Why is it important that pain medicine is included in the medical curriculum? Acute pain is an almost universal experience and arises from trauma, burns, infection, emergency and elective surgery, childbirth and severe medical illness. There is a high prevalence of chronic pain in Australia and New Zealand; evidence from large-scale studies show that approximately one in five adults experience chronic pain (37–39). Half of all cancer patients experience chronic pain, and one third will describe their pain as moderate or severe (40). The Global Burden of Disease Study 2016 placed low back pain, migraine, other musculoskeletal pain (such as autoimmune, inflammatory, joint, ligament, tendon and muscle disorders) and neck pain in the top six causes of years lived with disability in Australia and New Zealand, alongside depression and anxiety (41, 42). In 2018, 3.24 million Australians were living with chronic pain, and it was estimated that in 2016–2017, about 770,000 adults in New Zealand experienced pain almost every day (43, 44). Chronic pain is common in children and adolescents, and in the elderly (45–47). In New Zealand, Māori have the highest rates of chronic pain compared with other population groups, and chronic pain is more prevalent in areas of high socio-economic deprivation (48, 49). Acute and chronic non-cancer pain rates in Australia and New Zealand are likely to continue to rise, related to the ageing population, lifestyle changes leading to obesity and inactivity, and the epidemiological shift from infectious diseases to non-communicable diseases (such as diabetes and arthritis) (43, 50–52). Advances in treatment of cancer have led to an increase of painful neuropathic conditions (53).

Medical practitioners need to recognise at-risk populations, and implement effective strategies for acute and chronic pain assessment and management so as to reduce the public health burden of pain (54).

What challenges are medical graduates likely to face when providing pain treatments in their local health system? There is no clinical specialty where the basics of pain management are not relevant because acute and chronic pain are features of each of these disciplines (7).

Proposals have been made both nationally and internationally to mobilise medical education stakeholders (patients, medical practitioners, allied health professionals and governmental bodies) to integrate a formal comprehensive pain medicine curriculum into medical school training (5, 33, 50, 62, 87, 115). An academic–clinical partnership is needed to develop effective collaborative approaches to improving pain medicine competencies of medical students.

An Australian study examining beliefs and clinical practice behaviours related to low back pain among multidisciplinary health professional students recommended more consistent alignment of evidence-based education regarding low back pain across disciplines (94). The problem of limited integration of pain content in pre-licensure health sciences curricula such as nursing, dentistry, occupational therapy, physiotherapy, pharmacy and social work has been identified in Canada, Europe and the USA (73, 81, 82, 91–93). The delivery of effective pain management can be complex and requires multidisciplinary team approaches (116). It is important that health professional students are provided with a common understanding of the basic principles of pain management in order to prepare them to work as part of an integrated multidisciplinary team (8, 117).

On a national scale, the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists (FPM ANZCA) has partnered with the Australian Government (through the Therapeutic Goods Administration) to support pain education for nurses and medical students. The Better Pain Prescribing initiative involves funding for nurses and medical students to access the Better Pain Management e-learning programme on the multidisciplinary, patient-centred approach to the assessment, diagnosis and management of people experiencing pain (88, 118, 119).

Medical schools need to collaborate with different stakeholders (academics, medical training regulators, professional medical colleges, and patient/consumer groups) to meet their responsibility for ensuring that pain medicine education is effectively integrated into the medical curriculum.

The original IASP curriculum was updated and entered its fourth edition in 2017 (120, 121). This IASP Curriculum Outline on Pain for Medicine is intended as a guideline for medical school curriculum planning, to draw attention to key pain concepts that should be taught during the medical training (121).

According to IASP, principles that should guide the pain curriculum for the entry-level physician are: •

Pain is multidimensional requiring comprehensive and ongoing assessment and effective management.

With the advances in the educational research and emphasis on competency-based education, pain management experts and educators became aware of the absence of pain management core competencies for entry-level health professional students (2, 123). It was felt that this deficiency was possibly one of the reasons for the lack of pain education in training programmes (2). In 2012, the Expert Interprofessional Pain Competencies Consensus Group (EIPCCG) comprising leaders from multiple professions with expertise in pain management, education science and development of evidence-based consensus came together to develop core competencies in pain assessment and management for entry-level health professional education (2). The recommended pain management competencies were categorised into four domains: multidimensional nature of pain, pain assessment and measurement, management of pain, and context of pain management (see Figure 2) (2). These domains address the fundamental concepts and complexity of pain; how pain is observed and assessed; collaborative approaches to treatment options; and application of competencies across the life span in the context of various settings, populations and care team models (2). These core competencies were based on the IASP interprofessional core curriculum (124).

