Pain and palliative care: the knowledge of medical students and the graduation gaps
- By Medicine Mates
- Posted 372 days ago
Pain and palliative care: the knowledge of medical students and the graduation gaps
Florentino Fernandes Mendes1
João Antônio Vila Nova Asmar1
Pauline Lopes Carvalho2
Fernanda Laís Loro2
1Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Medicina, Porto Alegre, RS, Brasil.
2Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Fisioterapia, Porto Alegre, RS, Brasil.
3Universidade Federal de Ciências da Saúde de Porto Alegre, Curso de Enfermagem, Porto Alegre, RS, Brasil.
BACKGROUND AND OBJECTIVES:
Currently, the medical course does not provide complete education and handling of pain, and it is also devoid of disciplines addressing thanatology in palliative care. The objective of this study was to evaluate the knowledge about pain and palliative care of medical students and their perception on how these themes are taught the graduation course.
We invited to participate in the survey students of the medical school who are concluding the fourth, fifth and sixth year of graduation at the Federal University of Health Science of Porto Alegre. The demographic and characterization data of the sample were collected, and a questionnaire was applied and validated with 19 direct questions about pain and palliative care.
Forty-seven students agreed to participate in the study. The vast majority mentioned not receiving enough information during the undergraduate program about the proper handling of patients with pain, and patient care in a terminal situation.
This study highlights education gaps on pain and palliative care in medical schools. It shows the difficulties of the students have to put the theoretical knowledge into practice, for example, their insecurity in handling pain, especially when it comes to the use of opioids.
Keywords: Academic institutions; Analgesia; Medical students; Palliative care; Students
Care provision by health professionals to patients with pain allows the rational use of the health system and drugs, in addition to humanitarian aspects involved. It also provides a reduction in disabilities and absenteeism due to pain. Consequently, public health care expenditures and the psychosocial and economic repercussions due pain1are reduced. In addition, the pain presence is associated with a longer hospitalization period2, and its evaluation is related to the reduction of analgesic use and mechanical ventilation duration3. However, it still occurs in professional health institutions that do not have enough capacity to recognize, evaluate and take effective measures to control the pain symptom4.
Correct pain control and its treatment face barriers related to 1) professionals’ knowledge deficit in relation to pain phenomenon dimension; 2) reluctance to use opioid analgesics due to lack of knowledge5-7; 3) belief in pharmacological dependence; 4) difficulty in believing the patients manifestation in response to pain experience and interventions to ameliorate it4.
As with knowledge about pain, knowing about palliative care is fundamental to deciding on the best behavior, once is through this the physician will be able to integrate psychological, social and spiritual aspects in the care, having good communication with the patient, his family, and the multiprofessional team and promote autonomy by providing diagnostic and prognostic’s information8.
Most of the medical curriculum briefly integrate the pain issue and in clinical stages, this is often a non-existent subject9-11. Indeed, in a study conducted at the University of Michigan, only 10% of physicians had received formal education about pain and its treatment during medical school, medical residency and/or continuing education12. Therefore, lack of knowledge about pain makes it difficult for physicians to correctly diagnose and treat it, which reveals the need to improve pain education during undergraduate medical courses13,14.
Likewise, many medical curricula are devoid of disciplines dealing with the thanatology addressing palliative care. The teaching of health professionals, including the physician, is more technical-oriented, sometimes neglecting the human side8. Therefore, as with pain, palliative care is not sufficiently taught during graduation15,16. In Brazil, knowledge about palliative care is often acquired in other undergraduate fields as an intuitive feature due to lack of specific training17.
This study aimed to evaluate the knowledge about pain and palliative care, and the perception about these subjects’ teaching during graduation, by the students at the end of the fourth, fifth and sixth years of the medical course at The Federal University of Health Sciences of Porto Alegre (UFCSPA).
All students of UFCSPA medical course, which in December 2016 were finishing their fourth, fifth, or sixth year of graduation, were invited to participate anonymously and voluntarily, totaling 264 students. Researchers contacted the survey undergraduates via online networks. The Free Informed Consent Form (FICF) was sent, and the questionnaires were made available through Google Docs.
All 264 students in the fourth, fifth, and sixth years of the UFCSPA medical course were invited to participate in the study, and the final sample consisted of all the students who answered the online instrument, being, therefore, a non-probabilistic sample.
