Advancing Pain Care—Core Competencies for Pain Management


  • Kenneth W. Kizer MD, MPH

    Distinguished Professor, Director
    1. University of California Davis School of Medicine and Betty Irene Moore School of Nursing
    2. Institute for Population Health Improvement, Sacramento, California
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  • Disclosure: None to report.

The various unpleasant sensations that collectively are known as pain are among the most important means by which the body signals that it is hurt or malfunctioning, and everyone experiences pain in one form or another at least occasionally. Regrettably, many people experience pain as a regularly recurring or continuous part of their lives as a result of advanced age, injury, or chronic illness, among other reasons.

Because pain so often accompanies injury or illness, it is the overall most common symptom that causes people to consult a physician or other health care provider. And because pain is such a common and important symptom, much time and attention in health care professional training is devoted to understanding the various types of pain and to learning to recognize the diagnostic significance of the anatomic location, character, frequency, intensity, and other characteristics of pain. Indeed, we are taught that the nature of one's pain in and of itself can be largely diagnostic of some conditions. In stark contrast, relatively scant attention in health care professional training is given to understanding how to successfully manage pain in its many forms and contexts.

The lack of attention to managing pain in health care professional training is perplexing given the frequency of pain as a symptom and the large number of people who would benefit from effective pain management. An estimated 100 million American adults suffer pain on a regular basis [1], at a staggering annual cost of more than $600 billion [2]. The lack of attention to pain management in health care professional training is further perplexing in so far as relief of pain has been one of the most fundamental and transcendent responsibilities of physicians and other health care professionals in all cultures throughout history.

In this issue of Pain Medicine, Fishman and colleagues report the results of an interprofessional consensus development process that has produced for the first time a clear delineation of core competencies in pain assessment and management for prelicensure health professional education [3]. These competencies are logically and strategically categorized into four domains: 1) the multidimensional nature of pain, 2) assessment and measurement of pain, 3) management of pain, and 4) the context of pain management. Promulgation of these pain management core competencies represents a major milestone in advancing pain care that should be widely applauded for multiple reasons.

First, these core competencies address an important population health problem that is currently inadequately addressed in the curricula of medical, nursing, pharmacy, and other health care professional training. As noted by Fishman and colleagues, pain management education in prelicensure learning is fragmented, inconsistent, and seemingly ineffective [4-7]. This fragmentation and lack of standardization has led to disparate pain care and poor pain outcomes in vulnerable populations [8, 9]. Paradoxically, while pain is both widely undertreated and unequally treated in the United States today, as a nation we have the highest level of opioid use in the world [10]. Such poor pain management outcomes have elicited calls for an educational roadmap that crosses professions and educational levels to promote equitable pain care [11]. The lack of such a roadmap undoubtedly has been a significant contributing factor to the current epidemic of prescription opiate abuse [12, 13]. The core competencies in pain management advanced by Fishman and colleagues provide the template for a pain management educational roadmap that should lead to more predictable and consistent higher quality care.

Second, these pain management competencies were developed by an interdisciplinary consortium and have a clear interdisciplinary focus. As such, they better simulate the realities of health care practice than the generally siloed approach to health care professional training prevalent today.

Pain is a health problem whose context and management are influenced by myriad stakeholders, including health care practitioners, community-based and professional organizations, policy makers, regulatory and accrediting bodies, business and industry, health care payers, and advocacy groups. The diversity of stakeholders involved in pain care has led to laudable improvements in recognition and diagnosis of pain, processes of clinical care, and treatment technologies, including pharmaceutical products. However, too often these advances have been achieved without understanding and agreement among stakeholders on how to prepare the health care workforce to operationalize them in a way that delivers better care. Fishman and colleagues offer an important starting point from which to begin addressing these gaps.

Third, a competency-based approach to health care professional education provides clear goals for what is important to accomplish in pain care, while not being prescriptive about how to achieve the competencies necessary to achieve the desired outcomes. This gives educators flexibility in accomplishing the requisite learning. A competency-based approach to learning overtly recognizes the complexity of health care and health care professional training, and that there is no single pathway for reaching the desired destination. Further, a competency-based approach recognizes the evolving and ever-changing nature of medical science, clinical care guidelines, and diagnostic and therapeutic technologies.

Fourth, these competencies are directed at prelicensure trainees and thus are aimed at an especially impressionable and important time in professional maturation that reasonably can be expected to establish a solid foundation for pain management in whatever further training the practitioner pursues. Similarly, as health care delivery increasingly moves toward team-based care, it is important that trainees be prepared to practice in an interprofessional milieu that will increasingly be the norm. The need for interprofessionality is tangibly recognized and addressed in these competencies.

Fifth, the core competencies are grounded on a set of principles and values. In an area as complex and nuanced as pain management, the importance of having clearly understood and shared values cannot be overstated. Values provide a critically important compass for finding one's direction in uncertain or confusing situations, as so often is the case in pain management.

The pain management core competencies developed by Fishman and colleagues fill an important void in health care professional training and are long overdue. If utilized as intended, these competencies should lead to the development of a health care workforce having demonstrated competence in caring for patients in pain, higher performing health care systems, and improved health care outcomes. The process used to develop these core competencies also provides a model for how health care professional curricula might be better developed for other complex population health problems such as obesity management, hypertension, health care-associated infections, and patient safety, to name some.