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Cancer pain education among family physicians
Vol. 14 No.2 1It/lfust 1997
74 Journal of Pain and Symplom Mrwagrmumt
Original .k-tide
Cancer Pain Education Among Family Physicians Paul A. Sloan, MD, Michael B. Donnelly, PhD, Barbara Vanderveet; RN, Mark Delomas, MD, Richard W. Schwartz, MD, and David A. Sloan, MD Depart1llfmts oj Anesthesi%gy (RII.S., B. v., M.D.), and Surgery (M.B.D., 11. 11(S., D.II.S.), University oj Kentt/chy Co/bige oj Medicine, Lexington, KI!/ltuc/')I USA
Abstract 17ds study used /Ierformance-basell testing (olijective stnutured clinical t7Jalualion, OSCt.j to evaluate the shills oJ/am.ity /Ih),sicians in assessing and mmwgillg Ihe s/mere /min of fL cancer jmtient, and evaluated a 1m" method oj education about Lite lIltlnagemcl1t of Cfmcer jlGin. Twent)'{our jllimary care physician, comjlleled a deiai/J,d Imin a.ssessment oj the sallte standardized cmlcer pain /mtient (Part A). A proctor observed the intervh~"s and rated the jlhysirians on a variety of Ilre-detennined items believed to be im/lortant Jar f,ain assessment. 11" flhysicians were then allowed 5 min to mm,,"" management questions about the IIGtient's cancer flGin (Part B). Afte.- revh~uing each jlhysician:, flCrformance on Parts A and B, the proctor I}rovided immediate feedback and instrllction (Part C) on bruic flrincijlles of cancer pain assessment and management. On average, the jlrimary care physicians asked 52% (:!: 4.5%) of tlte indicated questions of a detailed jmin rus.ssment. Performance was poorest in asking abollt previous jlain hi,tory, lemi,oral pattern oflJain, and flain intensity. P"'.formrlnce on the flain assessment was best for eliciting fJain location and jlain-relievingfacto". Primary care flhysicirl1ls obtained mean scores of 36% (:!: 3%) on Part B of the OSCE. Although ol,ioid therajly was Jrequently fmscribed, only 42 % of flrescrijllions were for regular administration. Performance on Parts A and B correlated Iloorly with years in practice, and older jlh)'sicians tended to ilerform a less detailed jlain assessment than their younger colleagues. Most ilhysicians enjoyed /Jarticiflating in this instructional format and believed that the 1,roclor feedback increased the educational value of the module. 71," results of our study suggest that many family f;hysiciol1s may be inadequate in their clinical assessment and management oj cancer imin. Our study sUflports the need for continuing education in cancer I,ain management, regardless of )'ears in practice. Further study should evaluate the effects of different educational jlYograms on clinicalj}ractice in palient care. J Pain Symptom Manage 1997; 14:74-81. © u.s. Cancer Pain Reli£jCOI1t1nittee, 1997.
Key Words Cancer jJain, education, /Jain assessment., analgesia, objective structured clinical examination, standardized f,atiellts
Address refnint 1"equc!ils to: Paul Sioail. MD, Deparl:ment of Anesthesiolobry'. Un iversily of Kentucky Hospital, 800 Rose Street, Lexington, KY 40536. Arl'CplCd Jor IJUblicotion: Oclober 18, 1996. © U.S. Cancer "Paill Rclicl"Coralmillcc, 1997 Published by Et~e~ iel', New York, Nt:w York
0885·3924/97/$17.00 I'll S0885-3924(97)OOOJO·9
1'01. 14 No. 2 11111.'11.<1 1997
Call((~r
Pain Educatiu11 Among Ph),sicians
Introduction Each year, more than one million peoplc in America are found to have cancer, and one of every five deaths is caused by this disease.' At the time of cancer diagnosis, 35% of patients are already experienc ing moderate to severe pain; when cancer reaches its advanced stages, 70% of patients will experienc e pain." The public fear of cancer is partly related to the anticipati on of severe pain and the expectation that canccr is always linked wi til severe pain.3 Because most cancer pain can be adequatel y controlled by standard analgesics and co-analgesics given on a regular basi!,,-) the World Health Organiza tion understan dably advocates the education of health care professionals in the practical aspects of cancer pain managem ent." The variable control of pain puts large numbers of cancer patients at risk for poor pain managem ent, and methods that might be effective in modifying the current practice of cancer pain managem ent should be considere d. Elliot and Elliot reported significant number of incorrect concepts about cancer pain managem ent among physician s and suggested that innovative medical education at all levels (medical school, residency, fellowships, and continuin g medical education ) is needed to present new knowledge about 6 opioid usc in cancer pain managem ent. The objective structured clinical examination (OSCE) has been used to evaluate physicians in training. 7 In this format, physicians individua lly encounte r patients (actual or simulated ) and are asked to obtain a history or to perform a focused physical examinat ion. This performan ce-based assessmen t tool has been used to documen t deficienci es in the assessment and manageln ent of cancer· pain among housestaff ." At the University of Kentucky, we have modified the OSCE for teaching pUlposes and have described the use of a structured clinical instructio n module (SCIM) to teach aspecls of gastrointe stinal and breast disease. 9 This study was designed to use performa nce-base d testing to evaluate the skills of family physicians in as,essing and managing the severe pain of a cancer patient, and to evaluate the SCIM as a method of instruction about the managem ent of cancer pain. This report will (a) describe how well this
75
group of physicians performe d; (b) identify the performa nce characteri stics that differentiate competen t performa nce from incompetent performa nce; (c) determine the effect of experienc e on performan ce; and (d) answer several methodol ogical questions about the SCIM, including the evaluation of its acceptability by family physicians and differellce s in how the SCIM is evaluated relative In type of proctor.
