Pediatric Pain Management Education in Medical Students: Impact of a Web-Based Module

Abstract

Objective:

Reports from the Institute of Medicine and American Medical Association's Pain and Palliative Medicine Specialty Section Council emphasize the need for pain management education in medical schools, yet training in pediatric pain management (PPM) is limited. In this pilot program, we evaluated the effectiveness of a web-based PPM module on knowledge, confidence, attitudes, and self-reported skills in medical students.

Methods:

Third- and fourth-year medical students (n=291) completed the module and a knowledge test. Of these students, 53 completed a pre- and postsurvey of confidence, attitudes, and self-reported skills and module evaluation.

Results:

For the 291 students, knowledge scores increased significantly by 21.8 points (95% confidence interval [CI]=19.7–23.8; p<0.001). The majority of scores on the survey items significantly increased postmodule, including: increase in confidence in assessing pain in pediatric patients (6% to 25%; p=0.004), increase in responses of “strongly disagree” or “disagree” to the belief that opioids will delay diagnosis (62% to 85%; p=0.005), and increase in responses of “frequently” or “very frequently” to “how often do you use behavioral instruments to assess pain severity?” (35% to 57%; p=0.008). The majority reported they intend to make changes in behavior or practice (71%), and would recommend the module to fellow students (88%).

Conclusion:

This pilot program supports the effectiveness of a web-based module in improving knowledge, confidence, attitudes, and self-reported skills in PPM. Evaluation responses indicate high-quality content. Further evaluation for sustained impact is warranted.

Introduction

Pain is associated with a number of chronic and life-threatening illnesses of childhood such as cystic fibrosis, cancer, and sickle cell disease, yet studies indicate that medical education on pediatric pain management (PPM) is limited. In a study of 246 graduate medical residents, 59% rated their medical school preparation in pain management as “fair” or “poor.”¹ More significantly, in another study, only 8.8% of medical students reported they had received education on PPM.² In fact, a survey conducted by the Association of American Medical Colleges revealed that only 3% of medical colleges require a course on pain management.³

Pediatric residency training does not appear to close this educational gap. In a study on palliative care, pediatric residents showed no significant improvement in knowledge, competence, experience, or comfort in all areas of palliative care over time.⁴ Furthermore, the pediatric residents identified their greatest educational need as pain management. Similarly, pediatric residents scored poorly on knowledge of pain and symptom management, particularly in the area of assessing pain in the child with cognitive impairments, regardless of year in residency.⁵ Pediatric residency directors recognized this deficiency. In a survey of pediatric residency directors (n=246), only 38.2% believed their graduating residents were competent in palliative care.⁶

The inadequate emphasis on medical training in PPM may be partially reflected in patient care practices. Numerous studies have demonstrated that pain is inadequately managed in children.^7–10 Effective pain management begins with well-trained health care providers, as is supported in recent reports from both the Institute of Medicine (IOM) and the American Medical Association's Pain and Palliative Medicine Specialty Section Council, which emphasize the need for pain management education in both medical schools and graduate medical education programs.^11,12

To address the need for a more comprehensive medical education on pediatric pain, we developed and pilot-tested a web-based educational program: the Pediatric Pain Management (PPM) module. Our premise was that medical students should be provided with basic knowledge of pain management in children. This module was in addition to the pain curriculum they received in their medical education. Our purpose was to evaluate the effectiveness of the module on improving knowledge, confidence, attitudes, and self-reported skills.

Methods

Participants

A pretest-posttest one-group design was used. All third- and fourth-year medical students from the Virginia Commonwealth University (VCU) School of Medicine were invited to participate, which included 178 third-year and 184 fourth-year medical students. All had finished their pediatric clerkship and medical school pain curriculum prior to the study.

Module development

The PPM module was created within an existing web-based curriculum entitled VCU Pain Management: An Online Curriculum.¹³ Briefly, VCU Pain Management is an innovative case-based curriculum that covers pain assessment and treatment, fibromyalgia, neuropathic pain, prescription drug misuse, and legal aspects of controlled substance prescribing. In line with national trends in medical education, PPM was absent from the pain management curriculum. Thus, it was developed for this study. A group of experts in pediatric pain developed the content of the PPM module.

