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Medical Licensing Test Should Include More Prescription Drug Safety

Researchers – including a team from the University of Pennsylvania School of Nursing (Penn Nursing) and the Perelman School of Medicine at the University of Pennsylvania – have identified gaps in pain-related education for health care providers that leave out important aspects of safe and effective pain management competencies, including those specific to opioid safety. These findings may help explain one reason for the current public health crisis of inappropriate pain management and prescription drug abuse.

The study was recently published online in the journal Pain Medicine and found that although pain-related testing was substantial, it overwhelmingly focused on pain recognition rather than all of the other important aspects of pain and its treatment.

“This study represents a major advancement in drawing attention to medical licensing exam pain knowledge and competency questions,” said co-author Rosemary Polomano, PhD, RN, FAAN, Associate Dean for Practice and a professor of Pain Practice at Penn Nursing; and a professor of Anesthesiology and Critical Care in the Perelman School of Medicine at the University of Pennsylvania. “We hope that our work serves as a model methodology to evaluate whether are we testing what we should be teaching and whether we are teaching what we should be testing to meet competencies in pain management.”  

The research team evaluated the scope and nature of pain-related content within the United States Medical Licensing Examination (USMLE), which is a sequence of tests that must be successfully completed by every allopathic physician to obtain an unrestricted state medical license. This was the first appraisal of pain and related content within the USMLE. Using novel assessment criteria, researchers examined approximately 1,500 questions to determine the nature of pain-related content in each question and how well it corresponded to the pain-related competencies that physicians should have developed.

“While there has been great concern regarding the current opioid epidemic, there is also a pain epidemic with approximately thirty percent of American adults suffering from chronic or recurrent pain,” said co-author Martin D. Cheatle, PhD, an associate professor of Psychiatry in the Perelman School of Medicine at the University of Pennsylvania. “This study highlights the dearth of relevant pain medicine content on the licensing examination which reflects the current medical school curriculum. Improving pain care for the countless number of individuals who suffer from pain and curtailing the opioid crisis in part entails developing core competencies in pain medicine in medical school. Hopefully the results of this study and its methodology will lead to additional research in this area.”

Questions about how pain is recognized vastly outnumbered those that assessed provider understanding about the basic nature of pain and its biological, psychological and social elements, all of which require different levels of knowledge and skill to provide safe and effective care. In fact, the study showed that only a small minority of questions addressed what to do once pain was recognized by the clinician.

The study finds that topics other than pain assessment and recognition – including the needs of special populations – merit greater representation in testing for medical provider licensure. To the credit of the USMLE developers, pain was well-represented in the questions that were reviewed, but in line with what is seen in health education curriculum, critically important topics in pain management, including the risks inherent in opioid prescribing, could only be found in a small fraction of questions on the test. This correlates with the paucity of questions related to prescription safety and misuse that were found when reviewing the test for key public health issues that must be addressed within the curriculum and training in medical schools.

“Promoting excellence in pain care starts with assuring that competencies in pain medicine are adequately tested in national licensing exams for our clinicians,” said co-author Adrian Popescu, MD, an assistant professor of Clinical Physical Medicine and Rehabilitation in the Perelman School of Medicine at the University of Pennsylvania. “Mandating competencies in pain medicine education for accreditation of health professional schools and licensing of their graduates is paramount. This will only improve the pain care for the populations we serve.”

The authors suggest that test content could be augmented to further encourage understanding and skill development related to the key public health issues arising from back pain, chronic pain resulting from surgery and trauma, as well as military injury-related pain and chronic disease pain. Improving pain education for both students and practicing clinicians will substantially help reverse the excessive reliance on opioid medications as a pain reduction tool. They hope the findings can guide future versions of the USMLE test and serve as a catalyst for much needed reform in pain education for health professionals.

“The great advances over the past 2 decades in our understanding of the epidemiology, pathophysiology and behavioral neuroscience of painful conditions and the treatment of acute and chronic pain have not translated widely into education for all health professionals and improved care for our patients,” said co-author Rollin Gallagher, MD, MPH, a professor of Psychiatry and of Anesthesiology and Critical Care in the Perelman School of Medicine at the University of Pennsylvania. “The NIH’s 2016 National Pain Strategy calls for such education, and the USMLE graciously offered our team an opportunity to evaluate what is tested about pain which is an important first step determining priorities in medical education.”

This study was led by a team from the University of California-Davis (UCD): Scott Fishman, MD and Heather Young, PhD. Additional co-authors include: Laurel Beckett, PhD; Yueju Li, MS; Jennifer Mongoven, MPH (all from UCD); Daniel B. Carr, MD (Tufts University School of Medicine); Beth Hogans, MD (Johns Hopkins University); Joanna Katzman, MD (University of New Mexico School of Medicine); Sean Mackey, MD (Stanford University); James Rathmell, MD (Harvard Medical School); Richard W. Rosenquist, MD (Cleveland Clinic); and David Tauben, MD (University of Washington).