Methods Twenty-fo ur primary care physicians , who had been in practice for 1-20 years, volunteered to participa te in this course while attending a primary care n~view course. Each physician was asked to complete a detailed pain assessmen t of the same simulated standardized cancer pain patient. The details of this method of evaluation have been previously published and are reviewed in part, along with our modificat ions of this method for teaching purposes. R Each physician was given 5 min to interview the actor portraying a patient with severe pain caused by unresecta ble, terminal rectal cancer. [n this initial segment of the OSeE (Part A), the simulate d palient gave consisten t. responses , and all physicians were able to complete the pain interview in the allotted time. The standardi zed patient described severe, constant low back pain of a nociceptiv e type. The patient did not describe any oescriptor s or neurologi cal changes that would suggest neuropat hic pain. A proctor evaluated the pain assessmen t interview. For this study, three proctors of different ranks were used during· all segmenls of the OSCE: a faculty anesthesiologist, a senior resident in anesthesiology, and a senior nurse pain specialist. The prc>ctors quietly observed the interviews (one proctor per physician) and rated physicians on a variety of pre-deter mined items believed to be importan t for a complete pain assessment. For example, physicians .were rated on their ability to assess pain on~;et, pain location, pain descriptio n, pain int,ensity, temporal pattern of pain, aggravating and relieving factors, previous pain history, review of systems, review of psychosocial history, and medical history. For each item not performed, a score of zero was given, a score of one or two was given if the
76
SIUfm et Cli.
1i,1. 14 No.2 AUIfU.,' 1997
item was per/onned poorly; and a score o[ two or [our was given if the item was performed well. At the elld of Part A, the proctor made several global judgment. of each physician's overall performance. The standardized patient also rated the interpersonal skills of each primary care physician. In Pari B, the physician Was allowed 5 min to answer three managelnent questions about the
paLient seen in Part A. No furl her i,,[ormation regarding Il,e patient's pain history was given to the physician. Each physician was asked to WIite out an analgesic presCliplion [or Il,e patient, to describe a management strategy if the patient. was unwilling to undergo opioid therapy because of addiction COllcerns, and La describe the management of ongoing severe cancer pain noted ,It it fullow-up visit despite prescribed analgesic thempy. The physician was also asked to list alternative "non-drug" analgesic therapy that .night be useful in Il,e management of cancer pain. The c\",iluation of each physician's perfol~ mance on Paft B was carried out immediately after compleJon of the tesLing session. Performance was rated on a predetermined checklist ver-' similar to the type used in a structured sh t answer ex.aminution. After reviewing ea<:.. physician's performance on Parts A and B, the proctor provided immediate feedback and instruction (P~rt C) on basic principles of cancer pain assessment and managemenL The proctor who evaluated each physician in parts A and B provided the 5 min of instruction to that physician in parL C. At the end of the session, each physician completed a ten-item evaluation of the cancer pain module. Measures of overall performance and of pel~ formance on specific items on Part A and Part B were summarized by several dcsctipLive statistics. Pearson '5 correlatiom were used to determine whether or not differences in performance measures could be attributable to amount of experience in family practice. Repeated-measures oneway analyses of variance (ANOVAs) were used to identity specific ilems 011 which Ille family practitioners per fonned best and worst. The 0.05 level of confidence was used to identity significant differences.
Results On average, the primary care physicians asker! 52% (± 4.5%) of the indicated ques-
4 VOIJMvcfl OLrtsbadlng
Fig. 1. Mean global evaluations of physician pain assessment.
tions for a detailed pain assessment. Thirty-five percent of the participants obtained between 40% and 60% of the information; this may be considered as "11compassing the high level of Il,e below-average range and the luw level of til" average range. Only one parl.icipant asked !llOre than 80% of the indicated questions. Figure 1 presents the means of Il,e four global ratings, Descriptively, the proctor evaluations of lhe doclor-p~tdcllt interactions were the highest, and Il,eir evaluation of overall performance, the lowest, although the differences between these two "extrclues" were relatively small, All four global ratings were in the avel~ age range. Howevcl; when the proctors were asked to make ajudgment of whether the physician was competent or noncompetent (yes or no evaluation), performance was viewed less positively: the proctors viewed the perforInances of 55% of the primary care physicians
as incompetent. There were also statisLically significant diffel~ enccs in how well l11e specific items were pel~ formed (F =3.81; df = 8, 200; P < 0.0001, from repeated-measures ANOVA). Performance on l11e pain assessment was best for eliciLing pain location (mean = 3.25, on a four-point scale, zero to four), pain-relieving factors (mean = 1.54, on a two-point seale, zero to I1vo), and asking the standardized patient about psychosociai history (mean = 1.21, on a tIVo-point, zero to 11~0 scale). Performance was poorest in asking about previous pain history (mean = 0,5, zero to I1VO scale), temporal pattern of pain (mean = 2.08, zero to four scale), and pain intensity (mean = 1.4l.', zero to four scale). On average, the primary cat'e physicians obtained scores of 36% (±3%) on Part B of the OSeE, Sixty-two percent of the scores were
_1"_01_._I_4_N._"_.-,-Z_A_'-,'I':,-U-,-sfc-'9'-9-'7_ _ _ _--'C;;."'-'-!C;.;."'-'-rP;;."'-'-·"...:I:::£t;;.lu;;.Cfllio..cn...:A.::,::.:"0-,U1'-',~'_,I:...'I"IJ",'!j/;.;.'o",·".:.:":.."_ _ _ _ _ _ _ _ _ __
50
Mean
=2.2 (0.3 semi
'0 30
c~
20
1j
~
10
Unsellsfactory
Below Average
Above Average- AVerage++ Avcrrge Outstanding
Fig. 2. O\'erall cvalmuion of Part B performance.