The PPM module consists of four competencies: (1) recognize the barriers to effective PPM; (2) perform a pediatric pain assessment; (3) describe the pathophysiology of pain in children; and (4) manage pediatric-related pain and analgesic side effects. Each competency includes two to five learning objectives. Each learning objective is categorized as representative of one of the six Accreditation Council for Graduate Medical Education (ACGME) core competencies and is measured by pre- and postmodule survey and knowledge test items (Table 1).¹⁴ In addition to evidence-based content, each section includes applied case examples. The module incorporates pediatric pain assessment tools, pharmacology and summary tables, references, and web links for use in clinical practice. Self-evaluation includes self-study questions in the applied case examples and a knowledge-based pre- and posttest, both with immediate feedback.

Table 1.

Pediatric Pain Management Module Competencies, ACGME Competencies, and Example Knowledge Test Questions

Module competencies with learning objectives	ACGME competency	Example knowledge test questions
1. Recognize the barriers to effective pediatric pain management € Identify barriers to pain management in children € Provide evidence-based rationale to address myths in pediatric pain management	Systems-based practice	A 6-year-old male presented to the emergency room with severe abdominal pain, vomiting, and fever. His past medical history is significant for attention deficit disorder and asthma. He picks the face on the FACES scale that correlates with a score of 8 out of 10. By phone consultation, the surgeon has requested an abdominal CT with contrast. With this self-reported pain rating, an appropriate intervention is: Response options: A. Administer acetaminophen 15 mg/kg per rectum. B. Administer morphine 0.1 mg/kg intravenously and reassess effect within 30 minutes. C. Wait for the diagnosis to manage the pain. D. Wait one hour and reassess.
2. Perform a pediatric pain assessment € Describe special considerations of the pediatric pain assessment € Summarize the elements of the pediatric pain history € Identify developmentally appropriate pediatric pain intensity assessment tools € Identify developmentally appropriate tools that assess the functional and psychosocial impact of pain € Identify outcomes of pediatric pain management	Patient care	An 8-year-old child with spastic quadriplegia was admitted to the pediatric unit postoperatively after a tendon release. She is severely developmentally delayed and nonverbal. Which of the following would provide the most accurate assessment of this child's pain? Response options: A. Medical staff report. B. Parent report. C. Physiological measures. D. Validated observational pain assessment tool.
3. Describe the pathophysiology of pain in children € Identify consequences of unrelieved pain in infants and children € Describe the developmental differences in pain perception in children	Medical knowledge	Long-term consequences of unmanaged pain include all but: Response options: A. Addiction. B. Chronic pain. C. Hypersensitivity. D. Lower pain threshold.
4. Manage pediatric-related pain and analgesic side effects € List 3 nonpharmacological strategies for pediatric pain management € Identify 2 appropriate analgesics for each level of pain (mild, moderate, and severe) in children	Medical knowledge	A child with chronic cancer pain has been receiving progressively increasing daily opioid analgesics for 2 months. Yesterday, the child was receiving morphine 20 mg/ hour intravenously. Today, the dose was increase to 25 mg/hour intravenously. The likelihood of the child developing clinically significant respiratory depression is: Response options: A. Less than 5%. B. 5%–10%. C. 11%–20%. D. 21%–40%.

ACGME, Accreditation Council for General Medical Education.¹⁴

Measures

The measures included a pre- and postknowledge test and a pre- and postsurvey. The survey assessed confidence, attitudes, and self-reported skills. The items were from previously published instruments^1,15 and were modified based on input from pediatric faculty at VCU Medical Center. The 21-item presurvey included three demographic questions, two questions on pediatric pain training, three on confidence, seven on attitudes, and six on self-reported skills. The 28-item postsurvey repeated the presurvey questions and included seven module evaluation questions (e.g., quality, ease of use, impact). Two of the evaluation questions were open-ended questions: “As a result of the PPM module, will you make any changes in your behavior or practice?”; “If yes, what changes?” and “Please offer suggestions to improve the PPM module and/or offer additional feedback.” The knowledge test consisted of 11 case-based items that correspond with the module competencies (See Table 1). It was imbedded in the PPM module and was administered at the beginning and end of the module.

Procedure

An introductory e-mail followed by an e-mail with a link to the presurvey (SurveyMonkey©; SurveyMonkey, Palo Alto, CA) was sent to the students, followed by three reminders. Though participation in the study was voluntary, the completion of the PPM module was required by the VCU School of Medicine's Associate Dean for Education. No incentives were offered. Once the presurvey was closed, respondents received an e-mail with a link to the PPM module. The postsurvey was sent approximately 1 to 2 weeks after module completion, followed by three reminders. Because the knowledge test existed within the module, all students who completed the module completed the knowledge test. However, only those students who chose to participate in the study completed the pre- and postsurvey. The module takes approximately one hour to complete and can be completed in more than one session. The study ran from April to July 2010. The VCU Institutional Review Board approved this study.

