The Pain-free Pain Education of Medical Students
I distinctly remember a group discussion in my second year of medical school regarding a patient in the emergency department complaining of lower back pain. She was a postal worker who had been taking opioids for lower back pain for several years. Her prescription had recently run out, and her primary care doctor was refusing to refill the prescription without an appointment – the next available appointment was weeks away. She was visibly in distress on exam but had no other positive findings. The question was posed: What do you want to do with this patient?
Opinions were varied, but surprisingly polarized given that we were all only in the second year of medical school. Some wanted to treat the pain acutely and discharge, others wanted a psychiatric evaluation, one person opted for a prescription to bridge the gap to the follow-up and a few were adamant the patient was drug-seeking. Unsurprisingly, the conversation revolved around the opioid epidemic and a medical provider’s role in fueling a crisis where growing numbers of people are dependent on prescription medications; an issue that is further explored by two students in this edition of AANS Student.
Lack of Pain in Education
As students, we are woefully underexposed to pain’s pervasiveness in medicine until late in our education, during clerkships. Pain is pervasive, a common presenting symptom for many diseases. Despite our studying of A-delta and C-fibers, the spinothalamic tract, gate control theory and inflammatory and opioid pharmacology, consideration of the patient’s experience of pain is rare. Interesting and necessary classroom discussions regarding societal and cultural differences in the perception and role of pain in health and disease are triaged to the background due to time constraints and the difficulty in testing knowledge of such topics. Little is taught beyond “pain should be adequately controlled” and “recommend follow-up with a pain specialist” in cases of chronic pain.
There are some studies investigating how medical students’ attitudes towards pain changed throughout their education:
- A 1992 study involving first year students found that attitudes towards pain became more complex and subjects were more likely to acknowledge pain as real after completing a six-hour course on pain (1).
- A 2000 study revealed a similar trend in attitudes towards opioid prescriptions in a longitudinal study of students in their first year and fourth year of medical school. In their fourth year, students demonstrated significantly less fear of prescribing opioids, although as many as one-half of fourth year students maintained concerns regarding prescribing pain medication (2).
- A 2007 study found that, compared to first-year students, fourth-year students experienced increased empathy regarding pain in the elderly and were more willing to prescribe opioid medications; however, the same students reported greater anxiety about interacting with chronic pain patients (3).
I am curious to know how the discussion among my classmates regarding the postal worker with back pain would change towards the end of medical school; these small studies suggest that the discussion would be more nuanced and less extreme. The increased anxiety evidenced in fourth year medical students regarding interactions with chronic pain patients, however, is a worrisome sign that the issue of pain is inadequately addressed in medical education.
Neurosurgeons have the unique ability to directly interact with and alter the biological structures responsible for painful sensations, and the treatment of pain syndromes by neurosurgeons has a long history spanning from Victor Horsley and Harvey Cushing to present day deep brain and motor cortex stimulation. It is important for students entering the field to remember that pain is a complex issue that cannot be ignored in neurosurgery. It is important to explore patients’ expectations regarding pain associated with their condition and surgery. The unique intersection of neuroanatomy, physiology and patients suffering from chronic pain conditions enables neurosurgeons to advocate for patients suffering from chronic pain and tailor research to the treatment of these conditions.
2. Weinstein, S. M., Laux, L.F., Thornby, J.I., Lorimor, R.J., Hill, C.S., Thorpe, D.M. & Merrill, J.M. (2000). Medical students’ attitudes toward pain and the use of opioid analgesics: implications for changing medical school curriculum. Southern medical journal. (5) 472-478.
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