between 20% and 50%. The overall global evaluations were also quite low. The mean (:':SEM) ratinr- on a six-point scale ranging from unsatisfactory (zero) to outstanding (five) was 1.9 :': 0.2. Figure 2 presenl' a frequency distribution sumnlarizing these ratings. Approximately 70% of the physicians
were rated as below average or low average. Although 83% of the physicians prescribed opioid analgesic therapy (79% of the,e by oral administration), only 42% prescribed regular opioid use. Orally administered nonsteroidal anti-inflammatory drugs (NSAlDs) were prescribed by only 42% of the physicians, and only 17% prescribed for regular administration. Seventy-nine percent of the physicians did not prescribe an analgesic as needed for breakthrough pain. Only 540% of the physicians treated the patient'e feai' of addiction in an approFriate mailne~- 'with continued opioid therapy, and explanation to Ihe patient that addictive behavior is highly un iikely in this setting of cancer pain treatll1Cnt. The persisting pain problem was managed by increasing the opioid dose for only 54% of physicians. One might expect that years in practice would correlate with one or more of the pcrfOfInance l11easnres. To determine whether if
this lvas the case, we compared years in prac~ tice with the following: (a) percent ofin[orilIation obtained in Part A and Part B; (b) the two overall global ratings; (c) the interpersonal skills ratings by both the patient a",1 t.he proctor; and (d) the physician's organizational skills. Only the amount of information obtained in Part A correlated significantly with years in practice (r= -0.45, P< O.O!». That is, older physicians tended to do a less detailed pain assessment than di1 younger ones. To determine whir.h items differentiated competent £i'om noncompetent perfonnance in the pain assessment, independent-groups l test"} were carded out comparing these two groups on bOlh specific and global measures. On only two of the 12 specific performance items were there statistically significant differences: a"essing pain onset (t = 2.20, P < 0.05) and assessing pain intensity (I = 3.85; II < 0.001). The competent group received statistically significantly higher evaluations than did the noncompetent group on all five of the general ITIeasurcs of performance. Among tbese items, the global rating of how organized the physician was in performing the pain assessment (mean of the competent group, 2.83; mean of the noncompetent group, 1.35; I = 6.17; P < 0.001) was the most discriminating among the global items in Part A. Because no conlpelence rating was Blade in Part B, each item was correlated with the overall evaluation of Part R performance. Table 1 presents each Jf these correlations. The effectiveness of the SCIM was evaluated in two ways. First, the participating physicians judged the value of the SCIM as an instruction,,1 method. Second, AN OVA was used to determine whether differences in how the SCIM was evaluated conld be related to the proctor. Overall, the physicians viewed the SCIM as an above-average method of assessing
TaM, I Part B Correlation of Specific Items with the Overall EvaJuation .Jf Performance Item p rxy Item Incrc;ase opioid use Nerve block-altcTIlativc analgesic therapy Percent of anSWers that were COiTeCl Additional PRN analgesic f01' hrcaJ..lhroligh pair. Explanation that "addiction" is Hot an issue NSAID prescdhcd Opioid prescribed NSAID. llo'l:;;tcroidal anti-inflammatory drug
77
0.78 0:14 0.74 0.63
<0.00] <0.001 <0.00]
O.5H
<0.001 <0.0]
0.48 0.46
<0.02
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10L 14 No. 2 A1I[llsl 1997
Sloan el al.
ruM
Disagree
Agree
Mean(±sem} Ph~sieian Rating
1.
Overan. the module tested important and rel.vant clinical skills.
2
4
5
4.54 (.11)
2.
OvcraJl. the module was a realistie losl crmy clinical skills.
2
4
5
4.23 (.16)
3.
This module provided information about clinieal skills thai has 4
5
4.08 (.16)
4.
This canoor pain module idenlilied slreng1/l and deficits in my clinical skills.
2
4
5
J enjoyed participating in this inslructional formal
2
4
5
6.
Ther. was sullicient time 10 complele the pain history.
2
5
4.15(.18)
7.
There was sufficienl time to complele the questions.
2
4
5
4.23 (.15)
8.
This module w.. not unduly stressful for me.
2
4
5
4.38(.15)
9.
The feedback given you by the instructor increased the 4
5
4.76 (.10)
not been provided by other assessmenl methods.
2
edu.alional value of this module. 10.
3
3
4.04 (.18) 4.50 (.13)
Whal is yO'Jr overall .valuation of this pain module os. method for ..aluatingyour clinieal skills? 2
4 4.10(.14)
Poor
Below Average
Average
Above Average Outstanding
Fig. 3. Pain management stru.:turcd clinical instruction module evaluation form with mean physician rating of itcm5.
clinical skills (mean = 4.10 ± 0.14 on a fivepoint scale). Eighty-eight percent of the physicians believed that the OSCE was above average or out,tanding. There were statistically significant differences among the nine specific items (Figure 3) used to evaluate the SCIM (F = 3.SI; dfS. 200; P< 0.001). Physicians agreed most with statements that the feedback given by the instructor increased the educational value of the SCIM (mean = 4.77 ± 0.1 0), that the SCIM tested important clinical skills (mean = 4.53 ± O.II), and that they enjoyed participating in this instructional format (mean = 4.50 ± 0.13). They agreed least, yet still with an above-a,·erage raung, that the cancer pain SCIM identified strengths and deficits in their clinical skills (mean = 4.04 ± O.IS) and that the SCIM provided information about clinical skills that has not been provided by other assessment methods.
The overall evaluation of the SCIM suggests that not alI proctors had the same effect on the physicians' reaction to the SCIM (F = 5.98; df= 2,23; fJ= O.OOS). The OSCE proctored by the faculty member and the resident (faculty Inean =: 4.35 ± 0.15; resident lucan ~ 4.38 ± 0.18) were rated signilicantly higher than that proctored by ti,e nurse (mean = 3.50 ± 0.27). The proctoring by faculty member, resident, or nurse was approximately equally divided among the family physicians.
