Skip to content
Publicly Available Published by De Gruyter April 29, 2019

Educational interventions to improve medical students’ knowledge of acute pain management: a randomized study

  • Mette Poulsenª , Kristian Dahl Friesgaard , Sophie Seidenfaden , Charlotte Paltved and Lone Nikolajsen EMAIL logo

Abstract

It has been consistently documented that the treatment of acute pain is inadequate. Education of medical students is an obvious strategy to improve this. We therefore conducted a study in which 217 medical students were randomized into one of three groups: a control group (no intervention) and two intervention groups (education with e-learning alone or e-learning combined with simulation-based training). We hypothesized that the combined intervention would be superior to no intervention and e-learning alone. All students completed the same multiple choice questionnaire twice with an interval of approximately 1 week. During this 1-week interval, students in the two intervention groups completed either an 45-min interactive case-based e-learning program, or the e-learning program and a simulation-based training. We showed that the theoretical knowledge about treatment of acute pain increased in both intervention groups but students who received the combined intervention felt more confident in the future handling of patients.

Several efforts have been made over the years in order to improve the management of pain. As regards the treatment of acute pain in hospitalised patients, these efforts include the introduction of Acute Pain Services [1], increased use of multimodal and regional analgesia [2], implementation of pain treatment guidelines, use of validated pain rating instruments, and education of staff [3]. An obvious strategy is to educate medical students about treatment of pain, using modern teaching methods such as e-learning and simulation-based training. The latter method is more resource demanding and the additional value may be questionable [4]. We therefore decided to carry out a randomized study in which medical students were randomized into one of three groups: a control group (no intervention) and two intervention groups (education with e-learning alone or e-learning combined with simulation-based training). We hypothesized that the combined intervention would be superior to no intervention and e-learning alone as regards increase in theoretical knowledge and confidence in the future handling of patients.

The study was carried out at Aarhus University, Denmark, during a 3-week period between August and November 2017. All medial students (n=217) in their last semester of the Master’s degree in Medicine received oral and written information about the study and they all agreed to participate. The students were then randomized into one of three study groups: a control group (n=71); an intervention group receiving education via an interactive case-based e-learning program (n=75); and a second intervention group receiving a combination of the e-learning program and simulation-based training (n=71). Randomization was performed using a computer-generated randomization list (STATA version 13.1, StataCorp, TX, USA). The students randomized into one of the two intervention groups received an electronic link to the e-learning program to complete at home. The e-learning program used an interactive case-based format and took approximately 45 min to complete. It contained an introduction covering important aspects of pain and its treatment, followed by four patient cases with questions and in-depth answers. The students randomized to the combined intervention also participated in simulation-based training at Corporate HR, MidtSim. They were divided into groups of 8–9 students and trained for 45 min by a simulation instructor. The simulation scenario included a patient with severe acute pain caused by an open tibial fracture. The first part focused on treatment of the patient’s pain, the second part focused on treatment of morphine-induced respiratory depression with antidote administration. All students, both those randomized to the control group and the two intervention groups, answered the same multiple choice questionnaire (MCQ) twice with an interval of approximately 1 week; students in the two intervention groups completed either e-learning alone or e-learning and simulation combined during this 1-week interval. The MCQ contained 20 pain-related questions. Each correct answer was given a 5-point score, yielding a total maximum score of 100 points. The students were also asked to assess their confidence in the handling of acute pain (three questions on a 5-level Likert scale), and to state if they found the pain education at the university sufficient (yes/no answer). Statistical analyses were conducted using STATA. The primary outcome (change in theoretical knowledge of pain management, evaluated by MCQ scores before and after completing the educational intervention) was analysed using Kruskal Wallis test, and Mann Whitney U-test was used for pairwise comparisons. The secondary outcome was the difference in treatment confidence, analysed using χ2 test. All p values <0.05 were considered statistically significant. The data were collected in Research Electronic Data Capture (REDCap) [5].

