Cancer pain education for physicians in practice: Establishing a new paradigm

VoL 12 No. 6 Lkcemk I996

364 Jmmal of Pain and Symfkm Man-

Cancer Pain Education for Physicians in Practice: Establishing a New Paradigm David E. Weissman, MD Llikima of Hem&& OncdogR PaUiaIive Medicine F’rogran. Drpanmm~ of Medicine, h&did Chlkge oJ Wisconsin, Mitwaukee, Wisconsin

Tmditional education methods fm physicians have failed LO impact posirively upon cnncer pain clinical pm&x. This article pmsmfs (I new paradigm for physician cancer pain education based on principles of adull learning and physician behnrim theory. Three hey issues lhal weave together education and inslitulionalizalion issues are rzukwed: (a) how to make physici’otfi aware that their current prackze behavior is las lhan oplimak (b) hmo to match education objeciiues with a#ro/niote education fmmals; and (c) how to change pain managmnent practices wilhoul imposing new burdens on physician practice. 0 U.S. Cancer Pain Relief Committee, 1996. J Pain Symptom Manage 1996;12:364-371. KeyCancer pain, palliaku

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hirodu&m In a recent editorial, “Pain relief into practice: rhetoric without reform,” Kathlren M. Foley, MD, reiterated the well+zstabiished fact that the ttanslation of existing !.nowledge about cancer pain into improved clinical care continues to be a major problem in American health care.’ Cancer pain clinical guidelines have been written and disxminated. quality assurance measures established, and curricula written for various health professional groups, but all indications are that the current level of cancer pain management still remains far below a desire<&standard?” Ad&r.ssr+izu~~DavidE.We&man, H.?tllXology Onwlqy Dti. Froeden Hospital&s& 9200 Wst Wuvonsin Awnue. Milwaukee,Wl5326, WA. Aoaptal&6rp February28.1996. 8 U.S. cancer Pain Relief t-klmmilLee. 1996 i’ubbhed hy Ekebier. New UC& New York

Because drug thempy is the mainstay of cancer pain relief and physicians are the “keepers of the keys to the medicine cabinet,” physician education has been viewed as essential to make improvements in cancer pain management. In fact, the standard paradigm for thinking about the problem of poor cancer pain management often places blame for the problem largely on the physician, leading LO the idea that providing physician education till solve the problem. Traditional physician education programs, such as continual medical education (CME) meetings, staff conferences, and journal articles, however, are now recognized as ineffective at changing cancer pain practice behavior.” This article reviews the current status of physician cancer pain education, focusing on physicians-in-practice, and discusses a new o8aH924/96/$15.00 Pl1tioa53*4(96)00185-6

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-tOGl?tCf?S-Pain Managemmt: pnysiciwr Issues The reasons physicians poorly manage cancer pain have been well studied, including both basic knowledge deficits and attitude issues.‘-” Chief among the attitudinal barriers are feats of addiction and serious toxicity (for example, respiratory depression), feats of the consequences of such outcomes (for example, malpractice), and feats of regulatory scrutiny. Among the knowledge deficits, how to perform a thorough cancer pain assessment, and understanding the pharmacology of opioid and adjuvant analgesics are the predominant problems. Other, even more problematic barriers include the very nature of how pain is perceived and treated by physicians, time constraints (time in direct patient care and time to institute practice changes), and financial issues related to drug/procedure costs. Barrier5 relevant to physicians are similar to those that apply to nurses, pharmacists, and other health professionals, especially fears of using opioid analgesics, lack of understanding of pain assessment,and issues of time and money. When combined with the recognized widespread patient and public barriers to better pain control, it is clear that this problem extends Elr beyond a simple physician issue, and, in EXI, is a highly complex societal problem. It is now well accepted that improved basic knowledge is not sufficient to improve cancer pain practice. 6~‘z’~”The fir more difficult task of confronting inappropriate attitudes that result in poor practice patterns must also be addressed. Because inappropriate attitudes (for example, exaggerated fear of opioidinduced respiratory depression) are demonstrated as undesirable practice behaviors (inadequate doses prescribed), undentanding the motivations for physician beh+or and behavior change can serve as a framework for considering future cancer pain education suategies. Creco and Einberg’s reviewed the subject of changing physician behavior, providing a list of potential metbods and discussing the available research documenting outcomes of each method (Table 1). As they noted,