Questions were asked to characterize the sample, including the year of the student’s education, gender, marital status, the previous need for medical care in the medium or long term, health plan and medical specialty to be chosen after graduation. Students’ satisfaction with the undergraduate course and their performance were evaluated using the visual analog scale (VAS) from zero to 10 (zero indicating dissatisfaction and 10 indicating total satisfaction). To verify knowledge about pain and palliative care, a questionnaire with 19 direct questions on these subjects, previously validated18 and applied in a study with medical students from the State of São Paulo19 was applied.
The Ethics and Research Committee in Human Beings of UFCSPA, protocol No. 2,162,651 of July 7, 2017, approved this study.
From the variables obtained in the socioeconomic questionnaire, it was possible to identify the profile of the 47 students who agreed to participate in the research. Undergraduates of the fifth year are the majority (46.8%), followed by the fourth year (42.6%) and sixth year (10.6%). The male sex (53.2%) and the single marital status (97.5%) prevailed. In relation to the specialization area, 18 areas were mentioned, of which are highlighted surgery, with 11 interested students, neurology with 5, dermatology and pediatrics both with 3. Regarding access to health through plans, most of them enjoy private access (78.7%), and only 14.9% have reported having already needed medical care for the medium or long term. Students’ satisfaction with the medical course, and with their own performance in the undergraduate course, both received a score of 8 with higher frequency (44.7 and 29.8% of the sample, respectively).
With regard to theoretical knowledge, it is seen that: 97.9% of students answered they know some scale for pain assessment; as well as 80.9% of participants reported knowing the World Health Organization’s “analgesic ladder” for pain handling; 97.9% stated they know the difference between nociceptive pain and neuropathic pain; 74.5% are aware of the antidepressants action mechanism in pain handling. On the other hand, the problem of clinical practice stands out: 78.7% of students report insecurity in the analgesia handling of cancer patients; 76.6% do not know which drug and dose to start opioid treatment; 87.2% do not know the equivalents for rotating opioids; 76.6% do not feel confident about prescribing opioids.
Objective questions were applied with a “yes” or “no” response to evaluate the knowledge of medical students about pain and palliative care (Table 1).
Table 1 Medical students' knowledge and perceptions of pain and palliative care - continuation
Pain is a problem with great impact on public health, since its prevalence is high, becoming the main complaint in 40% of the primary care services20. Similarly, a substantial part of primary health care involves patients with chronic pain21. In hospitalized patients, the pain prevalence is also high, possibly because the analgesics use is inadequate, which testifies the patient’s lack of health care22 and the tendency of health professionals to underestimating and neglecting the pain felt by the patients23. Thus, as a function of pain, hospitalized patients report a significant worsening of their functionality and greater suffering. There are data in the literature indicating pain’s handling strategies need to be reviewed with the necessary criticism24. In view of the patient pain handling’s lack of adequacy, it is necessary to look for significant knowledge deficits about principles currently accepted in the practice of pain handling, as well as beliefs that may interfere with the correct care of the patient’s needs25.
From this study results, it was possible to observe that the majority of the students reported not receiving enough information during the undergraduate course in relation to the correct handling of patients with pain (76.6%), being that all these students (100%) pointed out the need to improve their knowledge in the treatment of people with pain. Compared to a study conducted using the same questionnaire in the State of São Paulo, response rates for such questions were similar (58 and 97%, respectively)19. Thus, it is possible to infer the existence of a gap in the pain’s teaching in medical schools nationwide; however, more studies would be necessary to confirm this hypothesis.
Along the same lines, there are international studies that point out similar deficiencies in medical schools9. Study results with medical students who graduated from five Finnish medical schools in 2001 show those definitions of pain, research on pain as well as aspects of pediatric and geriatric patients with pain were insufficiently taught. Only 34% of the students had access to in-depth studies on the subject, and only 15% had access to research projects in pain medicine. Besides, the lack of teaching about the concept of a multidisciplinary pain clinic was recognized by almost all students26. In another study, which reviewed the education of 368 licensed physicians in Michigan, it was shown that 30% did not report formal education on pain handling12.
