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The RACGP Curriculum for Australian General Practice 2016

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Curriculum coverThe complete 2016 Curriculum consists of a number of units in addition to contextual units. All units will be available for download as a PDF shortly.

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Pain management

Definition

Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.1

Pain is always subjective and each person's individual experience of pain is related to their life experiences, such as injury in early life.

Stimuli that cause pain may be associated with actual or potential tissue damage. While this sensation in itself may be unpleasant, there is also an accompanying emotional experience including fear.

Patients who are unable to communicate verbally can still experience pain and may need appropriate pain relieving treatment.

Some people report pain in the absence of tissue damage or any likely pathophysiological cause, which may indicate a psychological basis. Based on subjective reports, there may be no way to distinguish their experience from that due to tissue damage. If a patient regards their experience as pain, and if they report it in the same ways as pain caused by tissue damage, this should be accepted as pain. This definition avoids tying pain to the stimulus.

Experiences that resemble pain but are not unpleasant, such as pricking, should not be called pain. Unpleasant abnormal experiences (dysesthesias) may also be pain, but are not necessarily so because subjectively they may not have the usual sensory qualities of pain. There is a wide range of terms to describe types of pain and pain related syaamptoms.1

Curriculum in practice

The following case illustrates how the pain management curriculum applies to general practice:

  • Graham, 34 years of age, is a telecommunications linesman who injured his back 18 months ago when a colleague abruptly dropped a heavy coil they were jointly lifting. The pain was instantaneous and severe, but without motor weakness. He spent 4 days in hospital before being able to mobilise sufficiently to be discharged. Since then he has continued to have low back pain with morning stiffness and a sciatic referral pattern if he coughs or sneezes. Walking or standing for any length of time triggers muscle spasms so he spends most of his time lying on his back with a pillow under his knees. He is able to dress himself, but is unable to bend over to put on his shoes so wears slip-on thongs. Previously, he was a fit man, but is now overweight and his wife is concerned that he may also be depressed. As he was no longer able to take care of their yard they have moved to be closer to their son. Physiotherapy appeared to help initially, but Graham no longer believes it is beneficial. He hates taking analgesia due to constipation, but will use over-the-counter codeine medications for severe bouts, in conjunction with alcohol.

Rationale and general practice context

Pain is associated with many general practice conditions, and diagnosis and management is often poorly understood and undertreated.

Patients in pain and their carers may feel hopeless, helpless, deserted and angry and doctors may experience frustration when pain fails to respond to treatment.

General practitioners manage the majority of patients with pain in Australia for both front line and last resort in pain management. Expertise in pain management is developed through education and exposure to clinical experience. Specialist advice in pain management can supplement general practice competence but cannot replace it. Interdisciplinary approaches are often helpful.

Pain is a very common general practice problem.2 The National Health Survey 2007–20083 of adults over 18 years of age reported that 9.7% of participants said that they had severe or very severe pain; 19.3% said that they had moderate pain, and 39.1% reported mild or very mild pain. These levels of pain were associated with varying levels of disability as listed in Table 1.

Table 1. Adults with body pain, as reported in the National Health Survey 2007–08, Australian Bureau of Statistics3

Level of reported disability associated with pain(%)

Bodily pain experienced

Profound or severe activity limitation

Other disability or restrictive long term health condition

Has no disability or restrictive long term health condition

Total

None

11.5

16.9

43.4

31.9

Very mild or mild

21.0

38.3

41.2

39.1

Moderate

29.0

10.2

11.4

19.3

Severe or very severe

38.6

14.6

4.0

9.7

Related curriculum areas

Refer also to the curriculum statments:

Training Outcome of the five domains of general practice

1. Communication skills and the patient-doctor relationship

PAIT1.1

Use patient centred approaches and clear communication between the patient and doctor that acknowledge how the subjective nature of pain presents many diagnostic and management challenges to the general practitioner.

PAIT1.2

Use careful and close communication to monitor therapeutic progress and maximise success of pain management outcomes.

PAIT1.3

Know how patient perceptions of pain are influenced by a complex range of factors, including past experience of pain, medication history, family, culture, social and occupational history and how this can sometimes make communication challenging.

PAIT1.4

Incorporate a knowledge of how differing expressions and understandings of pain across cultures can sometimes make communication challenging.

2. Applied professional knowledge and skills

PAIT2.1

Have a wide knowledge of pain management in a wide range of medical conditions, including undifferentiated problems.