Discussion Burge and Latimer suggest that the weIJprepared family physician is the ideal doctor to be involved in the. comprehensive delivery of palliative care to paticnts. 1O With the changing mode of health-care delivery in America, the family practitioner is increasingly involved
Iill. 14 No. 2,tux'c.! 1997
Canrer Pain Belucaliun
in the total care of the palien l, and the pain specialist is seen as an available conSUlk'lIlt to help with difficult clinical scenarios. Indeed, in the United Kingdom, family physicians have been found to be responsible 90% of the time for the care given during the last year of a cancer patient's life. 1 1 If good palliative care is to be administered, the family physician must have a basic understanding of the assessment of cancer pain and the management principles required to relieve this pain. The results of our study suggest that many family physicians may be inadequate in their clinical assessment and management of cancer pain. Some basic items important in a detailed cancer pain assessment were inli'equently asked by our group. For example, most physicians did not ask, Of asked poorly, about the measur\!~ mcnt of pain intensity during the interview. Recent studies have shown that most practitioners would welcome postgraduate education on pain management. 12.13 The Wakefield ct al. I" survey of family phydcians found that the more experienced physicians perceived less need for further training in pain management. The results of our study show, however, that there was little difference in performance on the assessment or management of cancer pain between less a>ld more experienced physicians. Indeed, the older physicians tended to provide a less adequate pain assessment than their less experienced colleagues. Our study supports the need for continuing education in cancer pain management regardless of years in practice. Many surveys have demonstrated that physicians are deficient in knowledge about cancer pain. 13- Jll The use of performance-based testing in our study provides additional data from the observation of actual standardized physician-patient interviews. The opportunity to observe physicians in simulated structured environments provides objective evidence for how physicians actually practice, as opposed to the knowledge information obtained from survey data. For example, a recent cancer pain knowledge survey administered to physicians in southern Italy found that 100% of respondents assess pain location and pain description; and 81% also assess pain intensity.17 The survey data arc in ~triking contrast to the results of our study showing that 54% and 70%, respectively, of physicians assess pain
Amoll~
Physicians
79
description and pain intensity, respectively. poorly or not at all. The direct observation of physician deficiL' noted during the [,ain intelc view was a powerful educational tool in the teaching of cancer pain principles in Part C. Most physicians prescribed orally adminislered opioid analgesic therapy for this patient with severe cancer pain. This practice, consistent with published guidelines on the management of cancer pain, is encouraging. IH How· ever, only 42% of physicians prescribed the regular use of opioids. Similarly, although many physicians prescribed oral NSAlDs, vcry few prescribed regular dosing of NSAIDs. Although providing an analgesic as needed for breakthrough pain is widely accepted, I!' it was rarely prescribed for the standardized patient. There is clearly a need for focused continuing medical education on the appropriate use of analgesics and co-analgesics in the management of cancer pain. The use of "non-drug" analgesic therapies has been recommended as .an adjunct for the management of cancer pain. 20 Ferrell found that heat and massage were helpful to patienL' wilh cancer pain, and that both patients and families were very eager to usc these non-drug interventions. 21 Relaxation therapies. massage, and physical therapies were the most frequently recommended alternative non-drug analgesics in our study. Both radiotherapy and chemotherapy have a defined role in the management of cancer pain. The fact that radiotherapy and chemotherapy were listed by only 8% and 0%, respectively, of physicians in this study as alternative analgesic therapies indicates that further pain education is required in this area. To achieve good pain control for all patients, physicians need to learn a wide variety of pain-relieving techniques. The standard continuing medical education workshop has been found somewhat ineffective in changing the practice habits of physicians. 22 The clinical formaL of our education module combines patient interaction with immediate evaluation and feedback to the physician regarding both the strengths and weaknesses of the cancer pain assessment and management plan. Further studies are required to investigaLe the efficacy of this educational format in changing the practice habib of physicians. Four characteristics of successful teaching programs in palliative care are
80
included in our cancer pain module: the identification of educational needs of the specified group; a clear statement of goals and objectives of the teaching program; the use of methods that involve active participation: and an
evaluation to provide feedback. 2:1 The abili ty to apply knowledge has been argued to be one of the most important skills necessary for physicians in the 21st century.2. We believe that this cancer pain module can not only measure the knowledge application skills of physicians, but also educate physicians in these areas. This cancer pain education InoduIc was
extremely well accepted by most physicians. The physicians el1joyed participating in this instructional format and found the immediate feedback given by the proctor very valuable. This type of performance-based evaluation and instructional feedback has been criticized because it requires a significant time cOlIlmitment by faculty members and therefore may not be reasonable or cost effective. Because our study showed that both residents and faculty anesthesiologists received similar ratings from the participating physicians when serving as proctors, this necessary manpower may be provided in university hospitals by resident physicians. The use of residents would increase the feasibility of providing this instructional format on a widespread basis. The nurse proctor was rated lower than the physician proctors (however, still above average), which may reflect the reluctance of practicing ph~si dans to be instructed by others outside of their field of practice. This finding requires further evaluation and study. Finally, the deficits in the a'5essment and management of cancer pain found among family physicians highlight the need for evaluating the effects of different educational programs on clinical practice and patient care. The performance-b;,scd testing module may be an excellent pretest and posttest tooi for measuring the efficacy of different educational programs. It could also be modified for use in the recertification processes of various health disciplines. The strengt;l of this tool is that it clearly demonstral~s activity and behaviors that physicians display in their day-to-day practices.
Vol. 14 No. 2 A!l~oIJI 1997
Siorm et af.
References 1. Cancer facl., .md Iigurcs-1994. Atlanta: American Cancer Society. 1995: 1. 2, Portenoy RK. Cancer pain: epidemiology and
syndromes. Cancer 1989;(;3:2298-2:107. 3. Levin ON, Cleeland CS, Dar R. Public altitudes toward cancer pain. Cancer 1985;56:2337-2:,39. 4. Grund S, Zcch D, Schug SA, Lynch J, Lehman KA. Validation of the \Vorld Health Organization guiclcJillcs £'01' cancer pain relief during the last, days and hours of life.] Pain SymptolJl Manage 1991;6: 411-422. 5. Cancel" pain relief and palliative carc. Report of
a WHO Expert Cammillee (World Heallh Organization Technical Report Series, 804). Geneva:
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7. Sloan DA, Donnelly MD. Schwarz RW, Strodel WE. Thc objective structured clinical examination: the new gold standard for evaluating postgraduate clinical performance. Ann Surg 1995;222:735-742. 8. Sloan PA, Donnelly MD, Schwartz RD, Sloan DA. Cancel' pain assessment and management by
houseslaff. Pain 1996 67:475-481. g. Sloan DA, Donnelly MR, Zweng T, ct al. The strnctured clinical instruction module (SCIM): a noveJ stratcf.:,'Y for improving the instruction of clinical skiils.] Surg Res 1995;58:605-61O. 10. Burge FI, Latimer FJ Palliative care in medical education at McMaster University. .J Pallial Care 1989;5:16--20. 11. Doyle D. Education. and training in palliat carc.