Statistical analysis

SAS version 9.2 (SAS Institute Inc., Cary, NC) was used for all data management and statistical analyses. Descriptive statistics including means and standard deviations (SDs) for continuous variables and frequencies and percentages for categorical data were computed. Paired t tests for continuous responses and McNemar's tests for categorical responses were used to test for changes in responses pre- to posttest and pre- to postsurvey.

Results

At the close of the study, 291 of the medical students had completed the PPM module, 152 were third-year medical students (52%) and 146 were males (50%). Of those, 53 completed both the pre- and postsurvey. Of the 53 medical students who completed the survey, 51% were female, and 49% were third-year students. Regarding their rating of their pediatric pain training, only 13% (7/53) rated their training as “good” or “excellent” on the presurvey, regardless of gender or year in training.

Knowledge

Although all 291 students completed at least some of the 11-item pre- and postknowledge test, there were only 279 who completed the pretest and 285 who completed the posttest questions, with 17 who did not entirely complete either. There was a significant increase of 21.8 (SD=17.3, 95% CI=19.7–23.8) points from pre- to post-PPM module completion (paired t=20.8, df=273, p<0.001). Following are examples of results of individual knowledge items, with associated competency. On an item that addressed the “Recognize the barriers to effective pediatric pain management” competency that asked about whether to medicate for severe abdominal pain prior to diagnosis, the percent that correctly responded to administer an opioid increased from 71% to 99%. On an item that addressed the “Perform a pediatric pain assessment” competency that asked what instrument should be used to assess pain in an 8-year-old child with severe developmental delays, the percent correct increased from 62% to 97%. Prior to module completion, 38% had incorrectly chosen medical staff report, parent report, or physiologic measures rather than the correct answer of behavioral/observational pain assessment tool. On an item that addressed the “Describe the pathophysiology of pain in children” competency that asked about the potential long-term consequences of unrelieved pain in children, the percent correct increased from 60% to 95%. Prior to module completion, 40% had incorrectly included addiction as a long-term consequence, as opposed to the correct responses of chronic pain, hypersensitivity, and lower pain threshold.

Confidence

The survey included three items on confidence. Two of three confidence items had significant increases in responses of “confident” or “very confident” after completion of the PPM module, including “How confident are you in assessing pain in pediatric patients?” (6% to 25%; p=0.004), and “How confident are you in your ability to treat pain in pediatric patients?” (4% to 20%; p=0.01). However, the third confidence item, which addressed confidence in “ability to prescribe opioids,” did not show a significant increase (4% to 13%; p=0.06).

Attitudes

Regarding negative attitudes, four of seven questions showed significant improvement in attitudes after completion of the PPM module (see Table 2). For example, there was a significant increase in responses of “strongly disagree” or “disagree” to “Young infants cannot tolerate opioids for pain relief” (58% to 83%; p=0.001). Scores on several attitude items did not significantly change pre- to postsurvey because most respondents strongly endorsed them in the presurvey. For example, for the item “Babies do not experience pain,” 100% responded “strongly disagree” or “disagree” on both the pre- and postsurvey.

Table 2.

Responses to Attitude Items on Pre- and Postsurvey

Item	Presurvey	Postsurvey	P value
Percent responses of “strongly disagree” or “disagree”
Young infants cannot tolerate opioids for pain relief.	58.3	83.3	0.001
Using opioid analgesics for acute pain in children will delay the diagnosis of the underlying source of pain.	61.7	85.1	0.005
Children are not able to accurately report their pain.	60.9	82.6	0.004
Children do not experience as much pain as adults.	100.0	97.9	^a
A patient's request for additional or higher dose pain medication always indicates addictive behavior.	95.8	100.0	^a
Babies do not experience pain.	100.0	100.0	^a
Percent responses of “very frequently” or “frequently”
I believe what my pediatric patients tell me about their pain.	70.2	87.2	0.005

A statistical test was not performed because no one responded “neither agree nor disagree/agree/strongly agree” pre- or postsurvey.