The EFIC and IASP core curriculum have been recommended by expert pain researchers as a suitable structure for pain teaching in the undergraduate curriculum (14, 17, 18). The IASP Curriculum Outline on Pain for Medicine has been used as a reference to develop content of pain management courses in medical schools in Greece, the USA (Johns Hopkins University, Virginia Commonwealth University, New York University, University of Washington, State of Michigan medical schools), Finland, the UK and Canada (University of Toronto) (16–21, 23, 125–127).

In 2016, the EIPCCG pain management core competencies formed the basis of the document Strengthening Pain Content in Medical School Curricula, which was developed by an expert panel as a tool for integrating pain management content specifically into medical school curricula (128). Potential teaching methods and suggestions for education strategies and content were identified for each learning goal (128). The document also mapped the pain management core competencies with the Association of American Medical Colleges' Physician Competency Reference Set (128). The EIPCCG pain management core competencies have also been used as a framework for postgraduate continuing professional development for pain educators and clinicians (129).

A workgroup from the University of California was tasked to develop a set of core educational competencies to address pain, substance overuse disorder and safer opioid prescribing for adoption across the six medical schools in the academic health system (130). The final set of University of California pain and substance use disorder competencies was compiled in 2019 (130). Both medication management and nonpharmacological strategies to address pain and substance overuse disorder were included.

A curriculum audit of pain medicine education at medical schools in Australia and New Zealand showed that while 42% of medical schools had partially implemented the recommended IASP Curriculum Outline on Pain for Medicine, none had successfully achieved full integration of this comprehensive curriculum (121). Pain medicine curricula in Australia and New Zealand focused mainly on the neurophysiology, clinical assessment and biomedical treatment of pain, primarily using analgesics (131). A focused review of pain medicine education at medical schools internationally noted similar gaps in the breadth of core topics between the IASP-recommended pain medicine curricula and documented educational content (11–13, 15, 16, 131). These international surveys found that essential topics reflecting the biopsychosocial framework and multidisciplinary treatment of pain were underrepresented at most medical schools (132).

Medical students in Australia and New Zealand display gaps in proficiency in pain medicine knowledge, skills and attitudes, especially with regard to clinical pharmacology, understanding evidence-based pain management options for individual patients and concepts such as allodynia and central sensitisation (10, 133, 134). International studies have shown a similar lack of pain medicine competencies of medical students (135–138).

Pain medicine education needs to ensure that medical graduates are confident in their ability to respond to patients with pain, understand how the patient is experiencing pain, and recognise their own cultural and emotional response to pain (23, 139).

Pain management is complex and requires an understanding of the multidimensional aspects of the pain experience and its related management (121). Clearly defined objectives are important to connect learning activities and content with the pain medicine competencies doctors will require in clinical practice (29, 34, 132).

Traditional teaching methods such as lectures and seminars are commonly used for teaching the foundational concepts of pain management (basic sciences of pain processing and pharmacological therapy) to provide a well-structured base on which further knowledge is built (140, 141). More sophisticated strategies are likely to be required to provide opportunities for students to learn advanced competencies such as delivery of patient-centred pain management within the multiprofessional teams, empowerment of patients to self-manage their pain, explaining concepts such as central sensitisation to patients, and adapting pain assessment and management to the unique needs of special populations (2, 141). Formative OSCEs and structured clinical instruction modules have been used to improve pain medicine competencies of medical students (20, 142–146). Individual medical schools in the USA and Canada have developed dedicated pain modules using small-group discussions, expert-led sessions and patient interactions to improve students' clinical skills, attitudes and knowledge with regard to pain assessment and management (20, 23, 125). Case-based teaching and problem-based learning have also been used to develop the pain management skills necessary to apply knowledge in clinical situations (19–21, 125, 144, 145, 147–150). Expert pain medicine educators have stated that students are more likely to be engaged in pain education with student-centred learning and problem-based learning that includes the use of personal stories of pain (151).

