to
social programs for the underinsured/uninsured
 Accept personal responsibility for improving patient safety and quality of care
Professionalism
Goal
Residents must demonstrate a commitment to carrying out professional responsibilities
and an adherence to ethical principles.
Competencies
Residents are expected to:

Show compassion, integrity and respect for others

Show respect for patient privacy and autonomy
Objectives
The PGY 2/3 will be able to:
 Follow all HIPPA guidelines
 Address the individual social and cultural needs of the patient
Interpersonal and Communication Skills
Goal
Residents must demonstrate interpersonal and communication skills that result in the
effective exchange of information and teaming with patients, their families and
professional associates.
Competencies
Residents are expected to:

Communicate effectively with patients and families across a broad range of
socioeconomic and cultural backgrounds
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
Communicate effectively with physicians, other health professionals and
health related agencies
Recognize situations where consultations and referrals to other specialists are
necessary to effectively manage the care of the patient

Objectives
The PGY2/PGY3 resident will be able to:
 Convey the most important pieces of information to other health care
professionals during patient presentations
Learning Opportunities (residents)




Direct patient care
Informal discussions
Mentoring/modeling
Formal didactics
Assessment Method (residents)



Attending evaluation of the resident on New Innovations
Procedure evaluations: Procedure Log review at the end of the rotation
Resident performance on the annual In Training Examination
Assessment Method (Program Evaluation)




Resident evaluation of rotation and the attending physician
Evaluation of the In Training Examination performance by resident year and by
overall program
Annual program review and assessment by residents and faculty
Graduate performance on ABFM certification examination
Level of Supervision
The resident functions under the direct supervision of the attending physician.
Educational Resources
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Evidence at point of care: UpToDate, Epocrates
Family medicine residents are encouraged to complete the appropriate
questions under the Pain Management section of Core Content Review at
www.corecontent.com
American Board of Pain Medicine website at www.abpm.org
American Academy of Neurology (Pain Medicine Section) website. at
www.aan.com
Major textbooks of Internal Medicine (Harrisons’, Cecil’s, etc.) and Family
Medicine (Rakel’s).
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