A Global Year for Pain Education: Progress, Trends, and the Way Forward

Pain education is entering a new era of progress and impact, heralded by the recent announcement of a Global Year for Excellence in Pain Education by the International Association for the Study of Pain [1]. In collaboration with that effort and to further spur scholarship and innovation in this area, Pain Medicine is releasing a special collection of pain education and training articles published by the Journal [2]. Since 2000, Pain Medicine has consistently identified and published scholarly work pertaining to pain education. Indexed by PubMed, more than 300 articles pertaining to pain education, curriculum, or competency have been published in the Journal since 2000. Some of these articles incorporate educational outcomes and interventions [3], whereas other articles have focused on advancements in education and training outright. The content articles from the early period, that is, 2000–2005, demonstrates that most articles addressed medical pain management with a focus on the education of medical students, residents, and fellows [4–6]. The emphasis on medical pain management is reflective of that era when the historical models of health care still predominated with attention to medicalization of “patient complaints” and perpetuation of paternalistic models of care [7]. Topics included reports of educational interventions intended to increase physician knowledge of pain clinical medicine and enhance skillfulness in procedural pain management, in addition to nascent plans to develop pain medicine residencies and the publications describing efforts to incorporate training experiences into the clinical framework. Cancer and ethics were important areas of early progress in identifying the need for education and defining the terms of educational excellence. At this stage, education was viewed as an endeavor that conveyed medical knowledge from attending physicians to trainees, and sometimes to patients. Nonetheless, protean changes were occurring in health care, in education, and society at large, leading to more inclusive and collaborative approaches to learning, teaching, and assessment of trainees [8–10]. Long-sought success in attracting national mandates for better education was spurred by patient and veterans advocacy organizations that supported Congressional passage of three bills. First, in 2009, the Veterans Pain Care Act and the Military Pain Care Act required that the Veterans Administration and the Department of Defense provide a focused pain management program in each Department and present an annual report back to Congress on progress in achieving more effective pain management; second, the Affordable Care Act required that the Institute of Medicine (now the National Academy of Medicine) complete a comprehensive review of pain management in the United States, which led to its report identifying the burden of pain as a public health problem and outlining the state of pain management education and clinical care in the United States [11]. A subsequent publication by the National Institutes of Health (NIH), the National Pain Strategy, outlined steps to improve pain management, including a section dedicated to education and training [12]. Further efforts to develop educational material for national and international use include the work of the NIH’s Pain Consortium, the International Association for the Study of Pain, and the Pain Management Work Group of the Department of Veterans Affairs and Department of Defense’s Health Executive Council [13–16], as well as the American Academy of Pain Medicine and the many efforts outlined in this virtual issue of Pain Medicine focused on pain education and training [17–21]. The recent CARA law passed by Congress to address the opioid overuse epidemic contains a further mandate for improved pain management [22], and a National Pain Management Task Force has been convened to begin work. Since 2008, a dramatic growth in interest in pain education research has been well documented in the pages of Pain Medicine. The content of recent education and training publications in Pain Medicine demonstrates enormous progress in scholarship, collaboration, and innovation. Increased professionalism in this area is evident as groups focus on the needs of patients and caregivers in navigating complex health systems and facing chronic conditions that are difficult to manage. There is more interest in the development and implementation of culturally appropriate educational programs, linkages between high- and low-resource care settings, and addressing the needs of those impacted by opioids both through safety programs, such as naloxone kits, and efforts to taper opioids, better inform opioid prescribing [23], and adopt active patient-centered pain management strategies. The application of standards of scientific process is evident in the use of methods such as randomized education trials, use of educational comparator groups, development of materials through focus groups, and inter-rater reliability measures. Most importantly, there is an expansion in the professional commitment to pain care to include the fuller interprofessional care team, to explore the educational needs of these teams, to develop appropriate educational experiences, including simulation-based learning, and to evaluate the effects of education or lack thereof on clinical outcomes [18,19,24]. Taken as a whole, the recent work in pain education and training demonstrates several major trends that are evident in pain education today and will influence the field in the years to come; these are collaboration, scholarship, and a focus on health innovation that is both patient-centered and globally aware (Table 1). Major trends in pain education research The first major trend is collaboration and inclusion. Collaboration and inclusion is a broad trend that is manifest in several realms and leads to transformative improvements in health care at all levels. Collaboration and inclusion occurs between patients, caregivers, and providers seeking to define and disseminate educational materials that are culturally sensitive and meaningful for patients and providers [16]. Collaboration and inclusion are occurring between educators and trainees at all levels of education endeavoring to understand the needs of learners and to better define the modes of learning and more effective practices in didactic settings [9,25]. Collaboration and inclusion can occur between health professionals of all kinds, in the form of interprofessional education, collaboration, or