PAIT2.2

Understand how information gathering and examination skills are critical for clinical for managing pain management.

PAIT2.3

Integrate pain management into all aspects of general practice clinical work when appropriate, especially in continuity of patient care.

PAIT2.4

Understand the potential significant long term challenges that pain management may present to the GP's skills, in particular, chronic pain.

3. Population health and the context of general practice

PAIT3.1

Understand that general practice is both the front line and the last resort in pain management.

PAIT3.2

Understand how pain is one of the most common and diverse presentations in general practice and a significant cause of patient morbidity, as well as affecting the wellbeing of family and carers.

PAIT3.3

Understand the cultural, social, family and work factors that play a significant role in its daily management in general practice.

4. Professional and ethical role

PAIT4.1

Know the professional and legal requirements that have a significant affect on chronic pain management.

PAIT4.2

Work, as a GP, in close coordination with other professionals within a multidisciplinary team for successful pain management outcomes.

5. Organisational and legal dimensions

PAIT5.1

Ensure ongoing practice availability and accessibility arrangements to help alleviate patient suffering.

PAIT5.2

Know how organisational systems ensure that patients with pain are regularly monitored, as well as ensuring that all legislative requirements around analgesia are met.

Learning objectives across the GP professional life

Medical student

1. Communication skills and patient-doctor relationship

PAILM1.1

Outline how the relationship between the patient and the doctor is central to a good therapeutic outcome in pain management.

PAILM1.2

Outline the difficulties in communicating the pain experience.

PAILM1.3

Outline patient fears and attitudes toward pain medication use and methods to discuss these.

PAILM1.4

Describe how pain is a personal experience and that there are differences between people who are influenced by age, gender, culture and other factors.

PAILM1.5

Describe how lifestyle choices may assist the patient to manage pain.

2. Applied professional knowledge and skills

PAILM2.1

Describe the processes of nociception, pain transmission, peripheral sensitisation and central sensitisation.

PAILM2.2

Describe the differences between nociceptive, neuropathic and visceral pain and the implications of these for diagnosis and management.

PAILM2.3

Outline the burden of pain related disability.

PAILM2.4

Outline how pain often accompanies disease processes.

PAILM2.5

Describe the psychological influences and consequences of pain problems that are poorly understood by the medical profession.

PAILM2.6

Demonstrate how to obtain and record a systematic history that includes site, severity, quality, timing, progression, radiation, aggravating and relieving factors.

PAILM2.7

Demonstrate how to examine a patient to exclude serious and life threatening conditions and differentiate between nociceptive, chronic musculoskeletal, neuropathic and visceral pain.

PAILM2.8

Demonstrate a targeted diagnostic approach that screens for serious causes of pain and psychosocial risk factors.

PAILM2.9

Outline the role of an interdisciplinary approach to pain management.

PAILM2.10

Describe the technical aspects and costs of commonly used imaging modalities including their potential for patient discomfort.

PAILM2.11

Classify the major groups of medications used in pain management.

PAILM2.12

Outline different formulations of pain medications (eg. oral, rectal, intramuscular, subcutaneous, intravenous and epidural formulations).

PAILM2.13

Demonstrate how to access, interpret and use the best available evidence available in the pain management literature.

3. Population health and the context of general practice

PAILM3.1

Describe the diversity of chronic pain sufferers.

PAILM3.2

Describe how women report pain more than men, and how and why women are at more risk of chronic pain disorders.

PAILM3.3

Describe how men are at greater risk for some pain disorders (eg. cluster headaches and pancreatitis).

PAILM3.4

Describe how pain thresholds vary depending upon psychosocial and other factors.

PAILM3.5

Outline how the needs of patients vary as does their ability to access care.

PAILM3.6

Describe how poor pain management may be the result of sociopolitical and cultural values.

PAILM3.7

Describe how suffering due to pain is strongly influenced by 'what the pain means' not only to the patient in pain, but to their significant others.

PAILM3.8

Outline how pain management may include community services.

4. Professional and ethical role

PAILM4.1

Describe how chronic pain management is a new and developing area and how doctors need to regularly review changes in appropriate drug use and treatment strategies.

PAILM4.2

Describe how pain management requires regular monitoring of effectiveness in improving quality of life.

PAILM4.3

Describe how pain causes distress and distressed patients frequently produce emotional feelings in the doctor.

