1              INTRODUCTION

 

Higher pain training as a requirement for trainees wishing to work in an inpatient pain service (Affiliate Fellowship of the Faculty of Pain Medicine).

 

The changing face of the NHS and rising patient expectations are driving a need for change in the way that pain management services are organised and commissioned (1). In a resource limited NHS, traditional roles and practices may not be the most efficient way of delivering patient-centred care.  Cost savings may be made through service redesign. This offers opportunities for different ways of working for patients’ benefit. Integrated secondary care pain management services are seen as optimal in the emerging NHS landscape (2).

 

The preamble for the higher pain training section of the CCT in anaesthesia curriculum already states “the FPM recommend that these higher competencies are the minimum required for a trainee to consider a future consultant post with an interest in Acute Pain”. This advice is not being followed in most cases, and a recent national survey highlighted the need for a more comprehensive training programme for trainees wishing to work within or lead inpatient pain services (3).

 

Some of the skills required of inpatient pain consultants overlap with other higher and advanced training modules. These skills, including non-technical / human factors and regional anaesthesia may not be fully developed by the end of higher pain training. It is expected that trainees will focus on these aspects during their advanced anaesthesia training.

 

This advice document outlines curriculum learning outcomes for higher pain training for trainees in anaesthesia intending to lead an inpatient pain service and post CCT anaesthetists taking on this role.

 

This document may be used to tailor higher pain training for those wishing to work in inpatient pain management who do not intend to progress to advanced pain training. This approach does not preclude trainees from advanced pain training and is intended to provide advice for Regional Advisers, LPMESs and Trainees.

 

Trainees planning to continue to advanced pain training and work primarily in chronic pain outpatients may continue with the current approach to higher pain training if they wish.

 

Completion of higher pain training will allow trainees to apply for Affiliate Fellowship of the Faculty of Pain Medicine, without sitting the FFPMRCA exam. This will allow doctors working in acute pain medicine to become part of the FPM and access resources on the FPM website.

Trainees would be expected to complete higher pain training during years ST5-ST6, although completion of higher training may happen during the ST7 year. Ideally, the training should be completed within a 3 month block of at least 20 sessions, with minimal interference from general anaesthetic duties. In reality, it is accepted that on call requirements often continue during higher training, and that trainees will also need to maintain their skills in anaesthesia.

 

It is expected that post CCT anaesthetists will have achieved generic pain medicine competencies to the level of intermediate training in pain medicine within a GMC recognised anaesthetic program before undertaking this period of training. Post CCT anaesthetists would be expected to undergo the same period of higher pain training as trainees.

 

Completion of higher pain training is dependent upon satisfactory completion of the curriculum learning outcomes highlighted in annex A.

 

Assessment in anaesthesia is changing to reflect the GMC credentialing programme, with an outcomes based system utilizing the generic professional capabilities (GPC) framework. This document references the 2010 Anaesthesia CCT curriculum and the GPC framework domains.

 

The generic professional capabilities framework, sets out standards for training under nine key domains. These domains are:

 

Domain 1: Professional values and behaviours

Domain 2: Professional skills

Domain 3: Professional knowledge

Domain 4: Capabilities in health promotion and illness prevention

Domain 5: Capabilities in leadership and team working

Domain 6: Capabilities in patient safety and quality improvement

Domain 7: Capabilities in Safeguarding vulnerable groups

Domain 8: Capabilities in education and training

Domain 9: Capabilities in research and scholarship

 

Annex A (Page 5) outlines how training in inpatient pain medicine maps to the GPC framework. 

 

 

2              Core learning outcomes for higher pain training

 

Having completed higher pain training, the trainee should:

• “Be fully competent in the assessment and management of acute surgical, acute non-surgical and acute on chronic pain in all patients and in all circumstances, including infants, children, the older person, the cognitive impaired, those with communication difficulties, the unconscious and critically ill patient.”
• “Have knowledge and skills in the management of chronic and cancer pain.”
• “Be working to reduce the need for patients to seek help via the Emergency Department for their pain”.

