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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. 1 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 2 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 3 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 4 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: 5 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 6 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 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). 7 8