The use of high- and low-fidelity simulation to provide students with a variety of real-life situational experiences (for example managing pain crises or challenging patient scenarios), and exposure to group interdisciplinary pain management planning can improve levels of critical thinking ability (125, 141, 152–156).

Pain provokes a strong negative response primarily on the person experiencing it directly, but can also impact primary caregivers and medical students (144, 157–160). Medical schools need to provide opportunities for students that will encourage positive emotional development and resilience relevant to pain care in conjunction with clinical pain medicine knowledge (161). Effective pain management requires medical practitioners demonstrate empathy, foster productive communication and nurture positive relationships (162). Role playing, motivational interviewing training, communication skills training and improved observational skills training are educational tools that have been recommended to help build empathy (163). Teaching methods such as writing a brief pain narrative, describing pain depicted in a fine-art image, and assessing personal responses to the experience of pain have improved students' awareness of the affective dimensions of pain while fostering their emotional development (161). Journaling, discussion groups and structured reflection have also been used by an individual medical school with positive outcomes on pain competencies (161).

Exposing students to different clinical learning opportunities, such as multidisciplinary pain clinics, general practice clinics, hospital and home visits, helps students understand pain management in the context of varied patient populations, settings and care teams (2, 18, 29, 141, 142). This exposure is important so that students see the continuum of pain care and the impact of pain on patients outside the hospital setting (29, 142).

However, careful selection of clinical placement is important as there is the potential for medical students to be taught by clinicians have not been adequately trained in pain medicine, and therefore providing suboptimal pain treatment and demonstrating negative attitudes towards their patients in pain (8, 164, 165). The challenge is to ensure that medical students are exposed to meaningful clinical learning opportunities in pain medicine.

Web-based pain medicine resources are being developed (19, 142, 147, 148, 166). These modules have been useful for improving medical students' pain competencies in acute, cancer, paediatric, chronic non-cancer and chronic low back pain. The e-learning resources were recommended because they provided resources to simulate authentic real-world contexts and had the potential to facilitate learning face to face or in remote settings (166). Increased use and sharing of online pain medicine education resources could potentially address the staff and learning resource deficit that has been identified (167–170). These e-resources need to be cost-effective and updated regularly.

There is no gold standard for delivering pain medicine education and each medical school would need to determine which model is most suitable for their local context. Pain education could be sequenced from more foundational concepts at the beginning of the medical course to more advanced curricula towards the final years of the course, with required competencies attained at different stages. “Flipping the pain curriculum” has been suggested, so instead of the standard approach of beginning with and emphasising pathophysiological pain processes, students would be initially exposed to the epidemiology of pain and disability, as well as the social and psychological aspects of pain in society, and then move to the more detailed biomedical aspects of pain management (171).

A flexible modular approach integrated over the entire medical curriculum may be the best way to structure the pain curricula for some universities, with pain medicine a common theme throughout the curriculum and different specialities plus a dedicated pain medicine rotation (12, 18, 154). Pain medicine education needs to be systematically integrated into all disciplines since pain is ubiquitous in clinical settings. A curriculum map might be useful to sequence pain curricula and improve cohesion of the pain medicine teaching throughout the medical training programme (172).

Pain medicine competencies need to be assessed for formative and summative purposes to encourage learning, to enhance the importance of pain medicine education, to identify education gaps in the curriculum with respect to pain medicine and to ensure that new graduates are competent and safe to enter the workforce (173, 174).

The Pain Medicine Assessment Framework (PMAF) has been recommended to encourage a systematic approach to the task of assessing medical students' pain medicine competencies (121, 175). This framework emphasises the core pain medicine competencies recommended for pre-licensure health professionals by the EIPCCG (2) as well as the IASP Curriculum Outline on Pain for Medicine (121).

Assessments need to focus not only on pain medicine knowledge but also on clinical skills and attitudes. Written assessments such as multiple choice questions are reliable and practical to assess cognitive pain medicine knowledge and higher order thinking (such as applying knowledge to clinical situations) (173, 176–178). The OSCE assessment has been used effectively to assess medical students' pain competencies such as clinical knowledge, communication, empathy and attitude in a variety of contexts (acute, low back and cancer pain) (20, 145, 147, 179, 180). Progressive medical schools have developed alternative assessment methods (such as reflective journals, vignettes and portfolios) and multifaceted assessment processes to measure multiple domains of competence in clinical pain medicine practice (23, 125, 148, 173).