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17. Mercadante S, Salvaggio L. Cancer pain knowledge in suuthern hal}': data from a post-graduate rdi~sher course.] Pain Symptom Manage ]996;11: 108-115. 18. Jacox AK, Carr DB, Payne R. Management of cancer pain. Clinical practice guideline no, 9,
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Acp!-!r~
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.r Am Gerialr Soc 199 I ;39:64-73.
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22. Clccland· C. I{cscarch in cancel' pain: what ''Ie know and what we need to kllow. Cancer I ~lB J;67: 82:~-827.
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249,252 .
74 Journal of Pain and Symplom Mrwagrmumt
Original .k-tide
Cancer Pain Education Among Family Physicians Paul A. Sloan, MD, Michael B. Donnelly, PhD, Barbara Vanderveet; RN, Mark Delomas, MD, Richard W. Schwartz, MD, and David A. Sloan, MD Depart1llfmts oj Anesthesi%gy (RII.S., B. v., M.D.), and Surgery (M.B.D., 11. 11(S., D.II.S.), University oj Kentt/chy Co/bige oj Medicine, Lexington, KI!/ltuc/')I USA
Abstract 17ds study used /Ierformance-basell testing (olijective stnutured clinical t7Jalualion, OSCt.j to evaluate the shills oJ/am.ity /Ih),sicians in assessing and mmwgillg Ihe s/mere /min of fL cancer jmtient, and evaluated a 1m" method oj education about Lite lIltlnagemcl1t of Cfmcer jlGin. Twent)'{our jllimary care physician, comjlleled a deiai/J,d Imin a.ssessment oj the sallte standardized cmlcer pain /mtient (Part A). A proctor observed the intervh~"s and rated the jlhysirians on a variety of Ilre-detennined items believed to be im/lortant Jar f,ain assessment. 11" flhysicians were then allowed 5 min to mm,,"" management questions about the IIGtient's cancer flGin (Part B). Afte.- revh~uing each jlhysician:, flCrformance on Parts A and B, the proctor I}rovided immediate feedback and instrllction (Part C) on bruic flrincijlles of cancer pain assessment and management. On average, the jlrimary care physicians asked 52% (:!: 4.5%) of tlte indicated questions of a detailed jmin rus.ssment. Performance was poorest in asking abollt previous jlain hi,tory, lemi,oral pattern oflJain, and flain intensity. P"'.formrlnce on the flain assessment was best for eliciting fJain location and jlain-relievingfacto". Primary care flhysicirl1ls obtained mean scores of 36% (:!: 3%) on Part B of the OSCE. Although ol,ioid therajly was Jrequently fmscribed, only 42 % of flrescrijllions were for regular administration. Performance on Parts A and B correlated Iloorly with years in practice, and older jlh)'sicians tended to ilerform a less detailed jlain assessment than their younger colleagues. Most ilhysicians enjoyed /Jarticiflating in this instructional format and believed that the 1,roclor feedback increased the educational value of the module. 71," results of our study suggest that many family f;hysiciol1s may be inadequate in their clinical assessment and management oj cancer imin. Our study sUflports the need for continuing education in cancer I,ain management, regardless of )'ears in practice. Further study should evaluate the effects of different educational jlYograms on clinicalj}ractice in palient care. J Pain Symptom Manage 1997; 14:74-81. © u.s. Cancer Pain Reli£jCOI1t1nittee, 1997.
Key Words Cancer jJain, education, /Jain assessment., analgesia, objective structured clinical examination, standardized f,atiellts
Address refnint 1"equc!ils to: Paul Sioail. MD, Deparl:ment of Anesthesiolobry'. Un iversily of Kentucky Hospital, 800 Rose Street, Lexington, KY 40536. Arl'CplCd Jor IJUblicotion: Oclober 18, 1996. © U.S. Cancer "Paill Rclicl"Coralmillcc, 1997 Published by Et~e~ iel', New York, Nt:w York
0885·3924/97/$17.00 I'll S0885-3924(97)OOOJO·9
1'01. 14 No. 2 11111.'11.<1 1997
Call((~r
Pain Educatiu11 Among Ph),sicians
Introduction Each year, more than one million peoplc in America are found to have cancer, and one of every five deaths is caused by this disease.' At the time of cancer diagnosis, 35% of patients are already experienc ing moderate to severe pain; when cancer reaches its advanced stages, 70% of patients will experienc e pain." The public fear of cancer is partly related to the anticipati on of severe pain and the expectation that canccr is always linked wi til severe pain.3 Because most cancer pain can be adequatel y controlled by standard analgesics and co-analgesics given on a regular basi!,,-) the World Health Organiza tion understan dably advocates the education of health care professionals in the practical aspects of cancer pain managem ent." The variable control of pain puts large numbers of cancer patients at risk for poor pain managem ent, and methods that might be effective in modifying the current practice of cancer pain managem ent should be considere d. Elliot and Elliot reported significant number of incorrect concepts about cancer pain managem ent among physician s and suggested that innovative medical education at all levels (medical school, residency, fellowships, and continuin g medical education ) is needed to present new knowledge about 6 opioid usc in cancer pain managem ent. The objective structured clinical examination (OSCE) has been used to evaluate physicians in training. 7 In this format, physicians individua lly encounte r patients (actual or simulated ) and are asked to obtain a history or to perform a focused physical examinat ion. This performan ce-based assessmen t tool has been used to documen t deficienci es in the assessment and manageln ent of cancer· pain among housestaff ." At the University of Kentucky, we have modified the OSCE for teaching pUlposes and have described the use of a structured clinical instructio n module (SCIM) to teach aspecls of gastrointe stinal and breast disease. 9 This study was designed to use performa nce-base d testing to evaluate the skills of family physicians in as,essing and managing the severe pain of a cancer patient, and to evaluate the SCIM as a method of instruction about the managem ent of cancer pain. This report will (a) describe how well this
75
group of physicians performe d; (b) identify the performa nce characteri stics that differentiate competen t performa nce from incompetent performa nce; (c) determine the effect of experienc e on performan ce; and (d) answer several methodol ogical questions about the SCIM, including the evaluation of its acceptability by family physicians and differellce s in how the SCIM is evaluated relative In type of proctor.