With regard to palliative care specifically, the results observed in the present study showed that students perceive the lack of theoretical knowledge about the subject, since they did not receive enough information about the care of patients in terminal situation (89.4%) or about control of most common symptoms (dyspnea, vomiting, constipation, cachexia) in patients undergoing palliative care (80.9%). These results are similar to those of a study conducted at the Alpert School of Medicine in the United States, where it was shown that fewer than a half of students had worked with terminally ill patients, and almost a quarter of medical students did not feel prepared for common symptoms’ palliation including pain, nausea, shortness of breath and anxiety27. Thus, the study by Hermes and Lamarca8 confirmed the need to reformulate the curriculum of medical schools, due to the lack of disciplines involving palliative care.
Regarding pain, a characteristic observed from this study is that many students have reported difficulty in handling patients who require analgesia, despite claiming to have theoretical knowledge on the subject. In this sense, Leila et al.28 pointed out that when developing a pain education curriculum, the focus should be on pedagogical methods about how to help students apply the knowledge learned in their daily practice.
A study by Upshur, Luckmann, and Savageau21 found dissatisfaction with medical education on pain, and the need for emphasis on patient-centered approaches to treatment, including skills to assess the risk of opioid abuse and dependence. Accordingly, Lebovits et al.25 highlighted the unjustified fear of dependency as a misunderstood concept that needs to be revised. In this study, it was observed that 51.1% of students are more apprehensive about prescribing opioids for respiratory depression, and 34% are more afraid of chemical dependence. Therefore, it is clear that the need to demystify the use of opioids in medical schools persists.
Participated in this study only students from the UFCSPA medical course, and there is no specific discipline on pain in the undergraduate medical curriculum of this university. Despite this, 19.1% of the students answered affirmatively when asked about the existence of a specific discipline about pain in their college. In order to explain this result, it may be thought that these students have considered, in such response, the existence of the Anesthesiology discipline in the fourth graduation year or of optional disciplines on pain, which eventually are offered by the University.
It is important to emphasize the relevance of the discussion about pain education and palliative care in medical graduation since this implies the quality of health care delivery and that the present study results point to gaps in the teaching of these topics. It was also highlighted the students’ difficulties in transposing theoretical knowledge into professional practice, such as insecurity in the pain handling, especially in the opioids use, are demonstrated.
Sponsoring sources: Taxa Capes/ppgeh/UPF.
1 Ministério da Saúde (Brasil). Portaria nº 19/GM de 03 de janeiro de 2002. [Portaria na internet, acesso em 6 abril de 2017] disponível em: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2002/prt0019_03_01_2002.html. [ Links ]
2 Rufino GP, Gurgel MG, Pontes T, Freire E. Avaliação de fatores determinantes do tempo de internação em clínica médica. Rev Soc Bras Clin Med. 2012;10(4):291-7. [ Links ]
3 Ferreira N, Miranda C, Leite A, Revés L, Serra I, Fernandes AP, et al. Dor e analgesia em doente crítico. Rev Clin Hosp Prof Dr Fernando Fonseca. 2014;2(2):17-20. [ Links ]
4 Araujo LC, Romero B. Dor: avaliação do 5º sinal vital. Uma reflexão teórica. Rev Dor. 2015;16(4):291-6. [ Links ]
5 Jamison RN, Sheehan KA, Scanlan E, Matthews M, Ross EL. Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Manag. 2014;10(6):375-82. [ Links ]
6 Tournebize J, Gibaja V, Muszczak A, Kahn JP. Are physicians safely prescribing opioids for chronic noncancer pain? A systematic review of current evidence. Pain Pract. 2016;16(3):370-83. [ Links ]
