NEWS | January 24, 2018

Researchers say medical licensing test should include more prescription drug safety, misuse questions

Added focus for clinicians could help address opioid crisis


Research led by experts from the UC Davis schools of medicine and nursing has identified gaps in pain-related education for health care providers that leave out important aspects of safe and effective pain management competencies, including those specific to opioid safety. These findings, said the researchers, may help explain one reason for the current public health crisis of inappropriate pain management and prescription drug abuse.

Scott Fishman Scott Fishman

The study titled “Scope and Nature of Pain- and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE),” appeared online this week in the journal Pain Medicine and found that although pain-related testing was substantial, it overwhelmingly focused on pain recognition rather than all of the other important aspects of pain and its treatment.

“This is an unprecedented study, where we were allowed to examine the one test that every medical student in the nation must pass to receive a state medical license,” said Scott Fishman, professor of anesthesiology and pain medicine and lead author of the study. “Although we’ve identified a high rate of questions related to pain, they were disproportionately focused on pain recognition rather than other important aspects of competency in addressing a patient’s pain. Likewise, clinical education has long emphasized the assessment of pain, but has not adequately focused on all of the other aspects of safe and effective treatments for it.”

Fishman and study colleagues evaluated the scope and nature of pain-related content within the USMLE, which is a sequence of tests that must be successfully completed by every allopathic physician to obtain an unrestricted state medical license. Despite the importance of licensing examinations in assuring health care provider competency, this was the first appraisal of pain and related content within the USMLE.

Using novel assessment criteria, researchers examined approximately 1,500 questions to determine the nature of pain-related content in each question and how well it corresponded to the pain-related competencies that physicians should have developed.

Questions about how pain is recognized vastly outnumbered those that assessed provider understanding about the basic nature of pain and its biological, psychological and social elements, all of which require different levels of knowledge and skill to provide safe and effective care. In fact, the study showed that only a small minority of questions addressed what to do once pain was recognized by the clinician.

Heather Young
Heather Young

“Just as we have seen with the adoption of ‘pain as a fifth vital sign’ and other initiatives to raise awareness around pain, there was a substantial emphasis on ‘assessment’ of pain management in the USMLE,” said Heather M. Young, senior author of the study who serves as associate vice chancellor for nursing and dean of the Betty Irene Moore School of Nursing at UC Davis. “Being able to recognize pain in patients is very important, but raising this awareness without other crucial aspects of safe and effective pain management, especially with regards to medication safety and prescribing, leave clinicians in a precarious position.”

Young, who co-directs the UC Davis Center for Advancing Pain Relief with Fishman, added that “if our nation’s clinicians aren’t tested for their understanding of things like prescription drug safety and misuse, how can we expect them to be knowledgeable care providers for patients in pain?”

The authors said that topics other than pain assessment and recognition, including the needs of special populations, merit greater representation in testing for provider licensure.

“To the credit of the USMLE developers, pain was well-represented in the questions we reviewed, but in line with what is seen in health education curriculum, critically important topics in pain management, including the risks inherent in opioid prescribing, could only be found in a small fraction of questions on the test,” Fishman added. “This correlates with the paucity of questions related to prescription safety and misuse that we found when reviewing the test for key public health issues that must be addressed within the curriculum and training in medical schools.”

The study authors suggest that the test content could be augmented to further encourage understanding and skill development related to the key public health issues arising from back pain, chronic pain resulting from surgery and trauma, as well as military injury-related pain and chronic disease pain.

“Our detailed analysis of the USLME test questions is ultimately designed to help equip the next generation of clinicians to treat pain more safely and effectively, and to prevent pain when feasible,” Fishman said. “We believe that without clear goals for graduates to become competent in safe and effective pain management, schools that train health professionals will remain stuck with inadequate pain-care curricula. It’s ironic that pain education is still so lacking because pain is the most common reason patients seek clinical help.”

The authors said improving pain education for both students and practicing clinicians will substantially help reverse the excessive reliance on opioid medications as a pain reduction tool. They hope the findings can guide future versions of the USMLE test and serve as a catalyst for much needed reform in pain education for health professionals.

In addition to Fishman and Young, other study authors from UC Davis were Laurel Beckett, Yueju Li and Jennifer M. Mongoven. Other national authorities in pain and its management who served as authors included Daniel B. Carr, Beth Hogans, Martin Cheatle, Rollin M. Gallagher, Joanna Katzman, Sean Mackey, Rosemary Polomano, Adrian Popescu, James P. Rathmell, Richard W. Rosenquist, David Tauben.

The Mayday Fund provided a grant to support air and train transportation expenses and lodging near the National Board of Medical Examiners (NBME) headquarters in Philadelphia for panelists and one staff organizer. No payment for participation and/or honoraria was provided for any of the review panelists. In-kind salary support was provided by the Division of Pain Medicine in the School of Medicine and the Betty Irene Moore School of Nursing at the University of California, Davis.