In total, 193 out of 217 randomized students completed the study, yielding a response rate of 89% (Fig. 1). Before the educational intervention, 12 out of 210 students (5.7%) answered that they were satisfied with the existing education in acute pain management at the Medical School so far. The results of the MCQ test are presented in Fig. 2. The median MCQ test score for the e-learning group was 50 [interquartile range (IQR) 40–55] before and 75 (62.5–80) after the intervention. For the combined group the median MCQ test score was 50 (40–60) before and 80 (75–85) after the intervention. In comparison, the median MCQ score for the control group was 45 (40–60) before and 50 (45–55) after. Overall, the improvement in MCQ test scores was significantly different between the three groups (p=0.0001). However, by pairwise comparison, no difference in MCQ test scores was seen between the students completing the e-learning program [20 (15–35)] and the students completing the combined intervention [30 (15–35)], p=0.076. Table 1 shows the results of the students’ answers to the three questions about their level of confidence as regards management of acute pain. Before the educational intervention there was no significant difference in the answers to each question between the groups. After completed intervention there was an overall statistically significant difference between the groups (p=0.001). By pairwise comparison, the number of “strongly agree” and “agree” answers were higher in the combined group than in the e-learning group (p=0.001 for each of the three questions).

Fig. 1: 
        Flow chart for students included in the study. *Students not answering the initial multiple choice questionnaire (MCQ) test. #Students lost to follow-up by not answering the MCQ test after the intervention.
Fig. 1:

Flow chart for students included in the study. *Students not answering the initial multiple choice questionnaire (MCQ) test. #Students lost to follow-up by not answering the MCQ test after the intervention.

Fig. 2: 
        Results from the multiple choice questionnaire test (MCQ) presented as medians with interquartile ranges. The MCQ contained 20 pain-related questions and each correct answer was given a 5-point score, yielding a total maximum score of 100 points.
Fig. 2:

Results from the multiple choice questionnaire test (MCQ) presented as medians with interquartile ranges. The MCQ contained 20 pain-related questions and each correct answer was given a 5-point score, yielding a total maximum score of 100 points.

Table 1:

Results given as ratios (observed/total) of medical students answering “Strongly agree” or “Agree” to three questions about their confidence in the treatment of acute pain.

Control group
e-Learning
e-Learning+simulation
p-Valuea
Before After Before After Before After Before After
Question 1:

I feel secure treating acute pain including administration of intravenous morphine and other opioids
5/66 10/60 7/74 30/64 5/70 57/69 0.86 0.001
Question 2:

I feel qualified to treat patients with acute pain
8/66 9/60 9/74 36/64 5/70 57/69 0.54 0.001
Question 3:

I feel qualified to treat a patient with morphine overdose titrating the antidote naloxone
8/66 23/60 11/74 34/64 7/70 59/69 0.67 0.001
  1. A 5-point Likert Scale was used. aχ2 test for an overall difference between the groups before and after the intervention.

This study demonstrates that very few medical students were satisfied with the existing education in acute pain management at the Medical School, suggesting that more effort should be put into increasing the knowledge of acute pain management. Knowing that residents encounter a high proportion of patients with acute pain in their first years as clinicians [6], the need for proper training becomes even more evident. The most optimal educational approach to improve medical knowledge or skills is uncertain, but it has been shown that e-learning as a solitary instrument has a have poor effect compared with traditional learning methods [7]. Moreover, the results regarding the combination of e-learning and simulation are inconclusive [8]. Although several approaches to improve acute pain management have been tested in uncontrolled before-after studies, including education, guideline implementations, procedure-specific risk factor analysis, pain score documentation, audit, feedback and reminders, no “magic bullet” has been found [9], [10], [11]. However, it is likely that repeated and multifaceted interventions are necessary. In conclusion, we showed that an educational intervention increases knowledge and level of confidence in acute pain management among medical students. Further studies are needed to show if the increased knowledge retains over time and whether it is transferred into clinical practice for the benefit of patients.

  1. Authors’ statements

  2. Research funding: No specific funding was obtained for this research.

  3. Conflict of interest: There are no conflicts of interest.

  4. Informed consent: All included students gave their informed consent to participate in the study.

  5. Ethical approval: The study was approved by the Danish Data Protection Agency (2007-58-0010). The authors consulted the local ethics committee and they replied that ethical approval was not required for this study according to the Scientific Ethical Committees Act (section 14, subsection 1).