there is no single best method for changing behavior, and it is better to consider a combination of methods, best fit to the particular circumstances to be addressed. Three issues are raised by the authors to consider specifically when designing intervention strategies: “First. is the intervention appropriate for the desired change in practice . . . Second, do physicians support the proposed change in their practice. . . . Third, how will the intervention itself be perceived?“‘s As they apply to cancer pain, these questions could be rephrased and reordered as: First, how do vou make physicians become aware that their own style of clinical practice. reflecting their personal and professional attitudes and belief%, may not be optimal and tbar change is therefore warranted? Second, how do you match the desired change in knowledge or behavior to the appropriate educational format? Third, how do you bring about change in the practice of cancer pain management that will not impose upon physicians additional administrative or regulatory burdens? Each of these questions are reviewed here in the context of current cancer pain education strategies.

MakingI-%ysicians AWU7VZ7lat neyA?wPartoftiheI)rrblemr Although many American physicians may be aware that as a national issue, cancer pain management is a problem, it is the unusual physician who can admit that they are personally pan of the problem. Physicians tend by nature to think highly of their own skills and may have difficulty recognixing that their own attitudes and skills are less than optimal. After all, for physicians to admit that their skills in pain management are poor is to admit a failing in the single most basic aspect of patient

care. Nonetheless, because the admission, at least privately, that their skills need improvement is a hrndamental first step to improving cancer pain management, what methods are available to help physicians? Two common ways in which physicians can become aware of their own deficiencies as a motivation to change include testing and feedback. Tesling A test can be defined as a “systematic procedure for measuring a sample of behavior.“” Physicians are well accustomed lo taking tests, although after medical school, such tests are largely used for credentiing purposes or to obtain CME credits. How can testing be used IO make physicians more aware of their attitudes/ skills in cancer pain management? At its most fundamental level, test questions regarding cancer pain can and should be inch&d in all primary care and relit medical specialty cnzdentialing examinations. Although program directon vigorously contest thii issue in principle, it is clear that examirution content will dhve curriculum content. Thus. the fact thar cancer pain will be an area of credentialing content will help mowz cancer pain into curriculum content. A poor score on cancer pain questions within a larger credentialing examination is, however, unlikely to be known by the examinee and, therefore, will be unlikely to effect a desire for more leaming. Testingcanalsobeusedprimarilyasalearning tool. For example, prior to any teaching format (for example, a lecture on cancer pain 10 community physicians), a brief test can be adminiwd to learners. including both knowledge and attitude questions, hilighting key learning w Izarnen anz then immediately conkonted with questions to which they maynotknowtbeansw9r.thustai.5ingtheissue kmcednr)r. a stmng motivation for ofp”“al further learning. ting the same leamen to complele a post-test after the learning exercise help the hner understand the level of know+ edge~eimporianttobotbtbe learner and the educator4 again demonsuatestotbekzunercontenlareasneedinghrrlber edlxach.‘s Yet another way to utilize testing as a means to highlight ph+ian deficiencies is to help institutionalize pain management practices within a clinical facility. A facility (for ntample,