Methods Twenty-fo ur primary care physicians , who had been in practice for 1-20 years, volunteered to participa te in this course while attending a primary care n~view course. Each physician was asked to complete a detailed pain assessmen t of the same simulated standardized cancer pain patient. The details of this method of evaluation have been previously published and are reviewed in part, along with our modificat ions of this method for teaching purposes. R Each physician was given 5 min to interview the actor portraying a patient with severe pain caused by unresecta ble, terminal rectal cancer. [n this initial segment of the OSeE (Part A), the simulate d palient gave consisten t. responses , and all physicians were able to complete the pain interview in the allotted time. The standardi zed patient described severe, constant low back pain of a nociceptiv e type. The patient did not describe any oescriptor s or neurologi cal changes that would suggest neuropat hic pain. A proctor evaluated the pain assessmen t interview. For this study, three proctors of different ranks were used during· all segmenls of the OSCE: a faculty anesthesiologist, a senior resident in anesthesiology, and a senior nurse pain specialist. The prc>ctors quietly observed the interviews (one proctor per physician) and rated physicians on a variety of pre-deter mined items believed to be importan t for a complete pain assessment. For example, physicians .were rated on their ability to assess pain on~;et, pain location, pain descriptio n, pain int,ensity, temporal pattern of pain, aggravating and relieving factors, previous pain history, review of systems, review of psychosocial history, and medical history. For each item not performed, a score of zero was given, a score of one or two was given if the
76
SIUfm et Cli.
1i,1. 14 No.2 AUIfU.,' 1997
item was per/onned poorly; and a score o[ two or [our was given if the item was performed well. At the elld of Part A, the proctor made several global judgment. of each physician's overall performance. The standardized patient also rated the interpersonal skills of each primary care physician. In Pari B, the physician Was allowed 5 min to answer three managelnent questions about the
paLient seen in Part A. No furl her i,,[ormation regarding Il,e patient's pain history was given to the physician. Each physician was asked to WIite out an analgesic presCliplion [or Il,e patient, to describe a management strategy if the patient. was unwilling to undergo opioid therapy because of addiction COllcerns, and La describe the management of ongoing severe cancer pain noted ,It it fullow-up visit despite prescribed analgesic thempy. The physician was also asked to list alternative "non-drug" analgesic therapy that .night be useful in Il,e management of cancer pain. The c\",iluation of each physician's perfol~ mance on Paft B was carried out immediately after compleJon of the tesLing session. Performance was rated on a predetermined checklist ver-' similar to the type used in a structured sh t answer ex.aminution. After reviewing ea<:.. physician's performance on Parts A and B, the proctor provided immediate feedback and instruction (P~rt C) on basic principles of cancer pain assessment and managemenL The proctor who evaluated each physician in parts A and B provided the 5 min of instruction to that physician in parL C. At the end of the session, each physician completed a ten-item evaluation of the cancer pain module. Measures of overall performance and of pel~ formance on specific items on Part A and Part B were summarized by several dcsctipLive statistics. Pearson '5 correlatiom were used to determine whether or not differences in performance measures could be attributable to amount of experience in family practice. Repeated-measures oneway analyses of variance (ANOVAs) were used to identity specific ilems 011 which Ille family practitioners per fonned best and worst. The 0.05 level of confidence was used to identity significant differences.
Results On average, the primary care physicians asker! 52% (± 4.5%) of the indicated ques-
4 VOIJMvcfl OLrtsbadlng
Fig. 1. Mean global evaluations of physician pain assessment.
tions for a detailed pain assessment. Thirty-five percent of the participants obtained between 40% and 60% of the information; this may be considered as "11compassing the high level of Il,e below-average range and the luw level of til" average range. Only one parl.icipant asked !llOre than 80% of the indicated questions. Figure 1 presents the means of Il,e four global ratings, Descriptively, the proctor evaluations of lhe doclor-p~tdcllt interactions were the highest, and Il,eir evaluation of overall performance, the lowest, although the differences between these two "extrclues" were relatively small, All four global ratings were in the avel~ age range. Howevcl; when the proctors were asked to make ajudgment of whether the physician was competent or noncompetent (yes or no evaluation), performance was viewed less positively: the proctors viewed the perforInances of 55% of the primary care physicians
as incompetent. There were also statisLically significant diffel~ enccs in how well l11e specific items were pel~ formed (F =3.81; df = 8, 200; P < 0.0001, from repeated-measures ANOVA). Performance on l11e pain assessment was best for eliciLing pain location (mean = 3.25, on a four-point scale, zero to four), pain-relieving factors (mean = 1.54, on a two-point seale, zero to I1vo), and asking the standardized patient about psychosociai history (mean = 1.21, on a tIVo-point, zero to 11~0 scale). Performance was poorest in asking about previous pain history (mean = 0,5, zero to I1VO scale), temporal pattern of pain (mean = 2.08, zero to four scale), and pain intensity (mean = 1.4l.', zero to four scale). On average, the primary cat'e physicians obtained scores of 36% (±3%) on Part B of the OSeE, Sixty-two percent of the scores were
_1"_01_._I_4_N._"_.-,-Z_A_'-,'I':,-U-,-sfc-'9'-9-'7_ _ _ _--'C;;."'-'-!C;.;."'-'-rP;;."'-'-·"...:I:::£t;;.lu;;.Cfllio..cn...:A.::,::.:"0-,U1'-',~'_,I:...'I"IJ",'!j/;.;.'o",·".:.:":.."_ _ _ _ _ _ _ _ _ __
50
Mean
=2.2 (0.3 semi
'0 30
c~
20
1j
~
10
Unsellsfactory
Below Average
Above Average- AVerage++ Avcrrge Outstanding
Fig. 2. O\'erall cvalmuion of Part B performance.