research [18]. Collaboration between educators and statisticians and between researchers at multiple institutions leads to more robust, portable, and reliable outcomes. In short, collaboration is essential as we build a common language and expertise to deliver resilient and efficient solutions in complex health care environments. Collaboration and inclusion mean that educational scholarship and innovation develop more resilient and relevant solutions and that intentionality is essential for successful inclusion of women, minorities, those with disabilities, and relevant groups [10]. As noted above, legislative progress so essential to the current advances would have been impossible without broader engagement, collaboration, and inclusion. The second major trend is scholarship and intellectual accountability. Scholarship and intellectual accountability in pain education research are growing in many directions. With developing efforts to understand the relative roles of content, curriculum, and competency in contributing to building, organizing, and assessing pain education assets, a common expertise is evolving. Content is the granular detail of education, often captured in learning objectives and goals [17]. Curriculum is the organization of content into a course of study. Important challenges persist as pain specialists strive to incorporate pain content into overcrowded clinical courses of study. As noted many times, the amount of pain content in standard clinical training programs is far below what is needed to prepare practitioners for the enormous prevalence of pain in clinical practice [25–27]. Competency is the vision of educators in the modern era, preparing health care providers to engage patients in actively finding solutions to optimize health and solutions that are sensitive to the patient’s needs as a person: individually, culturally, and socially, as well as physically, mentally, and emotionally [18]. At the highest conceptual level, there is an effort to understand the vision and goals of pain education on theoretical and pragmatic levels. Basic principles of formal study design and planning for data analysis, as well as the contextualization of current work according to prior relevant scholarship, are evident in recent work. Indeed, one of the goals of this virtual collection of pain education and training articles is to assist researchers in identifying the relevant scholarship in this field. In addition, the principles of learner-centered education, recognition of the needs of and optimization of education for specific populations of learners, acknowledging the role and value of interprofessional engagement, and the application of ethical and public health principles in pain education and training are all essential trends in pain education scholarship. The work represents conceptual thinking about the educational process including addressing whether the study pertains to needs assessment, implementation, development of content, curriculum, or competency, and whether it considers the role of cognitive, behavioral, and socioemotional development of the learning population and the implications for patient-centered care. The third major trend is innovation. Innovation that is both globally aware and patient-centered is a vital major trend that characterizes much of the most effective published work in this area. From smartphone applications to remote-to-center tele-mentoring programs to online learning modules [13,14,20,28], there are many opportunities to develop and test new ideas in delivering pain education that is timely, relevant, and situationally appropriate. Reflective of the best new efforts are novel and appropriate educational models such as tele-mentoring [20] and pain education apps with potential to link high- and low-resource-based providers and have a global impact on improving pain care. Innovation must be inclusive of women and minority populations—in the professional team, in the patient populations addressed through education, and in the development of educational content. Pain education comes of age. Word cloud representation of pain education abstracts as published in Pain Medicine 2000–2005 and 2017–2018. Area of the respective diagrams is proportional to the number of publications in each time frame. Abstracts of published manuscripts pertaining to pain education were submitted to the word cloud program after removing words pertaining to required abstract structure (e.g., Introduction). This illustrates the emphasis on medical pain management in the early epoch and the evolution to toward the use of “care,” “chronic” management, patients, “primary” care, and awareness of opioids and competencies as important topics. In summary, there has been much progress, but much work still remains as there is no doubt that the enormous prevalence of pain as a clinical problem, as well as its societal burden, is still unmet by current approaches to preparation for practice [29]. Although some emphasis has been placed on the training of primary care physicians and team members [21], preparation at the most basic levels is lacking in most medical and health professions schools [25–27]. Training programs in surgical, oncological, and medical specialties and subspecialties must be attuned to the pain management needs of their specialty-specific population of patients as they pass through their respective settings. The needs in nursing schools have not been well characterized outside of Canada [27], but there is evidence that nursing licensure is more attuned to the needs for pain assessment than those required for medical training. The Liaison Committee on Medical Education standards do not mention pain even once. Psychology is undergoing dramatic changes to improve provider expertise in pain management [30], and although published data are sparse, pharmacy schools play an important role in educating dispensing providers in the risks and potential benefits of active pain therapies. Far more work and resources are needed in all these domains; we look forward to progress in the years to come. Our vision is a time when every patient with pain will encounter a capable provider who says “How can I help?” and is ready to do so. Funding: Support for this work was received from the National Institutes of Health (NIH) in the form of funding for the NIH Pain Consortium Johns Hopkins University Center of Excellence in Pain Education, NIDA 271201500066C-3-0-1. Conflict of Interest: The authors have no conflicts of interest to report.

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