 

These outcomes include most clinical skills required for an inpatient pain consultant. However, some knowledge and skills require clarification.

 

 

3              Pain management in specific patient groups:

 

There are two significant patient groups which are not emphasized in the higher curriculum: inpatients with exacerbations of chronic pain and patients with drug abuse or addiction problems.

 

The ability to manage patients with exacerbations of chronic pain in the inpatient setting is a core skill. This patient group forms a significant proportion of the work of an inpatient pain team (audits suggest 25-33% of consultant time). However, 50% of inpatient pain services feel they are not integrated with chronic pain services and 60% have no members with expertise in chronic pain management. Inpatient pain consultants need to be able to manage these patients effectively, but would seem to be under-trained at present.

 

The management of patients with opioid tolerance or addiction is currently part of the advanced pain curriculum, but needs to be introduced at the higher training level. Trainees need to understand the risks of starting opioids and anti-neuropathic medications. Some training within a drug misuse service is highly desirable.

 

PM_AK_04 describes the principles of pain management in patients with problem drug use, physiological tolerance, psychological dependence and addiction

 

4              Higher pain medicine skills

 

PM_HS_03 demonstrates the ability to perform, within the context of a full and appropriate pain management plan the following activities, including but not limited to:

• Manage an acute pain ward round;
• Assessment of a complex non-postoperative inpatient referral [eg cancer pain, sickle cell, abdominal/pelvic pain, opioid tolerance]
• Peripheral nerve blockade under ultrasound guidance.

 

For those planning to work in inpatient pain, chronic pain procedures may be less relevant. The ability to perform a variety of regional anaesthetic blocks relevant to acute pain management is important. Trainees should be able to manage continuous regional anaesthesia. In addition to peri-operative care, the use of regional anaesthesia in trauma, emergency medicine and palliative medicine should be appreciated and trainees should be competent in basic techniques.

 

 

5              Perioperative medicine skills / knowledge

 

Higher perioperative medicine training is mandatory and includes knowledge and skills relevant to higher pain training.

 

Trainees need to understand the significance of preoperative opioid use and its impact on post-surgical pain management. Patient education and expectation setting should also be included in pre-operative care. Perioperative risk assessment for the transition to persistent post-surgical pain and techniques to minimize this, are key skills. Involvement in pre-operative assessment and pre-optimisation programmes would therefore be beneficial. An understanding of enhanced recovery programmes, and how inpatient pain medicine may integrate with these is important.

 

POM_HK_01 describes strategies for prehabilitation and patient optimisation and the limits of such strategies.

 

POM_HK_02 demonstrates comprehensive knowledge of enhanced recovery pathways and their limitations.

 

POM_HS_03 uses risk scoring systems to inform communication with patients and colleagues

 

POM_HS_04 discusses treatment options and risks with patients, including those with complex comorbidities, taking into account their individual needs and requirements

 

 

6              Chronic pain medicine skills / knowledge

 

Although fewer sessions may be spent in the chronic pain clinic for trainees in inpatient pain management, knowledge of multidisciplinary chronic pain management is mandatory. Several key skills can be developed in the pain clinic. Trainees must have an understanding of the role of psychology and psychiatry in managing complex inpatient pain. They must also be able to assess the psychological aspects and social impact of pain on inpatients.

 

They must also have and understanding of the role of physical modalities in managing patients with acute on chronic problems and be able to refer such patients appropriately.

 

Trainees must have an understanding of the various unconventional analgesics used in managing chronic and acute pain, their mechanism of action and appropriate use in the inpatient setting. This involves an understanding of adjuvant medications such as ketamine, lidocaine and anti-neuropathic analgesic agents.