between 20% and 50%. The overall global evaluations were also quite low. The mean (:':SEM) ratinr- on a six-point scale ranging from unsatisfactory (zero) to outstanding (five) was 1.9 :': 0.2. Figure 2 presenl' a frequency distribution sumnlarizing these ratings. Approximately 70% of the physicians
were rated as below average or low average. Although 83% of the physicians prescribed opioid analgesic therapy (79% of the,e by oral administration), only 42% prescribed regular opioid use. Orally administered nonsteroidal anti-inflammatory drugs (NSAlDs) were prescribed by only 42% of the physicians, and only 17% prescribed for regular administration. Seventy-nine percent of the physicians did not prescribe an analgesic as needed for breakthrough pain. Only 540% of the physicians treated the patient'e feai' of addiction in an approFriate mailne~- 'with continued opioid therapy, and explanation to Ihe patient that addictive behavior is highly un iikely in this setting of cancer pain treatll1Cnt. The persisting pain problem was managed by increasing the opioid dose for only 54% of physicians. One might expect that years in practice would correlate with one or more of the pcrfOfInance l11easnres. To determine whether if
this lvas the case, we compared years in prac~ tice with the following: (a) percent ofin[orilIation obtained in Part A and Part B; (b) the two overall global ratings; (c) the interpersonal skills ratings by both the patient a",1 t.he proctor; and (d) the physician's organizational skills. Only the amount of information obtained in Part A correlated significantly with years in practice (r= -0.45, P< O.O!». That is, older physicians tended to do a less detailed pain assessment than di1 younger ones. To determine whir.h items differentiated competent £i'om noncompetent perfonnance in the pain assessment, independent-groups l test"} were carded out comparing these two groups on bOlh specific and global measures. On only two of the 12 specific performance items were there statistically significant differences: a"essing pain onset (t = 2.20, P < 0.05) and assessing pain intensity (I = 3.85; II < 0.001). The competent group received statistically significantly higher evaluations than did the noncompetent group on all five of the general ITIeasurcs of performance. Among tbese items, the global rating of how organized the physician was in performing the pain assessment (mean of the competent group, 2.83; mean of the noncompetent group, 1.35; I = 6.17; P < 0.001) was the most discriminating among the global items in Part A. Because no conlpelence rating was Blade in Part B, each item was correlated with the overall evaluation of Part R performance. Table 1 presents each Jf these correlations. The effectiveness of the SCIM was evaluated in two ways. First, the participating physicians judged the value of the SCIM as an instruction,,1 method. Second, AN OVA was used to determine whether differences in how the SCIM was evaluated conld be related to the proctor. Overall, the physicians viewed the SCIM as an above-average method of assessing
TaM, I Part B Correlation of Specific Items with the Overall EvaJuation .Jf Performance Item p rxy Item Incrc;ase opioid use Nerve block-altcTIlativc analgesic therapy Percent of anSWers that were COiTeCl Additional PRN analgesic f01' hrcaJ..lhroligh pair. Explanation that "addiction" is Hot an issue NSAID prescdhcd Opioid prescribed NSAID. llo'l:;;tcroidal anti-inflammatory drug
77
0.78 0:14 0.74 0.63
<0.00] <0.001 <0.00]
O.5H
<0.001 <0.0]
0.48 0.46
<0.02
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Sloan el al.
ruM
Disagree
Agree
Mean(±sem} Ph~sieian Rating
1.
Overan. the module tested important and rel.vant clinical skills.
2
4
5
4.54 (.11)
2.
OvcraJl. the module was a realistie losl crmy clinical skills.
2
4
5
4.23 (.16)
3.
This module provided information about clinieal skills thai has 4
5
4.08 (.16)
4.
This canoor pain module idenlilied slreng1/l and deficits in my clinical skills.
2
4
5
J enjoyed participating in this inslructional formal
2
4
5
6.
Ther. was sullicient time 10 complele the pain history.
2
5
4.15(.18)
7.
There was sufficienl time to complele the questions.
2
4
5
4.23 (.15)
8.
This module w.. not unduly stressful for me.
2
4
5
4.38(.15)
9.
The feedback given you by the instructor increased the 4
5
4.76 (.10)
not been provided by other assessmenl methods.
2
edu.alional value of this module. 10.
3
3
4.04 (.18) 4.50 (.13)
Whal is yO'Jr overall .valuation of this pain module os. method for ..aluatingyour clinieal skills? 2
4 4.10(.14)
Poor
Below Average
Average
Above Average Outstanding
Fig. 3. Pain management stru.:turcd clinical instruction module evaluation form with mean physician rating of itcm5.
clinical skills (mean = 4.10 ± 0.14 on a fivepoint scale). Eighty-eight percent of the physicians believed that the OSCE was above average or out,tanding. There were statistically significant differences among the nine specific items (Figure 3) used to evaluate the SCIM (F = 3.SI; dfS. 200; P< 0.001). Physicians agreed most with statements that the feedback given by the instructor increased the educational value of the SCIM (mean = 4.77 ± 0.1 0), that the SCIM tested important clinical skills (mean = 4.53 ± O.II), and that they enjoyed participating in this instructional format (mean = 4.50 ± 0.13). They agreed least, yet still with an above-a,·erage raung, that the cancer pain SCIM identified strengths and deficits in their clinical skills (mean = 4.04 ± O.IS) and that the SCIM provided information about clinical skills that has not been provided by other assessment methods.