Self-reported skills

Respondents' scores on most of the self-reported skill questions significantly improved after completion of the PPM module (see Table 3). For example, for skills related to pediatric pain assessment, there was a significant increase in responses of “frequently” or “very frequently” on use of behavioral instruments (35% to 57%; p=0.008) to assess pediatric pain severity. However, the frequency with which nonpharmacologic treatment options were recommended did not increase significantly (12.5% to 25%; p=0.06).

Table 3.

Self-reported Skills: Percent Responses of “Frequently” or “Very Frequently” on Pre- and Postsurvey

Item	% Presurvey	% Postsurvey	P value
If a pediatric patient is able to report his or her pain, how often do you use self-reported instruments to assess pain severity?	33.3	56.9	0.02
If a pediatric patient is unable to report his or her pain, how often do you use behavioral instruments to assess pain severity?	35.3	56.9	0.008
How often do you recommend nonpharmacologic treatment options to your pediatric patients who have pain?	12.5	25.0	0.06
How often do you prescribe opioids around the clock on a fixed schedule for initial postoperative pain?	19.0	52.4	0.001
How often do you prescribe opioids on an as needed basis for initial postoperative pain?	39.5	60.5	0.04
How often do you use local anesthetics prior to venipuncture in pediatric patients?	23.9	34.8	0.20

Module evaluation

On the postsurvey, the respondents completed seven module evaluation questions. Overall, the survey respondents rated the PPM module very positively. The majority (n=26, 53%) rated the quality of the PPM module as “high” or “very high” and 45% (n=22) rated it as average. Most respondents (n=33, 70%) reported the PPM was “easy” or “very easy” to use. When asked if they would recommend the PPM to fellow students, 88% (n=43) responded “yes.” The majority (n=30, 64%) reported they intend to use the web-based resources (e.g., tools, tables) in the future. Most (n=37, 76%) reported that both pain assessment and treatment are more important to them as a result of completing the module. Most (n=34, 71%) replied that after completing the PPM they would make changes to their PPM behavior or practice. When asked what changes they would make, selected replies included:

“Be aware of how to more accurately assess and treat pain in pediatric patients.”

“I better understand how to dose pain meds for children.”

“I may use behavioral models to assess pain versus the traditional pain scale of 1–10.”

“Will give pediatric pain the attention it is due.”

“Using more nonpharmacologic methods of pain control.”

Two participants provided suggestions for improving the module. One suggested making the PPM module more interactive. Another suggested making future access to the tools easier for when participants are in practice.

Discussion

Management of pain in children has been identified as an area requiring more training in medical education.¹⁶ Consistent with other studies, only a few of these third- and fourth-year medical students (13%) responded that their medical school education was “good” or “excellent” in training them to treat pediatric pain, further demonstrating that limited PPM training is offered in Liaison Council for Medical Education (LCME) accredited medical schools.

The basic foundation of pain management is knowledge. In this pilot, we demonstrated significant increases in knowledge of PPM through the PPM module. The significant gain reflects not only the effectiveness of the module but also the insufficient knowledge base in PPM. Similarly, in testing a PPM learning session with medical students, Cohen and Bennett¹⁵ found significant increases in knowledge in pediatric pain assessment and opioid pharmacology. However, a web-based module may offer an efficient approach to providing content and may allow students to learn at their own pace. The authors recognize that other educational methods need to be combined with knowledge in order to assimilate knowledge into practice. For example, the web-based module could be combined with team-based learning, simulation sessions, standardized patients, and/or expert demonstration to enhance competency-driven outcomes.

Overall, there was a statistically significant increase in medical student confidence in the areas of assessing and treating pain in children but not in prescribing opioids. An essential first step in adequately managing pain is pain assessment, thus it was encouraging that the greatest percentage of increase in confidence scores was in pain assessment (those who were “confident” or “very confident” increased from 6% to 25%). The increase in confidence in prescribing opioids was not statistically significant (3.8% to 13.5%), most probably because medical students have little experience with medically managing pain. Evidence suggests that low confidence in prescribing is not limited to opioids. Medical students have reported a low level of confidence in prescribing in general,^17,18 although confidence is somewhat lower with controlled drug prescribing.¹⁹ Although knowledge is important, application of skills is necessary to increase confidence, particularly with choosing and prescribing analgesics to children.²⁰

Attitudes based on myths or misconceptions are barriers to adequate pain management and can be challenging to overcome.^8,21–23 The authors chose to direct evidence-based information at 11 common pediatric pain myths in the competency “Recognizing the barriers to effective pediatric pain management.” The survey response of “disagree” or “strongly disagree” to the statement “Young infants cannot tolerate opioids for pain relief” increased from 58% to 83%, which is very encouraging. Qualitative module evaluation comments such as, “Less afraid to use opioids at a young age” and “Reduced hesitancy to give opioids” demonstrate a change in attitudes.