a hospital or a long-term care facility) that has begvn the process of improving cancer pain management can test its physicians knowledge and attitudes and measure the responses against published guidelines.’ This type of testing can then be used to pinpoint deficiencies suitable for educational intervention. This use of testing may only be possible, however, if the physicians have first agreed at least that a local, if not personal. problem exists. Other measures to local drug prescribing practices, patient satisfartion surveys, and so on may be needed first to document that cancer pain management within a medical facility does not meet national standards, before physicians are willing “buy into” the idea that their own practices need to be evaluated. Feedback Feedback is a more active method to make physicians aware of tbeu deficiencies. Feedback can be administered on a local level (for example. within a ph$cian practice grwp) or on a stale level (for example, state medical boards, peer review agencies). Such feedback may have no associated consequences attached to poor performance or it may include a positive education component and/or a negative diuiplinary action. Such consequences can be hum&zing ;rtd/or thwarening to an individual practitioner, who may ~91 agree with the relevance of the feedback Furthermore, if not for change accompanied by other r;dvaIio~ (for example, dedicated *&nation time or sup porting clinical environment for change), feedback will likely IXI to change ptactice behavior.

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Probably the single most important step toward developing meaningful cancer pain education progracns and materials is to acknowiedge the role of the physicii as an adult learner. As adult learners, physicians are oriented toward learning that is based on (a) a perception that they “need to know” a panic&r aspect of information, (b) information that is readily accessible and useable, and (c) information that is cons& tent with their prior experiences. All ph@cians have had some personal and/or profes5ional experience wilh cancer pain and pain Peatment that influences their attitudes toward pain,

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to care. Oc pkt tt~~)’ idudc phyical. ~ychological. and +itual that D C~t~t@hl lhat drug and nondrug tknpv mu.u be indiridualiud. padenm with chronic pain rccei& opioids arc not drug addicts.

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Unde~d Le Agency for HeaM Cur Policy and Research Cancer Pain Gtidelim recommendations.’ Describe the ~cmtttmn health profesknal. patient. and fkity barrier\ to cancer pain tnanagcmcnt. Dacrihc the essential elements of a cancer pain awssnen~ Drscrik the de of tilltrea-•u in cancer pain manqcment. Know the World Healdt Organization duce-stcp ladder approach for cancer pin.“’ Understand the role of acctaminophen and nonstcroidal mtiinflammatwy drugs (NSAltk) for mild cancer paw. tJndct%and dte indicacionr. main plumucdogical fraturcx and tackily of morphine. oxyrodonr. h~tiomorphonc. fentanyi. hydmcodone. and codeine. ldentil) prophylactic and active treatment apprmcbc% for cantnon opioid side cficct~. Define the features of opioii toletancc. ph+al and pyrhological dcpcndcncc. Descrik the indications. phammdogy. and toxicity of adjuvlnt analgcsic~. Describe the indications for psychdogical and anesthetic pain treatment approaches Understand an approach to mating pain in a curwnt OT fonncr rubuancc abuur. Know when to refer a cancer pain probkm to a special& Know the trkvmt state and kdet-.xl contruUed subwnces rrgtdationr. Know the ethii issues invdwd in cancer pain management.

Demonstrate communication ud cognit& skills necessary to obtain a pain aswwnent in adult. children. mnd patients with cognitiw impaimwm. conmt a diEi5enW diagnosis for dlt C O ”sc of pain. Develop an initial and long-tetm treatment plan for patienn nth pain and cancer. Utilii skilb of allied heallhure profesJionrlr in a cdlabwatk rflort to improw pain tnanag~mcnt. Know how to convert P patient’s dau of onl opiokk !.I a parentcrai opioid ana@= whik maintaining LOIIIIIIIIOW Prescribe

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u-e of 4xwt-acting and/or bngating including dose titration. Know how to assist patients uim have ps)rhdogical or spititual pain as a rompmnt of tbcir pain Counsel a patknt and family apprqwlteiy in the LLY of pain nrdicincx Counlel a patient who b fealful of taking opioid Gilta&ks.