Internationally, pain medicine learning is likely to be assessed using written examinations, if undertaken at all (11, 173). OSCEs and practical assessments for pain medicine are used by very few medical schools internationally; and by less than 10% of medical schools in Europe (14, 16, 131, 181). There is no national licensing examination in Australian and New Zealand, so medical schools need to develop their own assessment processes to ensure that graduates possess the range of pain medicine competencies to meet the complex needs of people in pain (30, 131).

Pain assessment and management provide an excellent model of interprofessional teaching and learning because of the multidimensional nature of pain (182). IPE is not fully integrated into the medical curriculum in Australia and New Zealand, and often exists as diverse discreet standalone programmes at individual universities (27, 183–186).

IPE has been shown to be effective for improving medical students’ pain competencies in a variety of settings, including general pain management, paediatric pain and acute pain (125, 146, 187, 188). The interfaculty pain curriculum at the University of Toronto, Canada, includes interprofessional small-group sessions focused on developing assessment skills and management plans for patients using standardised patients (21). The e-learning Pain Education Interprofessional Resource also delivered at the University of Toronto has been shown to improve health professional students' pain knowledge and understanding of collaborative care (166). Medical schools need to build interprofessional teaching and learning opportunities into the medical curriculum to reinforce the importance of health professionals working together to effectively manage pain (187).

Pain medicine is a relatively new healthcare field, but is rapidly evolving (63). In particular, the understanding of transition from acute to chronic pain, and translation of promising scientific advances into effective diagnostic, preventative and therapeutic strategies for patients have dramatically improved in the past three decades (189, 190). Identification of peripheral and central nociceptive processes, discovery of endogenous neurochemicals and recognition of the role of the immune system in the maintenance of pain have furthered the understanding of pain mechanisms, diagnosis and treatment (132). Internationally, there is a continuing gap between what is known about pain medicine and the translation of this into clinical practice (62, 190). In general, despite robust evidence for a biopsychosocial model of pain, many medical practitioners continue to focus on a purely biomedical approach to pain (191). Pain is often seen as a symptom of a disease and therefore given a low priority by medical practitioners (9). Pain medicine education needs to be prioritised by medical schools to ensure that future medical practitioners are able to effectively and safely manage pain. This will require concerted collaborative effort and advocacy to ensure that greater time and resources are allocated to pain teaching.

Raising the value of pain medicine education necessitates increased profile of pain medicine in the curriculum and the recognition of pain medicine as an independent discipline rather than the domain of subspecialty training. The discipline of pain medicine was recognised in Australia as a medical specialty in its own right in 2005, and was accredited as a scope of practice in New Zealand in 2012 (192). Currently, the University of Notre Dame Australia has the Churack Chair of Chronic Pain Education and Research, and the University of Sydney has a chair in pain medicine. There is no chair in pain medicine in New Zealand.

To support the development of pain medicine curricula at medical schools in Australia and New Zealand, the FPM ANZCA offers an annual prize to the best medical student in pain medicine at each medical school. Most medical schools do not make use of this opportunity to raise the profile of pain medicine (193).

Each medical school has a set of norms and values that underpin its curriculum (194). Explicit values can be apparent in the formal curricula, such as course content, hours, requirements and evaluation. In Australia and New Zealand, there appears to be a lack of dedicated pain medicine modules, minimal learning time and little evaluation of pain medicine competencies as a requirement for graduation (131). The medical curriculum has been described as overcrowded with multiple competing priorities, so it may be difficult to find space for a new pain medicine programme in an already compacted course (195, 196).

Important learning also occurs via opportunistic teaching during clinical ward rounds (the informal curricula). Students learn by example from interactions with their teachers, also termed the hidden curriculum. This hidden curriculum pertains to what is tacitly acquired by example during training as opposed to the formally explicit teaching that the medical school intends to deliver (197). Lack of teaching or clinical exposure on a topic also portrays a value judgement (null curricula) (29). The null curriculum of pain medicine would be the absence of teaching regarding the management and assessment of patients experiencing pain from the formal curriculum (29). The imbalance of topics at medical schools has been attributed to a failure to recognise the prevalence of patients' experiencing pain in most primary care practices and indeed in most specialities (18).

