INDIANA UNIVERSITY DEPARTMENT OF ANESTHESIOLOGY
CORE--Chronic Pain Inpatient and Outpatient
Goals and Objectives
GOALS and OBJECTIVES:
The goal of the Chronic Pain Rotation at the Indiana University School of Medicine is to train
physicians to be competent and compassionate practitioners of chronic pain. This rotation is
designed to develop the appropriate attitudes, knowledge base, and skills required to care for the
patient given the complexities associated with chronic pain. Trainees will greatly expand their
knowledge base, skills, and judgment so that they can recognize and manage complications
associated with chronic pain.
Basic Chronic Pain Anesthesia Resident Duties:
1. Obtain appropriate pain focused history and physical exam skills
2. Complete and informative written documentation
3. Complete and informative medical dictation skills
4. Obtaining an informed consent
5. Preparing patients for surgery or invasive procedures
6. Attendance at didactic conferences
7. Taking night call on a rotating schedule
8. Responding to requests for chronic pain anesthesia consults in a timely fashion
9. Maintaining a personal program of self-study and professional growth
10. Completing medical records promptly
11. Documenting all duty hours
12. Documenting all procedures
13. Monitoring self for fatigue
14. Dressing appropriately
15. Acting in a professional and ethical manner
16. Completing the appropriate evaluation instruments used by the department, including
QA forms
Educational Strategy:
The Chronic Pain Rotation is a one-month block. During the Chronic pain Anesthesia Rotation
residents will work with many members of the teaching faculty, but their educational experience
will be supervised by the Director of Chronic Pain Rotation, Dr. Joshua Wellington. In his
absence, Dr. Michael Dorwart will fulfill these responsibilities.
When rotating at an institution which is not the primary site of practice of the above mentioned
faculty, please contact the below listed individual:
Dr. Troy Pfefferkorn—VA
Dr. Ahmed Elsahy - VA
During the rotation in chronic pain, residents are expected to participate in journal club, and
morbidity and mortality conferences (QA).
Core Competencies:
The six core competencies are utilized as a template to evaluate residents during all Anesthesia
rotations. Residents will realize that of the vocabulary used to define these competencies are
similar to those used for other rotations. The Goals and Objectives that follow have been
specifically modified to meet the needs of the specific teaching rotation in which you are
currently participating. We ask you as the learner to consider how each of the subcategories
within these six competencies might relate to cognitive, motor and affective characteristics of
your education and your professional behavior. If while reading this document you discover an
area that requires update or improvement please bring these issues to the attention of either the
Course Director or the Program Director. We seek changes that will improve your educational
experience.
EDUCATIONAL OBJECTIVES
Medical Knowledge:
After completing this rotation, residents will have gained knowledge and practical experience in
the care of chronic pain patients by:
Pain Mechanisms and Pathways
1) nociceptors and nociceptive afferent neurons, wind-up phenomenon
2) dorsal horn transmission and modulation
3) spinal and supraspinal neurotransmission and modulation; opioid receptors
4) autonomic contributions to pain; visceral pain perception and transmission
5) social, vocational and psychological influences on pain perception
6) gender and age differences in pain perception
A. PAINFUL DISEASE STATES
1. Pathophysiology
a)
Acute Pain
b) Cancer-related Pain
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c)
Chronic Pain States
1) acute and chronic neck and low back pain
2) neuropathic pain states
(a) complex regional pain syndrome, types I and II
(b) postherpetic neuralgia
(c) phantom limb, post-stroke
(d) peripheral neuropathies (e.g., diabetic neuropathy)
3) somatic pain conditions: myofascial pain, facet arthropathy, etc.
2. Treatment
a)
Acute postoperative and posttraumatic pain
1) postoperative epidural analgesia
2) neuraxial opioids
3) peripheral nerve blockade and catheters
4) patient-controlled analgesia
5) other modalities, multimodal analgesia (nonsteroidal analgesics, electrical
stimulation, acupuncture, ketamine, etc.)
b) Cancer-related Pain
1) systemic medications, tolerance and addiction
2) continuous spinal and epidural analgesia
3) neurolytic and non-neurolytic blocks
4) World Health Organization analgesic ladder
c)
Chronic Pain (Non-Cancer-Related)
1) systemic medications: nonsteroidal anti-inflammatory drugs (NSAIDs),
opioid analgesics, anticonvulsants, antidepressants
2) spinal and epidural analgesia
3) peripheral nerve blocks
4) sympathetic nerve blocks
5) other techniques: TENS, spinal cord stimulation, neuroablation (surgical
and chemical neurolysis)
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Patient Care:
Using the above medical knowledge the resident is expected to:
1. Evaluate pain patients suffering from chronic pain and developing a treatment plan
2. Plan a comprehensive multidisciplinary approach to chronic pain issues as may be
necessary
3. Plan a comprehensive plan for chronic pain management in the post operative patient
4. Access and evaluating medical literature related to pain medicine via both text based
and internet sources
5. Demonstrate the ability to function as a chronic pain medicine consultant and
specialist in the post-operative patient
6. Determine the source of postoperative pain and provide adequate treatment
7. Master management of intrathecal, epidural and spinal medications used for chronic
pain as well as PCA, and adjuvant therapy
8. Skillfully perform various techniques, including, but not limited to:
a. Placement of spinal
b. Placement of epidurals
c. Placement routine trigger point injections, routine general nerve blocks
Interpersonal and Communication Skills:
After completing this rotation, residents will have gained experience and competence in:
1.