 

 

7              Non-technical skills

 

Non-technical skills are also important for inpatient pain consultants. Transferrable skills such as team working, leadership, innovation / QI / audit / research, management and education should be taught within the inpatient setting. Trainees should be able to appraise the evidence for novel pain treatments and conduct a risk assessment for their use in individual patients. During higher pain training, involvement in inpatient pain audit or QI projects is expected, with dissemination of results via a poster or verbal presentation if possible.

 

These skills are taken from the advanced anaesthesia CCT curriculum. They may not be fully developed by the end of higher pain training.

 

Annex A

 

Curriculum Learning Outcome: Higher pain training Managing pain in inpatients (acute pain, acute on chronic pain, chronic pain and cancer pain)	GMC Domain
Descriptors	Demonstrates safe and effective pharmacological management of acute and procedural pain in all age groups   Demonstrates professional behaviour with regards to patients, carers, colleagues and others   Delivers patient centred care including shared decision making Takes a relevant patient history including patient symptoms, concerns, priorities and preferences   Performs accurate clinical examinations   Shows appropriate clinical reasoning by analysing physical and psychological findings   Recognises complex pain (acute on chronic pain, exacerbations of chronic pain, opioid tolerance or misuse)   Formulates an appropriate differential diagnosis   Formulates an appropriate management plan   Explains clinical reasoning behind diagnostic and clinical management decisions to patients / carers and other colleagues Appropriately selects, manages and interprets investigations where necessary   Recognises need to liaise with specialty services such as liaison psychiatry and addiction medicine services and refers where appropriate   Prescribes safely   Manages infusion pumps, including PCAs, local anaesthetic infusion catheters, epidurals and other drug infusions   Can lead an inpatient pain team   Recognises acute medical illness   Recognises comorbidities and adjusts pain related medications accordingly   Demonstrates appropriate and timely liaison with other medical specialty services when required   Facilitates referrals to specialist palliative care when needed   Demonstrates effective consultation skills in challenging areas (e.g. ventilated in ICM, non-verbal patient and those with learning difficulties)   Demonstrates compassionate professional behaviour and clinical judgement   Demonstrates an ability to perform necessary practical procedures for safe, effective evidence-based practice   Promotes non-pharmacological pain management strategies when appropriate to do so   Promotes evidence-based pain medicine   Provides education and training to multidisciplinary team members   Active engagement with audit and quality improvement projects including reporting of adverse events   Demonstrates an understanding of the research literature relevant to inpatient pain medicine	GPC 1,2,3,6     GPC 1     GPC 1, 2   GPC 1, 2, 3     GPC 2,3   GPC 2, 3     GPC 2,3     GPC 2, 3   GPC 2, 3   GPC 1, 2, 3     GPC 2, 3     GPC 3, 5       GPC 2, 3   GPC 2, 3     GPC 2, 5   GPC 2, 3   GPC 2, 3       GPC 2, 3, 5     GPC 2, 3, 5   GPC 2, 3, 6, 7       GPC 1, 2     GPC 2, 3,6     GPC 2, 3     GPC 9   GPC 8     GPC 6     GPC 9
GPC Domains	Domain 1: Professional values and behaviours Domain 2: Professional skills Domain 3: Professional knowledge Domain 4: Capabilities in health promotion and illness prevention Domain 5: Capabilities in leadership and teamworking Domain 6: Capabilities in patient safety and quality improvement Domain 7: Capabilities in Safeguarding vulnerable groups Domain 8: Capabilities in education and training Domain 9: Capabilities in research and scholarship
Assessments	•Consultant feedback •MSF •DOPS •CbD

 

 

References

1.           Faculty of Pain Medicine of the Royal College of Anaesthetists. Deans Statement, 2014.

2.           Royal College of General Practitioners. Pain Management Services: Planning for the

Future – Guiding clinicians in their engagement with commissioners. Royal College of

General Practitioners, London. 2013.

3.         Rockett, M., et al., A survey of acute pain services in the UK. Anaesthesia, 2017. 72(10): p.