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A prescription for pain
Some medical schools now teach doctors-to-be how to offer relief
BY BETH BROPHY

Pain is the No. 1 reason patients see their doctors, yet doctors would admit that in many cases they are ill-equipped to help. More than 50 million Americans are disabled by chronic pain, according to Fenella Rouse, executive director of the Mayday Fund, a private foundation dedicated to reducing their suffering. Yet the profession, concerned about addicting patients to powerful narcotics, historically has failed to train medical students in the art of managing pain.

Now, it's an art gaining prominence in the curriculum. A growing consensus among physicians and public policy makers defines pain as a condition meriting treatment–not just a symptom–and holds that the vast majority of patients can be helped quite safely using drugs. This year, the body that accredits hospitals and nursing homes will implement new standards for the management of pain: Hospitals, for example, will be required to ask patients if, where, and how much they are hurting and to do whatever possible to ease any suffering. Late last year, the House of Representatives passed the Pain Relief Promotion Act, which would protect a doctor who practices physican-assisted suicide according to rigorous standards and would legitimize the use of opiates and controlled substances in treatment. For the first time last September, a doctor in Oregon was disciplined by a state board for undertreating pain in his patients. And the licensing exams that doctors-in-training take are starting to include questions on pain and end-of-life care. Thus, medical schools have a "strong incentive to do a better job teaching in these areas," says psychiatrist Susan Block, an expert on palliative care at Dana-Farber Cancer Institute in Boston.

Not a fringe. Nearly all of the country's 125 accredited schools devote a minimal amount of class time to death and dying issues, but only Beth Israel Medical Center in New York, a teaching hospital, has a department dedicated to pain and palliative care. "The ideal would be that every medical school has a department, and [that pain] is not viewed as a fringe item," says David Weissman, director of palliative care in the division of hemotology-oncology at the Medical College of Wisconsin. The school is one of a handful that have begun providing students with a more comprehensive understanding of what causes pain and how it can be alleviated.

"I learned it was possible to control pain, but the side effects were dramatic," says Aletha Akers, 28, a fourth-year medical student at Johns Hopkins University, which has created a mandatory course of study on pain management. Students learn, for example, which nerve pathways carry pain information and where along the pathways various drugs work. When Akers rotated through the surgical intensive care unit, for example, she helped treat a woman with bone cancer whose femur had been removed; one effect was excruciatingly painful blisters. The pain could be dulled by ketamine, Akers learned, but the potent drug could–and did–cause hallucinations.

Harvard students take a minimum of five hours of classes on pain and palliative care during their first and third years, which, as at Hopkins, is supplemented by bedside training. These subjects are also integrated into courses on pharmacology, ethics, and death and dying. One course matches students with a patient suffering from a life-threatening illness; the student follows the patient for a semester to monitor pain levels and treatment. Stanford University, Case Western Reserve, and Oregon Health Sciences are also in the forefront on pain management and palliative care.

The remaining challenge for many schools interested in adding pain management will be to overcome a shortage of qualified faculty, a dearth of research on chronic pain, and the competition for space in an already-crammed medical-school curriculum. Respect for the discipline, at least, is slowly being won.