There were positive gains in attitudes about assessing pediatric pain, specifically regarding beliefs about a child's report of pain. We were particularly encouraged by the increase from 62% to 85% in those who “disagreed” or “strongly disagreed” with the statement, “Using opioid analgesics for acute pain in children will delay the diagnosis of the underlying source of pain.” Literature suggests that pain has been undertreated at times due to unsupported fears of pain medications delaying diagnosis.²⁴ Dispelling this myth in an early phase of training is important. The positive changes pre- to postmodule for the attitudinal questions was impressive. The implication is that evidence-based information can change attitudes and dispel widely perpetuated myths that are a detriment to safe and effective pediatric pain care.

Medical students, although not directly performing many of the skills of a graduate medical resident or practicing provider, are developing their skills through a variety of supervised activities. Thus, a change in self-reported skills may indicate application of these skills in future practice. Similarly, students' responses that they will make changes in their behaviors and practice most probably indicate their intentions of how they will practice. Typical by observation and experience, only the numeric rating scale is used to assess pediatric pain. If a pediatric patient is developmentally or cognitively unable to self-report, then pain is often inadequately assessed.²⁵ After completion of the module there was a greater awareness of the availability of valid self-report and behavioral measures of pain, particularly for children at different developmental levels or who are noncommunicative.

This study had several limitations. The number of medical students recruited for the study (i.e., to complete the pre- and postsurvey) was low, most probably because there was no incentive provided to participate, and for the fourth-year medical students, it was close to graduation. Recruitment may have been low because the pre- and postsurveys were administered at times separate from when the module was completed. This was for medical school scheduling purposes. Participation may have improved with scheduling in-house completion sessions in the presence of a study coordinator, with the surveys given at the same time that they were completing the module. Incentives to complete the module may also have enhanced participation. Self-selection into the study may have resulted in a biased sample such that students more interested in pediatric pain may have been more likely to complete the survey. Although not all students who completed the PPM module chose to participate in the study, more than 400 learners have completed the PPM module within the VCU Health System and across the state of Virginia, indicating widespread interest in the module. Another limitation of the study was that it used a quasi-experimental pilot design; specifically, there was neither a control group nor randomization. Hence, caution should be taken in interpreting results. Further testing of effectiveness could include a randomized control trial (RCT), although an RCT can be challenging with an educational program in an academic setting. It may be feasible and informative to test with an RCT design whether having residents complete the module again, before they enter practice, increases the effectiveness of the module in improving pain management.

Conclusion

Our primary goal was to create a desirable and effective web-based module on PPM to begin to address the training deficiencies in this area. This study provided evidence that the PPM module was effective in improving knowledge, confidence, attitudes, and self-reported skills regarding PPM in third- and fourth-year medical students. Further evaluation of the effectiveness is warranted, not only with medical students but also with residents and practicing providers. Evaluation responses indicated that the PPM module provides quality content that respondents would recommend to their colleagues. Additionally, the respondents indicated they would use the module resources in practice. Respondents suggested improvements to the module such as interactive modalities to deliver and apply the content. Updates to the module will focus on this suggested approach. With improvements and the goal of using this as a shared medical education resource, the impact of the PPM module could be substantial on practice behaviors. As eloquently stated by one of the respondents after completing the module, the respondent “will give pediatric pain the attention it is due.”

Footnotes

Acknowledgments

The authors would like to thank C-Change for grant support of the development and evaluation of the Pediatric Pain Management module, the VCU School of Medicine and VCU Graduate Medical Education for its ongoing support of VCU Pain Management: An Online Curriculum. Additionally, the authors would like to acknowledge Theresa Murray, M.D., M.P.H. and Kerry Francis, PharmD for assistance in the development of the pediatric tools and tables and the VCU School of Medicine Office of Technology for ongoing educational partnership. A poster abstract of the web-based module was presented at the American Academy of Pain Medicine, March 2011, Washington, DC.

Author Disclosure Statement

No competing financial interests exist.

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