  6. Authors’ contribution: All authors contributed to planning of the study, interpretation of results, and writing the manuscript. MP, KF and SS were responsible for data collection. KF analysed the data.

References

[1] Nielsen PR, Christensen PA, Meyhoff CS, Werner MU. Post-operative pain treatment in Denmark from 2000 to 2009: a nationwide sequential survey on organizational aspects. Acta Anaesthesiol Scand 2012;56:686–94.10.1111/j.1399-6576.2012.02662.xSearch in Google Scholar PubMed

[2] Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: a review. JAMA Surg 2017;152:292–8.10.1001/jamasurg.2016.4952Search in Google Scholar PubMed

[3] Andersson V, Bergman S, Henoch I, Wickstrom Ene K, Otterstrom-Rydberg E, Simonsson H, Ahlberg K. Pain and pain management in hospitalized patients before and after an intervention. Scand J Pain 2017;15:22–9.10.1016/j.sjpain.2016.11.006Search in Google Scholar PubMed

[4] Cook DA, Hatala R, Brydges R, Zendejas B, Szostek JH, Wang AT, Erwin PJ, Hamstra SJ. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. J Am Med Assoc 2011;306:978–88.10.1001/jama.2011.1234Search in Google Scholar PubMed

[5] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, Conde JG. Research electronic data capture (REDCap) – a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009;42:377–81.10.1016/j.jbi.2008.08.010Search in Google Scholar PubMed PubMed Central

[6] Friesgaard KD, Paltved C, Nikolajsen L. Acute pain in the emergency department: effect of an educational intervention. Scand J Pain 2017;15:8–13.10.1016/j.sjpain.2016.11.004Search in Google Scholar PubMed

[7] Vaona A, Banzi R, Kwag KH, Rigon G, Cereda D, Pecoraro V, Tramacere I, Moja L. E-learning for health professionals. Cochrane Database Syst Rev 2018;1:Cd011736.10.1002/14651858.CD011736.pub2Search in Google Scholar PubMed PubMed Central

[8] Perkins GD, Kimani PK, Bullock I, Clutton-Brock T, Davies RP, Gale M, Lam J, Lockey A, Stallard N. Improving the efficiency of advanced life support training: a randomized, controlled trial. Ann Intern Med 2012;157:19–28.10.7326/0003-4819-157-1-201207030-00005Search in Google Scholar PubMed

[9] Gerbershagen HJ, Pogatzki-Zahn E, Aduckathil S, Peelen LM, Kappen TH, van Wijck AJ, Kalkman CJ, Meissner W. Procedure-specific risk factor analysis for the development of severe postoperative pain. Anesthesiology 2014;120:1237–45.10.1097/ALN.0000000000000108Search in Google Scholar PubMed

[10] Sampson FC, Goodacre SW, O’Cathain A. Interventions to improve the management of pain in emergency departments: systematic review and narrative synthesis. Emerg Med J 2014;31:e9–18.10.1136/emermed-2013-203079Search in Google Scholar PubMed

[11] Meissner W, Huygen F, Neugebauer EAM, Osterbrink J, Benhamou D, Betteridge N, Coluzzi F, De Andres J, Fawcett W, Fletcher D, Kalso E, Kehlet H, Morlion B, Montes Perez A, Pergolizzi J, Schafer M. Management of acute pain in the postoperative setting: the importance of quality indicators. Curr Med Res Opin 2018;34:187–96.10.1080/03007995.2017.1391081Search in Google Scholar PubMed

Received: 2019-03-01
Revised: 2019-03-26
Accepted: 2019-03-28
Published Online: 2019-04-29
Published in Print: 2019-07-26

©2019 Scandinavian Association for the Study of Pain. Published by Walter de Gruyter GmbH, Berlin/Boston. All rights reserved.

Downloaded on 29.3.2024 from https://www.degruyter.com/document/doi/10.1515/sjpain-2019-0036/html
Scroll to top button