Cancer pain assessment and management by housestaff

Pain control for cancer patients is a significant problem in health care, and lack of expertise by clinicians in assessing and managing cancer pain is an important cause of inadequate pain management. This study was designed to use performance-based testing to evaluate the skills of resident physicians in assessing and managing the severe chronic pain of a cancer patient. Thirty-three resident physicians (PGY 1-6) were presented with the same standardized severe cancer pain patient and asked to complete a detailed pain assessment. The residents then completed questions related to management of the cancer pain patient. In the cancer pain assessment, residents did well in assessing pain onset (70%), temporal pattern of pain (64%), and pain location (73%). However, only 33% and 45% physicians adequately assessed the pain description and pain intensity, respectively, and assessment of pain-relieving factors, previous pain history, and psychosocial history was done poorly or not at all by 70%, 88%, and 94% of residents. Only 58% of the residents were judged to be competent in this clinical cancer pain assessment. In the cancer pain management section, opioid analgesic therapy was prescribed by 98% of residents, and 91% used the oral route. However, only 18% of prescriptions were for regular use and 88% of residents did not provide analgesics for breakthrough pain. A significant number of graduated physicians were judged to be not competent in the assessment and management of the severe pain of a standardized cancer patient. Opioids and NSAIDs were the analgesics of choice; however, most were prescribed on a PRN basis only. Co-analgesics were rarely prescribed. Few physicians managed persistent, severe cancer pain according to the WHO guideline of increasing the opioid dose. The lack of significant difference in scores between junior and senior residents suggest that adequate cancer pain management is not being effectively taught in postgraduate training programs.