Students continue to learn from senior medical practitioners who have not been adequately trained in evidence-based pain management (9). For example, medical professionals consistently tend to underestimate pain and the suffering of their patients, and this tendency is more pronounced when the patient reports severe pain and depression (198, 199). This has affected medical students' capacity to trust their patients' accounts of their pain (165). The hidden curriculum has been mentioned in the context of medical school pain education, where students stated that pain was viewed as a nuisance rather than an important symptom and disease in its own right (164). Medical students have also described a hidden curriculum that suggests that chronic pain patients lack educational value and are too difficult to treat (165). Students indicated that since their training primarily emphasised objective measurements, diagnosis and curative treatment, they were unprepared to deal with the “subjectivity” of pain and inability to cure chronic pain (165).

Culture is a powerful force in shaping beliefs and behaviours about pain (200). In New Zealand, one model for understanding Māori health is the concept of te whare tapa whā – the four cornerstones (or sides) of Hauora Māori. In a traditional Māori approach, the inclusion of wairua (the spiritual dimension), the role of the whānau (family) and the balance of hinengaro (mind) are as important as the physical manifestations of illness (taha tinana).

Medical students need to be made aware of their own biases and prejudices towards patients with pain (164). For instance, recent research in New Zealand has highlighted that Māori adults who experience chronic pain are not being offered holistic explanations about the causes of their pain, and are instead being prescribed analgesics at the expense of best practice treatments (201). It is imperative that medical schools address cross-cultural pain education to ensure issues such as conflicting perceptions regarding pain expression and disparities (in assessment, analgesic requirements and treatment) (200).

The literature supports the concept that pain medicine education is best provided by specialists (medical and allied) trained in pain medicine (62, 202). Lack of qualifications of teaching staff at medical schools to provide pain medicine education has been highlighted internationally (62, 203). There is a lack of qualified SPMPs in Australia and New Zealand, particularly in the rural setting (43, 44). Medical schools in Australia and New Zealand spread students over a number of training centres, including rural sites (204). A lack of allied health professionals and general practitioners with professional training in pain management in rural districts has also been identified (205, 206). For students to effectively work in partnership with other health professionals when treating people with complex pain presentations, they need to understand and value other health professionals' roles and expertise (116).

Medical schools need to commit to building a team of medical and allied health pain specialists who are equipped with the skills and teaching resources required to deliver comprehensive pain medicine curricula. It is also clear that continuing professional development for medical practitioners who oversee clinical learning opportunities would be useful to ensure that medical students are provided with consistent evidence-based pain medicine teaching throughout their medical training.

Changes to the curriculum require much planning and financial investment, which may be prohibitive because of a lack of resources. Calls by specialist colleges (such as the FPM ANZCA) for changes to the curriculum to include more pain content may be ignored due to a lack of support and resources offered by these bodies (87, 154). The need for more research and development of pain education resources has been identified previously (89, 207). A systematic review of online pain resources for health professionals found that those available were helpful in improving learner knowledge and skills (207), however more support is needed for the development and distribution of pain medicine teaching resources to medical schools across Australia and New Zealand.

Curriculum designers will need to adapt these pain curricula to suit the needs of the local community they serve. For instance, in New Zealand, Māori have a pedagogical concept of “Ako” that acknowledges the way that new knowledge grows out of shared learning experiences; recognizing the knowledge that both teachers and learners bring to the learning environment (208). It affirms the value of building caring and inclusive learning communities. Studies have shown the need for culturally responsive pain management resources for people with persistent pain in New Zealand (201, 209). The pain medicine curriculum would need to be flexible in design for it to be incorporated into the diverse landscape of medical education in Australia and New Zealand.

Pain specialists in the UK have advocated for local clinical and educational champions for pain education to build strong alliances with deans of medical schools and non-specialists in pain in their local schools to facilitate the incorporation of pain education into the curricula (7, 210). Medical schools would benefit from identifying a local pain champion to drive integration of pain medicine education into the medical curriculum.