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towatd pin tratmcnt, and toward the Gew they have of themsctva as providen of pain n+~f.‘~ These experiences influence their attitudes dxntt the pctxortal meaning of pain for then+ st=lvcsand their patknts, and about such commonkarsastheti~kofopioidaddictionand rcspimoty depression. Education formats to convey cancer pain kmwkdge or proGde a means to overcome attitudinal bartiers can he broadly divided into kctures. ;academic detailing. small group experiences, and experknlia exeEach format hasstreqJtsandweaknes8t3,dependingonthc dcsirededucationobjectA~.Tablc2listssome common cancer pain education o@ect&s suitabkforplimaryQreph@&nSNc4ethatthese ohjectiws include attitudes, knowledge, and sk&Outlinedlaterhereucexampksofhow

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the different cduatiott fomuts can be matched to the diffemnt learning objecti\ps. larura Lectures are the most common format by which cancer pain education is conv+ to physiciansin-ptacticc and. in at least in one report, the method by which physicians wild most like to receive cancer pain information.” Education of factual content such as ptincipks of pain aBes5mcnt. and indications and use of drug therapy or antineoplastic treatment can be conveyed to a large audience using a letturc format. either as a direct kcture or by teleconferencing. Although preparation time and expenses arc generally reasonabk, kctures pFovide no opportunity for active kaming or diiussion of individual attitude issues.

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Thus, retention of facts and proper application to clinical practice should not be expected following an isolated lecture unless reinforced by other education formats. A variant of the lecture format, whiih involws at least a pottion of the audience in more active leaming. is a questionand-answer (Q&A) se+ sion in which an instructor leads a discus&n (any size audience is possible) based solely or in part on aur!!cnce questions. The QLM format an be melid in that it allows pArEpants 10 t&e clinical problems that prmide the u.rcber an opportunity to divuss faccuaf informauon within a clinical context. .is an unstructured format. however, the educational content may not meet predetermined objectives.

Academic detailing refen to a one-onone educational encounter with physicians, similar to the type of encounter between a physician and a representative of a pharmaceutical company.‘” The success of academic detailing lies in the use of a well-focused education message to an individual practitioner (for example. teaching a doseescalation scheme for a particular opioid). This education method has been demonstated to be an educational experience that will alter practice behavior.” Although not studied as a method in cancer pain. it has been used successfully to change physician prescribing for acme postoperative pain’s The drawback of this intervention is that it is both time and labor intensive.

!jldgmp expeliences, whether case-based or he formal problembosed approach, can in&de a tange of ltaming activities to meet many different educational objectives. Discus sion of inappropriate attitudes (for example, addiction, tolerance, linkage of prognosis to treatment intensity), feats about cancer pain practice issues (for example, legal and ethical issues), as well as direct knawledgpbased conwilt (for -pk. how 10 perform quraMgesic Qlcuhriom).areweUsuitedtoasmal@oup experience. When appropriately facilitated, snailgroup expexiences allow for peer dialogs, opporthties for team building, and the ability to dii feats and concerns openly. Smallgroup experiences, of which attending teaching roWtckhonecha5icexampie,areahoexceUent

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Tot discusing clinical cases that reinforce kCNre material abot:t pain assessment and management. Small group sessions, however. require a clear statement of the learning objecti\vs and substantial preparation time, including facilita tor uaining and case preparation.

Experiential exercises include a broad range of activities in which the Icarner plays an active role using either real or simulated expetiences. For example, role-playing exercises using a casebased format, with or without a standardized patient, and either a learner4eamer or leamerinstructor format, is an excellent wa)r to practice pain assessmentskills, reinforce other communication skills, and provide immediate learner feedback. Role-playing exercises can also be designed IO help physicians confront inapptoptiate attitudes that are barriers to effective pain management.*’ Fxercises can be readily audio taped or videotaped for further review and comment. Another example of an experiential opportunity IS one that provides for direct role modeling. Medical students and residents develop much of their practice habits by role modeling from their supervisors, and physician.+in-ptactice may model their clinical practice aher local or national “opinion leadets” (for example, a wellrespectcd community internist or hospice director).” Of note, the diimination of national pmcuce guidelines is usually insufficient by itself to - hange ptactice behavior and may require the training of local “opinion leaden”” Role modcling experiences can range from a “curbside” consulcation to a more formal preceptorship experience in which a physician spends time with an “expert,” learning at the bedside as an apprentice. Such experiences. while requiring considerable time and cost commitment by both he ph+ian “expert” and the apprentice. are an excellent means to foster appropriate at& tudesandtoimpanasolidknow~edgebme.Sevet-al such apprenticeship progtams are in place in the United !3ates

cocnbiningEducotionalFBecause different education formats have different strengths and weaknesses depending on the educational objective. it makes sense to combine formats to provide a richer education experience. The Role Model Program of the