The overall evaluation of the SCIM suggests that not alI proctors had the same effect on the physicians' reaction to the SCIM (F = 5.98; df= 2,23; fJ= O.OOS). The OSCE proctored by the faculty member and the resident (faculty Inean =: 4.35 ± 0.15; resident lucan ~ 4.38 ± 0.18) were rated signilicantly higher than that proctored by ti,e nurse (mean = 3.50 ± 0.27). The proctoring by faculty member, resident, or nurse was approximately equally divided among the family physicians.
Discussion Burge and Latimer suggest that the weIJprepared family physician is the ideal doctor to be involved in the. comprehensive delivery of palliative care to paticnts. 1O With the changing mode of health-care delivery in America, the family practitioner is increasingly involved
Iill. 14 No. 2,tux'c.! 1997
Canrer Pain Belucaliun
in the total care of the palien l, and the pain specialist is seen as an available conSUlk'lIlt to help with difficult clinical scenarios. Indeed, in the United Kingdom, family physicians have been found to be responsible 90% of the time for the care given during the last year of a cancer patient's life. 1 1 If good palliative care is to be administered, the family physician must have a basic understanding of the assessment of cancer pain and the management principles required to relieve this pain. The results of our study suggest that many family physicians may be inadequate in their clinical assessment and management of cancer pain. Some basic items important in a detailed cancer pain assessment were inli'equently asked by our group. For example, most physicians did not ask, Of asked poorly, about the measur\!~ mcnt of pain intensity during the interview. Recent studies have shown that most practitioners would welcome postgraduate education on pain management. 12.13 The Wakefield ct al. I" survey of family phydcians found that the more experienced physicians perceived less need for further training in pain management. The results of our study show, however, that there was little difference in performance on the assessment or management of cancer pain between less a>ld more experienced physicians. Indeed, the older physicians tended to provide a less adequate pain assessment than their less experienced colleagues. Our study supports the need for continuing education in cancer pain management regardless of years in practice. Many surveys have demonstrated that physicians are deficient in knowledge about cancer pain. 13- Jll The use of performance-based testing in our study provides additional data from the observation of actual standardized physician-patient interviews. The opportunity to observe physicians in simulated structured environments provides objective evidence for how physicians actually practice, as opposed to the knowledge information obtained from survey data. For example, a recent cancer pain knowledge survey administered to physicians in southern Italy found that 100% of respondents assess pain location and pain description; and 81% also assess pain intensity.17 The survey data arc in ~triking contrast to the results of our study showing that 54% and 70%, respectively, of physicians assess pain
Amoll~
Physicians
79
description and pain intensity, respectively. poorly or not at all. The direct observation of physician deficiL' noted during the [,ain intelc view was a powerful educational tool in the teaching of cancer pain principles in Part C. Most physicians prescribed orally adminislered opioid analgesic therapy for this patient with severe cancer pain. This practice, consistent with published guidelines on the management of cancer pain, is encouraging. IH How· ever, only 42% of physicians prescribed the regular use of opioids. Similarly, although many physicians prescribed oral NSAlDs, vcry few prescribed regular dosing of NSAIDs. Although providing an analgesic as needed for breakthrough pain is widely accepted, I!' it was rarely prescribed for the standardized patient. There is clearly a need for focused continuing medical education on the appropriate use of analgesics and co-analgesics in the management of cancer pain. The use of "non-drug" analgesic therapies has been recommended as .an adjunct for the management of cancer pain. 20 Ferrell found that heat and massage were helpful to patienL' wilh cancer pain, and that both patients and families were very eager to usc these non-drug interventions. 21 Relaxation therapies. massage, and physical therapies were the most frequently recommended alternative non-drug analgesics in our study. Both radiotherapy and chemotherapy have a defined role in the management of cancer pain. The fact that radiotherapy and chemotherapy were listed by only 8% and 0%, respectively, of physicians in this study as alternative analgesic therapies indicates that further pain education is required in this area. To achieve good pain control for all patients, physicians need to learn a wide variety of pain-relieving techniques. The standard continuing medical education workshop has been found somewhat ineffective in changing the practice habits of physicians. 22 The clinical formaL of our education module combines patient interaction with immediate evaluation and feedback to the physician regarding both the strengths and weaknesses of the cancer pain assessment and management plan. Further studies are required to investigaLe the efficacy of this educational format in changing the practice habib of physicians. Four characteristics of successful teaching programs in palliative care are
80
included in our cancer pain module: the identification of educational needs of the specified group; a clear statement of goals and objectives of the teaching program; the use of methods that involve active participation: and an
evaluation to provide feedback. 2:1 The abili ty to apply knowledge has been argued to be one of the most important skills necessary for physicians in the 21st century.2. We believe that this cancer pain module can not only measure the knowledge application skills of physicians, but also educate physicians in these areas. This cancer pain education InoduIc was
extremely well accepted by most physicians. The physicians el1joyed participating in this instructional format and found the immediate feedback given by the proctor very valuable. This type of performance-based evaluation and instructional feedback has been criticized because it requires a significant time cOlIlmitment by faculty members and therefore may not be reasonable or cost effective. Because our study showed that both residents and faculty anesthesiologists received similar ratings from the participating physicians when serving as proctors, this necessary manpower may be provided in university hospitals by resident physicians. The use of residents would increase the feasibility of providing this instructional format on a widespread basis. The nurse proctor was rated lower than the physician proctors (however, still above average), which may reflect the reluctance of practicing ph~si dans to be instructed by others outside of their field of practice. This finding requires further evaluation and study. Finally, the deficits in the a'5essment and management of cancer pain found among family physicians highlight the need for evaluating the effects of different educational programs on clinical practice and patient care. The performance-b;,scd testing module may be an excellent pretest and posttest tooi for measuring the efficacy of different educational programs. It could also be modified for use in the recertification processes of various health disciplines. The strengt;l of this tool is that it clearly demonstral~s activity and behaviors that physicians display in their day-to-day practices.
Vol. 14 No. 2 A!l~oIJI 1997
Siorm et af.
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Acp!-!r~
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.r Am Gerialr Soc 199 I ;39:64-73.
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