2.
3.
4.
Obtaining an accurate useful patient history appropriate for chronic pain management
Completing an informative, legible medical record
Communicating skillfully with patients and family members
Communicating information about anesthetic procedures with other colleagues
including referring physicians, nurses, and workers on ancillary services
5. Effective counseling of patients and families regarding methods of chronic pain
treatment, alternatives, and risks and benefits
6. Obtaining informed consent for chronic pain anesthesia procedures
7. Answering questions from the patient and or family members regarding the chronic
pain issues in a fashion that is readily understood
Professionalism:
After completing this rotation, residents will have gained experience and competence in:
1. Acting in a professional manner while providing patient care
2. Demonstrating reliability and dependability
3. Exemplifying compassionate and appropriate patient care
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4. Acquiring teaching skills essential for creating a positive learning environment,
including involvement in the education of medical students
5. Showing respect for patients
6. Providing for the emotional needs of patients
Systems-Based Practice
After completing this rotation, residents will have gained experience and competence in:
1. Understanding their role as a patient care advocate
2. Becoming familiar with the costs associated with the delivery of anesthesia care
3. Incorporating the concepts of cost-benefit analysis when considering therapeutic
options
4. Interpreting the constraints associated with management of the operating room and be
able to integrate this understanding into best patient care practices
5. Emphasizing safety for the patient as well as operating room personal
6. Obtaining a better understanding of the tools that are being utilized to assess best
practices in anesthesia by organizations such as Magnet and Leapfrog
7. Working towards developing team building skills
Practice Based Learning and Improvement:
After completing this rotation, residents will have gained experience and competence in:
1. Self-directed learning
2. Becoming more efficient at locating medical information associated with acute pain
3. Reviewing the medical literature related to the field of acute pain and integrating this
information with the care of the patient
4. Learning to better utilize information technology to access on-line medical
information pertaining to innovative diagnostic and therapeutic modalities in the area
of acute pain
5. Transferring knowledge about acute pain to other members of the healthcare team
(medical students, ancillary care personal and nursing staff)
Trainee Evaluations:
The Anesthesia Clinical Competency Committee (CCC) meets every other month to evaluate the
progress of the trainees. Specifically addressed are the six basic competencies and the chronic
pain anesthesia specific competencies outlined above. The instruments used to assess their
progress include an evaluation form which utilizes a scaled five point Likert scoring system
which assesses each of the six competencies. In house testing is also performed twice yearly to
insure that the trainees are acquiring the knowledge associated with the provision of a safe
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anesthetic. Residents are expected to take the in-training examination administered by the
American Society of Anesthesiologists/American Board of Anesthesiology (ASA/ABA).
On a more informal (and potentially more important) level, members of the teaching faculty
evaluate our trainees daily and provide them real-time feedback concerning their performance in
the delivery of anesthesia services. Informal discussions with the chronic pain residents any
deficiencies in patient care or knowledge base. Additionally, we try to know our trainees
personally to better understand and/or address underlying stressors or personal issues that may
interfere with learning and performance.
Every six months, the American Board of Anesthesiology requires that the Clinical Competency
Committee submit a Resident Training and Evaluation Report. In addition to the basic
competencies, we submit our evaluation of a trainee’s progress in the following areas:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
Demonstrates ethical/moral behavior
Is reliable, conscientious, responsible and honest
Learns from experience; knows limits
Reacts to stressful situations appropriately
Has no documented abuse of alcohol or illegal use of drugs during this report
period
Has no cognitive, physical, sensory or motor impairment that precludes individual
responsibility for any aspect of anesthetic management
Demonstrates respect for the dignity of patients and colleagues
Has no restriction, condition, limitation or revocation of license to practice
medicine
Understands anatomical, physiological, and pathophysiological concepts of organ
disease that culminates in the need for solid organ transplant
Collects and uses clinical data
Recognizes the psychological factors modifying pain experience
Communicates/works effectively with patients/colleagues
Demonstrates appropriate concern for patients
Demonstrates commitment to life long learning
Adapts and is flexible
Is careful and thorough
Generates complete, legible, and accurate medical record
Possesses business skills for effective practice management
Uses information technology to optimize patient care
Is an advocate for quality care
Recognizes gaps in knowledge and expertise
Demonstrates continuous practice improvement
Uses appropriate technical skills in diagnostic and therapeutic procedures
Completes study of management of chronic pain, cancer pain, and chronic pain
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Suggested Readings:
Suggested reading assignments to expand knowledge and patient care for this rotation include
but are not limited to the most recent editions of the following textbooks:
Clinical Anesthesia-Barash
Physical Examination of the Spine and Extremities – Hoppenfeld
Orthopaedic Neurology – Hoppenfeld
Practical Management of Pain – Raj
Cancer Pain – Patt
Atlas of Interventional Pain Management Techiques – Waldman
Atlas of Regional Anesthesia – Brown
Radiographic Imaging for Regional Anesthesia and Pain Management – Raj
Peripheral Nerve Blocks: Principles and Practice—Hadzic and Vloka
Clinical Anatomy of the Lumbar Spine and Sacrum – Bogduk
Neural Blockade – Cousins
Regional Block – Moore
Review articles on chronic pain anesthesia topics in the following peer reviewed journals provide
useful reading:
Anesthesiology
Anesthesia and Analgesia
British Journal of Anesthesia
Regional Anesthesia and Pain Medicine
Pain
ISIS Quarterly summary
Clinical Journal of Pain
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