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Wisconsin Cancer Pain Initiative (WCPI) is one example of such a progratn.~“~ In one g-hour education program, lectures presenting factual content are alternated with smallgroup, cawbased experiences to discuss attitudes and review skills, building from the lecture material. There is great learner satisfiction with this type of experience. and Ieamets can demonstrate a significant improvcmen: in immediate knowledge gained and also demonstrate knowledge rctention.yY”s The direct impact of this type of combined education format on actual physician cancer pain practice behavior has not been studied. Combining E&u&m Audiences Although there are certainly unique. discipline+pecific issues on cancer pain management, there is also tremendous overlap of attitude, knowledge. and skill issues among physicians, nutses, and pbartnacists. Thus, it is appropriate to consider developing education programs that include nurses and pharmacists together with physicians. Most commonly, this is done by advertising a conference on cancer pain for any interested health care professionals. Unfortunately, such programs typically attract few physicians, often at a nutse-tophysician ratio of IO to I. Another, more labor and cost-intensive approach is to recruit directly interested physicians, nurses, and pharmacists lo an education program. Two such progtatns. designed as both interdiiipb nary education experiences and attempts to begin the process of cancer pain institutionalization, include the WCPI Role Model Program and a progtam developed by Fcrrell and colleagues at the City of Hope Sattonal Medical Center.“~*N”4 ThegoalsofbothpmgramsaretoproGdea direct education experience and also to begin the process of instiNtiottal change tn the leamcts’ practice setting. In both. physicians and nutses who work in the same health care setting are recruited lo panicipate in an intense edua tion experience that includes Eutuaf content. knovkdgc concerning institutional change. and knowledge concerning cancer pain edtuation strategies. Roth programs generally rely on recmitrnent of the “choir.” that is, individuals alreAyawatethatcancerpainisapmh4emand who are interested in being change agents in their ittUiNtiOd Setting. hth program ha\C

documented good learner satisfaction with the education content and design; excellent secondary diawmination of information to other health care pmfemionak. p0tients. and the public; and the heginning steps to institutionalize better painmanagementptanicesintbehealthcare settintp of the learne~myss’ Neither approach. howner. has been directly studied to determine on iudiGdual physician practice its impact behavior.

The third issue in considering the reform of physician cancer pain practice ‘s to review how institutional or governmental changes desigr,ed to improrr pain management practices will be riewd by physic&s. a*, the godisw institute ptacticc changes that support improved pain management without imparing new administrative or regulatory burdens, which are more &an likely to be met with anger, suspicion or It r. Itnohing ph+iars in the dewAping of pt mess

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hen, them “buy into” the process. As Creco and Eise-nberg noted. “physicians will oppose changes they perceiw as threatening to their iiri~.7ood, selc esteem. serue of compcrcncc or autonomy. Thus interventions that dw rease phisicians‘ decision-making authority, reduce thetr income. chalfen~ their profeGonal judgments OrappeartOCompromisc patient carte are more likely to fail.“” They argue that physicians should be actiw=ly inwAved in the proceu of changeandsuggt%onemethudistoapplytechniques of industrial qtntity improbwmenr. Examples of administrative methods that alTect cancer pain practice behmior include creating barriers (for example, obtaining pharmacy approml hefore using meperidine) or reducing barriers (for -pie. prm-tdtng cquianalgesic .ables at nursing stations) Other examples of local admintsttati~e methods include the dc\=eloprnent of critical pathwan, star&~ puin assessment forms. and policies and prcxedures for opioii infusions. At the governmental IevA. sevctal states have passed legislation aimed at reducing regulatory barriers to prescribing opioidr and one state, Michiin. has passed legislation mandating physician pant edua60n.‘5S The manner in whtch thtK administrative changes arc