PAILM4.4

Outline how pain strains the capacity of individuals and relationships.

5. Organisational and legal dimensions

PAILM5.1

Describe how pain occurs at any time and that accessible and available care is important in reducing anxiety.

PAILM5.2

Outline how barriers to care can exacerbate the distress associated with pain.

PAILM5.3

Describe the therapeutic role of screening and recall for reassessment in pain management.

PAILM5.4

Outline how monitoring a condition requires recording a baseline to measure change against.

PAILM5.5

Outline the legal requirements in managing Schedule 8 medications.

PAILM5.6

Outline how Schedule 8 medications require regular reporting, and may require certification and reporting of confidential information.

Prevocational doctor

1. Communication skills and patient-doctor relationship

PAILP1.1

Demonstrate a compassionate approach to pain and suffering.

PAILP1.2

Identify the psychosocial risk factors for successful pain management.

PAILP1.3

Recognise that words cannot completely convey the patient's pain experience.

PAILP1.4

Describe how a clinician's personal attitudes to pain can affect the patient-doctor relationship.

2. Applied professional knowledge and skills

PAILP2.1

Demonstrate how to diagnostically differentiate between nociceptive, neuropathic and visceral pain and how to justify such a diagnosis.

PAILP2.2

Demonstrate how to make an appropriate referral for patients with undifferentiated pain problems.

PAILP2.3

Demonstrate how to take a history to exclude 'red flag' conditions and differentiate between nociceptive, chronic musculoskeletal, neuropathic and visceral pain.

PAILP2.4

Show how to perform an examination to exclude red flag conditions and differentiate between nociceptive, chronic musculoskeletal, neuropathic and visceral pain.

PAILP2.5

Demonstrate the management of acute nociceptive and visceral pain with appropriate pharmacological and nonpharmacological measures.

PAILP2.6

Describe the strengths and limitations of commonly used imaging modalities in determining the cause of pain.

PAILP2.7

Show how to use the major groups of pain medications in common acute and chronic pain conditions.

PAILP2.8

Describe the pharmacology of regimens of common painkillers including those for children and infants.

PAILP2.9

Recognise that treatment is easier if a patient understands the aetiology, management and prognosis of their pain.

PAILP2.10

Identify resources for pain management.

PAILP2.11

Outline other nonpharmacological pain management approaches.

PAILP2.12

Demonstrate the application of the results of an online literature search to answer clinical questions about pain diagnosis and treatment.

3. Population health and the context of general practice

PAILP3.1

Outline the numbers of people with chronic pain in the community.

PAILP3.2

Outline the prevalence and incidence of common pain syndromes in the general population.

PAILP3.3

Describe the pain management needs of older people and the dying.

PAILP3.4

Identify ways to work within the local cultural expectations to maximise the benefits for the individual patient.

PAILP3.5

Outline the loss of worth arising from lack of employment or the loss of societal interaction and its subsequent effects on health.

4. Professional and ethical role

PAILP4.1

Describe how to deal with personal attitudes toward pain management and develop an appreciation of how these may influence clinician decision making.

PAILP4.2

Outline how patients have a right to adequate pain relief.

PAILP4.3

Describe the difference between addiction and chronic medication use.

PAILP4.4

Outline how the large volume of current research into pain management may alter treatment.

PAILP4.5

Contribute to an interdisciplinary approach to pain management.

PAILP4.6

Describe how some pain management requires a team approach.

5. Organisational and legal dimensions

PAILP5.1

Identify barriers to pain management.

PAILP5.2

Describe how to ensure continuity of care.

PAILP5.3

Assess approaches to providing continuous care.

PAILP5.4

Evaluate the strengths and weakness of individual or team care.

PAILP5.5

Investigate approaches that monitor outcomes.

PAILP5.6

Compare opportunistic and scheduled assessment approaches.

PAILP5.7

Consider how to measure and record change.

PAILP5.8

Decide on parameters that indicate change.

PAILP5.9

Establish and record treatment and alternative options considered.

PAILP5.10

Demonstrate an awareness of community services that can assist overall management.

PAILP5.11

Detail the requirements for initiating and maintaining treatment with Schedule 8 medications.

PAILP5.12

Understand the local, state and commonwealth requirements in prescribing and administering Schedule 8 medications.

PAILP5.13

Describe approaches to meet legal requirements.

