Guidelines for anaesthesiologist specialist training in pain medicine
SECTION AND BOARD OF ANAESTHESIOLOGY1, European Union of Medical Specialists
The Section and Board of Anaesthesiology of the European Union of Medical Specialists aims (EUMS/UEMS) at harmonization of training of anaesthesiologists and at improvement of patient care throughout Europe. Pain medicine is considered to be an area of expertise in anaesthesiology although exclusivity is not claimed. The Section and Board has approved both a core syllabus for pain medicine to be part of the specialist training in anaesthesiology and an additional qualification in pain medicine following the completion of a 5 yr basic specialty training in anaesthesiology. These proposals were prepared by the Working Party on Pain Medicine of the Section and Board. It considers a multidisciplinary approach to pain to contribute to quality in care and has taken the initiative to set up a Multidisciplinary Joint Committee on Pain Medicine within the EUMS/UEMS, for which these guidelines define the area of expertise of anaesthesiology.
This document is divided into two sections and incorporated in the European Union of Medical Specialists (EUMS/UEMS) Section and Board of Anaesthesiology Guidelines on
- Pain medicine in anaesthesia specialist training.
- Additional qualification in pain medicine.
Acute pain medicine
Interest in postoperative pain management during the 1980s prompted the establishment of a new component of anaesthesiology practice. A postoperative analgesia or acute pain service may feature several modalities to combat postoperative pain. The basic objectives of such services include administering and monitoring postoperative analgesia and identifying/managing complications or side-effects of postoperative analgesic techniques. Implicit in these objectives is the inclusion of an active quality assurance programme directed at maintaining high quality patient care.
Chronic pain medicine
Differentiation between acute and chronic pain is important in clinical practice because pathophysiology and therapy may differ significantly. Pain persisting longer than 6 months can be viewed as chronic pain. Many departments of anaesthesia and individual practitioners have organized pain clinics whose function is based on the use of nerve blocks for the management of patients with difficult pain problems. The addition of psychological services, pharmacologic management (including drug detoxification) and physical therapy can markedly increase the range of patients who can be successfully managed in a nerve block clinic. The concept of an interdisciplinary approach to cancer pain management has recently been applied in many institutions.
Section 1 - Guidelines for specialist training in pain medicine
Core syllabus for pain medicine
- Non-steroidal anti-inflammatory agents (NSAIDs).
- Other systematic analgesics including adjuvants.
- Local anaesthetic agents.
Anatomy and physiology of pain
- Peripheral mechanisms of pain.
- Central mechanisms for pain transmission.
- Pain modulation.
- Factors which perpetuate pain.
- Psychological aspects of pain.
General principles of pain evaluation and management
- Pain assessment.
- History taking and physical examination in patients suffering from postoperative, cancer and neuropathic pain.
- Pain measurement in man, basic concepts and bias, scoring systems (visual analogue scales, verbal rating scales, etc.)
- Psychological aspects of pain (individual differences, socio-cultural influence, situational and environmental factors, the family and pain).
- Transcutaneous nerve simulation (indications and procedures).
- Perispinal opioid administration systems.
- Frequently used analgesic nerve blocks (diagnostic purposes and pain control).
- Neuromodification techniques - central axial stimulation.
Surgical and non-surgical methods
- Neurosurgical pain relieving procedures (basic knowledge, indications, contra-indications and complications).
- Psychological, psychiatric and behavioural interventions.
- Multidisciplinary pain management.
- Postoperative pain (mechanisms, psychological effects, treatment modalities, acute pain service).
- Pain following trauma.
- Acute pain in children.
Chronic pain medicine
- Diagnostic characteristics and treatment modalities of musculoskeletal, visceral, ischaemic and neuropathological pain.
- Headaches (migraine, tension headache, headache from cervical origin, cluster headache, atypical facial pain and trigemenial neuralgia).
- Low back pain (anterior and posterior compartment syndrome, radicular and pseudo-radicular syndrome).
- Neuropathic pain and pain syndromes (deafferentiation pain, phantom pain, sympathetic reflex dystrophy, causalgia, neuromata, postherpetic neuralgia and central thalamic pain).
- Cancer related pain.
- Pharmacological treatment with opioids, NSAIDs, acetaminophen, antidepressant anticonvulsive drugs and other mixed agents (co-analgesics).
- Indications and treatment possibilities using perispinal opioid administration systems.
- Transcutaneous nerve simulation; indications and procedures.
- Indications and treatment modalities using specific radiofrequency and neurolytic blockade techniques.
Case management and communication skills
- Show a relevant attitude towards patients suffering from chronic pain.
- Establish an acceptable contact with the patient and his/her family.
- Set up and maintain an acceptable contact with nurses, social workers, medical psychologists, psychiatrists, other consulting specialists and the General Practitioner.
- Show abilities of self-confidence, knowledge of his/her functioning and self criticism.
- Make adequate patient records.
Duration of pain medicine in anaesthetic basic specialist training
- Exposure to acute pain medicine in basic specialist training should be on a continual basis throughout the 5 yr of specialist training in anaesthesia.
- The chronic pain medicine component could be included in a 3-month module.
- Problem-based learning formats are recommended and simulators, where available, would have a valuable role.
- The role of log books or a portfolio in assessing pain medicine, including chronic pain, in basic specialist training is confined to the trainee's ability to undertake practical procedures.
- The board recommends that a minimum 10% of the multiple-choice questions in the Diploma of the European Academy of Anaesthesia (DEAA) examination should relate to acute/chronic pain medicine and that these issues be systematically evaluated in the oral examinations.
Recognition of institutions for pain medicine training
In the Joint European Board of Anaesthesiology (EBA) EUMS-UEMS/European Society of Anaesthesiology (ESA) Hospital Visiting Programme, current assessment of acute and chronic pain is limited to the presence or absence of this exposure and how the service is organized.
The sub-committee recommendations included:
- The Joint EBA/ESA Hospital Inspection Team should recommend that the Board's Pain Medicine Training Guidelines be adhered to.
- Where these minimum training opportunities are not available in certain institutions, trainees should be directed to acquire this training elsewhere.
- Individual department heads should use the Inspectors' report to strengthen their case with management to ensure that acute and chronic pain facilities are provided.
Section 2 - Additional qualification in pain medicine
- Refers to the concept of an add-on extra expertise qualification following the completion of a 5 yr basic specialty training in anaesthesia.
- This concept relates to multidisciplinary practice including neurology, neurosurgery, rehabilitation medicine, orthopaedics, psychiatry and others.
- The EBA will promote that the recently established UEMS Multidisciplinary Joint Committee on Pain Medicine will develop the curriculum/training/assessment and recognition criteria for this add-on qualification.
- To determine the quality of additional training, consideration will be given to the content and duration of pain medicine experience in basic specialist training.
- To acquire an add-on specialty qualification, an additional 2 yr pain medicine training may be undertaken.
Duration of training
- The Multidisciplinary Joint Committee on Pain Medicine will assess the curriculum to quantify the time and the number of modules needed for specialists to acquire the relevant knowledge, clinical exposure and practical skills.
- The Multidisciplinary Joint Committee on Pain Medicine will assess the role of log books and the role of an exit examination, including assessment of technical/communication skills and theoretical knowledge.
Recognition of institutions
- The Multidisciplinary Joint Committee on Pain Medicine will determine how institutions can be inspected to ensure they are suitable for training specialists who aspire to this add-on qualification.
Keywords:© 2007 European Society of Anaesthesiology
GUIDELINES; PAIN CLINICS; PAIN POSTOPERATIVE; EDUCATION; MEDICAL