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1. Understandme basicprinciplecof phrician practicebeharior. 2. View pl+zn educationa only one compncnt of a larger institutional plan for improvedpain management. 3. Involvephy&ianr in developing plans for institutional charrae?to pain management pnctices. . 4. Utilize principlesof adult learning when designing educationprograms. 5. Help physiciansrealizetheir own deficicncisr. 6. Match the desiredlearning ohjrctivc with an appropriateeducation format. 7. Work to include a smallgroup and/or experiential learning opportunity to all education cxperiellces.

viewed by physicians and the effect they have on physician practice have not been studied. Common sense dictates that for physicians to institute positive practices changes, they should be supported by a clinic;:l milieu that supports such changes.‘*“.2”.‘7 This includes pain education for nurses and allied health professionals, regular use of standardized pain assessment procedures, good pain assessment and treatment documentation, and a ystem of quality assurance for pain management. Roth the WCPI Role Model Program and the City of Hope program have included these concepts in their education design and both have demonstrated successin helping participants hegin the process of making these institutional changes. The process by which such changes take place is very timeconsuming and requires a major and continuing commitmeni, both by partici ants and their health care institutions.‘* B’ Furthermore, experience from the Role Model Programs has shown that the participants, even those who ate well motivated, must first develop a certain level of skill and comfort with the basic principles of cancer pain management before they can become effective change agents.

New Eduwtion Paradigm Table 3 outlines a proposed new model of how health educators should think about the issue of cancer pain education for physiciansin-practice. This model breaks the traditional

Vd. ?2 No. 6 Decmbn 1596

physician edtication paradigm that has proven to be of so little value in changing cancer pain practices. The model includes eight points that synthesize the material outlined here, placing emphasir OK principles of adult education and physician behavior. Points 1-3 highlight issues of physician practice behavior, stressing that physician education must not occur in a void-it must be coupled to changes in the clinical environment that will support new learning and practice changes. Change in the clinical environment, often referred to as the process of institutionalization, include (a) an institutional commitment to provide excellent pain management and the necessary administrative support IO ensure that goal is realized, (h) a system of pain assessment and documentation, (c) written standards of care including pain policies and procedures, (d) a system of accountability for poorly treated pain, (e) a program of quality assurance. including measures of patient satisfaction, and (f) a plan lor staff and patient/family education.‘.‘4.” Points 4-8 highlight sound adult education princtples. They stress a shift away from the traditional lecture format as the sole vehicle for cancer pain education to one that includes a combination of education formats and interdisciplinary learning experiences. The concept that solely providing facts to physicians will be sufficient to effect practice change must be abandoned. Farrell et z1I.2~and Foley’ have both stressed that lack of time, coupled with competing institutional pressures, is a key factor that limits even the best of intentions to change ptaclice. Therefore, along with a new paradigm for physician education, a new paradigm must be deveioped for thinking about how to change the culture of pain management on both a locai and a national scale. Some of this work is being done at the level of state cancer pain initiatives, working together with private foundations aud national organizations. Mucn more work is needed to define the most costeffective and time-effective education and evaluation strategies, and to streamline the process of cancer pain institutionalization. The challenge for the next 10 years will be to find the necessary resources, both haman and financial, to move forward and change the culture of pain management in this country.

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Dr. Weissman recognizes Dr. June Dahl f.x her ongoing support and insight into cancer

IS. Greco PJ. Eiinberg JM Changing physicians’ practices. New Engl J Med 1993;329:1271-1274.

pain physician education. The author’s work is supported by National Cancer Institute Cancer Pain Education grant R25 CA 57785. Dr. Websman is a Faculty Scholar in the Pro ject on Health in America, Sores Foundation.

14. The nature of psychologicalmeasurewent. In: Brown, FG, ed. Principles cf educational and psychological testing. New York: Hoh. Rhwhart and Winston. 1976:%18.

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