Vocational registrar

1. Communication skills and patient-doctor relationship

PAILV1.1

Describe the psychological influences and consequences of acute and chronic pain.

PAILV1.2

Demonstrate the ability to recognise the patient's needs and wants in terms of their pain management.

PAILV1.3

Describe the role of the placebo response in pain management.

PAILV1.4

Outline the differences between pain perception, suffering and pain behaviour in those from different cultures and backgrounds.

PAILV1.5

Demonstrate the skills and attitudes required for effective whole person care.

PAILV1.6

Describe how clinician attitudes, beliefs and feelings may affect pain management.

PAILV1.7

Describe information sources that may assist patients in pain to better manage their condition.

2. Applied professional knowledge and skills

PAILV2.1

Demonstrate a working knowledge of the frequency of different types of pain presentations in general practice.

PAILV2.2

Describe the difference between pain perception, suffering and pain behaviour.

PAILV2.3

Describe common patterns of pain referral and their clinical implications.

PAILV2.4

Demonstrate a short term strategy for dealing with undifferentiated pain problems.

PAILV2.5

Demonstrate history taking that addresses psychosocial factors and consequences of pain.

PAILV2.6

Assess the type and degree of pain related disability.

PAILV2.7

Perform an examination for generalised pain syndromes.

PAILV2.8

Justify the use of physical examination tests for pain.

PAILV2.9

Demonstrate the ability to document the pain presentation in terms of site and radiation, duration, quality, severity, associated signs and symptoms.

PAILV2.10

Demonstrate the management of nociceptive, chronic musculoskeletal, neuropathic and visceral pain with appropriate pharmacological and nonpharmacological measures.

PAILV2.11

Demonstrate incorporation of pain related disability into diagnostic and management decisions about pain.

PAILV2.12

Demonstrate integration of pharmacological and nonpharmacological approaches to pain management.

PAILV2.13

Demonstrate rational prescribing of complex regimes of pain medications.

PAILV2.14

Outline the strengths and limitations of commonly used history and examination items used for pain assessment history and examination.

3. Population health and the context of general practice

PAILV3.1

Analyse the diversity of chronic pain sufferers within the clinician's own patient population.

PAILV3.2

Describe how general practice pain management is different to the hospital setting because of the common occurrence of undifferentiated pain presentations in the community setting.

PAILV3.3

Outline how different manifestations and management needs for children and the elderly with pain.

PAILV3.4

Outline how cultural values and beliefs may affect management outcomes when prescribing treatments and offering management techniques.

PAILV3.5

Describe how a patient's family and employment can act as both a support and a liability in overall pain management.

4. Professional and ethical role

PAILV4.1

Outline the patient's right to privacy.

PAILV4.2

Outline how to balance an individual's right to privacy and the community's right to protect its members from harm.

PAILV4.3

Describe the situations when pain management requires a multidisciplinary approach.

PAILV4.4

Describe the legal obligations of the doctor in prescribing for pain management.

PAILV4.5

Understand community concerns about the narcotic debate and the influence this has on perceptions of both patients and families.

PAILV4.6

Appreciate that discussion with other medical practitioners may assist with drug management, but that emotional support for both patient and doctor can come from a much wider range of members of society.

PAILV4.7

Outline the influence of culture and ethnicity on pain perception and management.

PAILV4.8

Recognise that clinician self reflection is critical to improving pain management.

5. Organisational and legal dimensions

PAILV5.1

Demonstrate the development of mechanisms to ensure ongoing access to care.

PAILV5.2

Describe the role of team management in providing care.

PAILV5.3

Identify local services that may offer assistance to people experiencing pain (eg. stress management, yoga and meditation classes).

PAILV5.4

Identify potential gaps in care arrangements.

PAILV5.5

Develop systems to identify unmet need.

PAILV5.6

Develop and implement systems to recall and review patients and to monitor change in function and quality of life.

PAILV5.7

Establish baseline levels of pain from which a patient's functional changes can be measured such as improvement or deterioration.

PAILV5.8

Identify practice management issues relating to drugs of dependence medication prescription and dispensing.

PAILV5.9

Demonstrate the sharing of responsibility of pain management with patients including educating patients on legal limitations on treatment options.

PAILV5.10

Describe the learning process to ensure up-to-date knowledge of drug schedules (especially drugs of dependence), and commonwealth, state and other legislative requirements.