7 Pearson AC, Eldrige JS, Moeschler SM, Hooten WM. Opioids for chronic pain: a knowledge assessment of nonpain specialty providers. J Pain Res. 2016;9:129-35. [ Links ]
8 Hermes HR, Lamarca IC. Cuidados paliativos: uma abordagem a partir das categorias profissionais de saúde. Ciên Saúde Coletiva. 2013;18(9):2577-88. [ Links ]
9 Tauben DJ, Loeser JD. Pain education at the University of Washington School of Medicine. J Pain. 2013;14(5):431-7. [ Links ]
10 Loeser JD, Schatman ME. Chronic pain management in medical education: a disastrous omission. Postgrad Med. 2017;129(3):332-5. [ Links ]
11 Webster F, Bremner S, Oosenbrug E, Durant S, McCartney CJ, Katz J. From opiophobia to overprescribing: a critical scoping review of medical education training for chronic pain. Pain Med. 2017;23. [Epub ahead of print]. [ Links ]
12 Green CR, Wheeler JR, Marchant B, LaPorte F, Guerrero E. Analysis of the physician variable in pain management. Pain Med. 2001;2(4):317-27. [ Links ]
13 Hoang HT, Sabia M, Torjman M, Goldberg ME. The importance of medical education in the changing field of pain medicine. Pain Manag. 2014;4(6):437-43. [ Links ]
14 Bair MJ. Learning from our learners: implications for pain management education in medical schools. Pain Med. 2011;12(8):1139-41. [ Links ]
15 Eyigor S. Fifth-year medical students' knowledge of palliative care and their views on the subject. J Palliat Med. 2013;16(8):941-6. [ Links ]
16 Weber M, Schmiedel S, Nauck F, Alt-Epping B. Knowledge and attitude of medical students in Germany towards palliative care: does the final year of medical school make a difference? Schmerz. 2016;30(3):279-85. [ Links ]
17 Zalaf LR, Bianchim MS, Alveno DA. Assessment of knowledge in palliative care of physical therapists students at a university hospital in Brazil. Braz J Phys Ther. 2017;21(2):114-9. [ Links ]
18 Léon MX, Corredor M, Ríos F, Sanabria A, Montenegro M, Gónima E, et al. ¿Qué perciben los estudiantes de medicina sobre sus conocimientos en dolor? Análisis de la situación en Colombia. Med Paliat. 2007;14(1):33-9. [ Links ]
19 Pinheiro TR. Avaliação do grau de conhecimento sobre cuidados paliativos e dor dos estudantes de medicina do quinto e sexto anos. O Mundo da Saúde. 2010;34(3):320-6. [ Links ]
20 Mäntyselkä P, Kumpusalo E, Ahonen R, Kumpusalo A, Kauhanen J, Vinamäki H, et al. Pain as a reason to visit the doctor: a study in Finnish primary health care. Pain. 2001;89(2-3):175-80. [ Links ]
21 Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med. 2006;21(6):652-5. [ Links ]
22 Donovan M, Dillon P, Mcguire L. Incidence and characteristics of pain in a sample of medical-surgical in patients. Pain. 1987;30(1):69-78. [ Links ]
23 Trentin L, Visentin M, De Marco R, Zandolin E. Prevalence of pain in public hospital: correlation between patients and caregivers. J Headache Pain. 2001;2(2):73-8. [ Links ]
24 Abbott FV, Gray-Donald K, Sewitch MJ, Johnston CC, Edgar L, Jeans ME. The prevalence of pain in hospitalized patients and resolution over six months. Pain. 1992;50(1):15-28. [ Links ]
25 Lebovits AH, Florence I, Bathina R, Hunko V, Fox MT, Bramble CY. Pain knowledge and attitudes of healthcare providers: practice characteristic differences. Clin J Pain. 1997;13(3):237-43. [ Links ]
26 Pöyhiä R, Niemi-Murola L, Kalso E. The outcome of pain related undergraduate teaching in Finnish medical faculties. Pain. 2005;115(3):234-7. [ Links ]
27 DiBiasio E. Palliative and end-of-life care education among Alpert medical school students. R I Med J. 2013;99(4):20-5. [ Links ]
28 Leila NM, Pirkko H, Eeva P, Eija K, Reino P. Training medical students to manage a chronic pain patient: both knowledge and communication skills are needed. Eur J Pain. 2006;10(2):167-70. [ Links ]
Correspondence to: Rua Sarmento Leite, 245 - Centro Histórico, 90050-170 Porto Alegre, RS, Brasil. E-mail: firstname.lastname@example.org
Conflict of interests: none
Print version ISSN 1806-0013On-line version ISSN 2317-6393
Rev. dor vol.18 no.4 São Paulo Oct./Dec. 2017
04014-012 São Paulo SP Brasil
Tel.: (55 11) 5904 3959
Fax: (55 11) 5904 2881