Continuing professional development

1. Communication skills and patient-doctor relationship

PAILC1.1

Demonstrate the ability to coordinate a multidisciplinary team approach for a patient's pain management.

2. Applied professional knowledge and skills

PAILC2.1

Demonstrate evidence based approach to an individual's pain management.

PAILC2.2

Describe the features of central and peripheral sensitisation in chronic pain states.

PAILC2.3

Evaluate the response of patients to pain interventions and adjust practice in accordance with this evaluation.

PAILC2.4

Describe the differences in the neurobiology of pain in children and older people.

PAILC2.5

Demonstrate a consideration of the distinctive pain management requirements of children and the elderly.

PAILC2.6

Demonstrate how to recognise and manage pharmacological dependence in patients with chronic pain.

PAILC2.7

Demonstrate the use of simple measures to monitor pain and related disability in practice over time.

PAILC2.8

Monitor the use of investigations for pain and justify their use.

PAILC2.9

Outline the strengths and limitations of commonly used investigations for pain assessment.

PAILC2.10

Demonstrate openness to using new medications and techniques and evaluating their appropriateness as they become available.

PAILC2.11

Demonstrate a holistic long term strategy for dealing with undifferentiated pain problem.

PAILC2.12

Demonstrate the coordination of care for complex pain patients.

PAILC2.13

Document a comprehensive management plan for acute and chronic pain incorporating a stepped pharmacological plan and effective nonpharmacological measures.

3. Population health and the context of general practice

PAILC3.1

Identify the population of patients who may be susceptible to chronic pain.

PAILC3.2

Identify the prevalence of chronic pain within the clinician's general practice population.

PAILC3.3

Outline the socioeconomic burden of pain.

PAILC3.4

Identify areas of need in healthcare resources and act upon them for improved health outcomes for those with special needs.

PAILC3.5

Demonstrate an awareness of the diversity of cultural backgrounds within Australian society when dealing with pain issues.

PAILC3.6

Evaluate the psychosocial aspects of pain management in health advocacy.

PAILC3.7

Demonstrate an ability to upskill ancillary services within the community that can then benefit patients with chronic pain.

4. Professional and ethical role

PAILC4.1

Demonstrate a deeper understanding of the pain management dilemmas, which may be more appropriate to the GP's particular patient population.

PAILC4.2

Demonstrate an awareness of developments and research in pain and its management.

PAILC4.3

Demonstrate keeping up-to-date with governmental and legislative changes.

PAILC4.4

Demonstrate keeping up-to-date with changing community attitudes.

PAILC4.5

Further explore and describe the influence of culture and ethnic backgrounds on pain perception.

PAILC4.6

Demonstrate discussion of patient safety issues with colleagues to ensure that treatments are appropriate and errors in prescribing are avoided.

PAILC4.7

Demonstrate how to teach patient, family and carers about pain management.

PAILC4.8

Describe the challenges involved with working with other GPs and specialist pain management services.

5. Organisational and legal dimensions

PAILC5.1

Demonstrate the establishment of a risk management process to review a patient's ability to access pain management.

PAILC5.2

Develop reporting mechanisms to identify barriers to pain management.

PAILC5.3

Demonstrate review and modification of screening systems to reduce the risk of missing patients in pain. Audit recall systems to ensure they are effective.

PAILC5.4

Demonstrate provision of resources to patients that offer realistic outcomes.

PAILC5.5

Organise history data into coherent medical and legal reports.

PAILC5.6

Develop systems for the patient history that accurately allow for compliance with legal requirements.

PAILC5.7

Demonstrate ability to work in team approach in cases of chronic pain management with a variety of health professionals.

PAILC5.8

Comply with requirements in use of Schedule 8 medications.

PAILC5.9

Audit compliance and report of changes that are needed.

References

  1. International Association for the Study of Pain. IASP Taxonomy. 2011. Available at www.iasp-pain.org/AM/Template.cfm?Section=Pain_Defi...isplay.cfm&ContentID=1728#Pain.
  2. Britt HMG, Charles J, Henderson J, et al. General practice activity in Australia 2009–10. Canberra: Australian Institute of Health and Welfare; 2010.
  3. Australian Bureau of Statistics. National Health Survey: Summary of Results: 2007–2008 (Reissue). 2011. Available at www.abs.gov.au/ausstats/abs@.nsf/PrimaryMainFeatures/4364.0?OpenDocument.

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