Medical Students | Pain Medicine | UC Davis Health

Course Goals

From the experience on this rotation, students will be expected to gain five key skills:

1. Understand basic concepts of the physiology of pain.
2. Understand and be able to perform a pain-oriented evaluation and physical examination.
3. Understand the known diagnostic classifications of pain and their treatments.
4. Understand the complex interplay of medical, psychological and social issues with pain.
5. Understand the basic indications for and practice of analgesic therapy.

Entry Level

Third- or fourth-year students who have completed basic internal medicine and surgery rotations are eligible. Students are accepted as space allows. The UC Davis Division of Pain Medicine accepts one or two medical students per month for a four-week rotation. Extended rotations can be accommodated on a case-by-case basis. This rotation has no on-call responsibility requirement.

The staff and fellows work closely with each student, meeting daily. Students are required to attend all daily didactic teaching sessions as well as to participate in the outpatient and inpatient chronic pain service.
In general, students spend alternating time in the ambulatory outpatient clinic (seeing new and follow-up patients) and in the outpatient interventional procedure clinic assisting the team. The four-week rotation, however, is flexible and can be varied to suit the needs of each student. Thus, we will try to accommodate students who wish to spend more time on a particular service or with our complementary services, including behavioral health, physical therapy, acupuncture and pharmacy.

Topic Outline

Because pain often is a prevalent aspect of treating patients for a wide variety of conditions, this rotation offers applicable training for students interested in any clinical specialty. Participating students are directly involved with the practice of contemporary multidisciplinary pain management, including acute, chronic and cancer pain. Students work with attending staff members from disciplines of anesthesiology, internal medicine, physical medicine and rehabilitation, psychiatry and neurology.

Students become part of the team that performs medical management for patients with chronic pain and cancer pain in both the outpatient continuity care setting and the inpatient consultation setting. As an important part of the rotation, students develop familiarity with interventional procedures — trigger-point injections, epidural steroid injections (including interlaminar, transforaminal and caudal), sympathetic nervous system blocks (such as stellate ganglion, lumbar sympathetic ganglion, superior hypogastric ganglion and impar ganglion), facet joint procedures (including intra-articular and medial branch nerve blocks and radiofrequency neurotomy), intra-articular peripheral joint injections (encompassing shoulder, sacroiliac, hip and knee joints), peripheral nerve blocks (including occipital, ilioinguinal, and genitofemoral nerves), implantable devices (such as spinal cord stimulators and peripheral nerve stimulators) and intravenous ketamine or lidocaine infusions. The program offers a daily mix of formal and informal educational experiences. Students are exposed to contemporary thinking in pain treatment from multiple disciplines.

No Known Potential Course Overlap

No overlap is anticipated and to our knowledge no similar course is offered elsewhere in the medical school curriculum.

Grading

Student performance evaluation is based on the final assessment by the rotation director, Dr. Singh, informed by faculty and fellow comments and critiques.

This two-week hybrid distance learning course for fourth-year medical students includes an introduction to the pathophysiology, clinical assessment and management of lumbar spinal pain, cervical spinal pain, differential diagnosis and differentiation between sacroiliac, hip and shoulder joint pain, medication management with risk assessment, and non-pharmacological treatments including interventional pain procedures, acupuncture, and psychological support.

The course includes a pre-test, post-course assessment, 6+ hours of pre-recorded lectures, journal article reviews with assessment questions, and an outline for two days of direct observation in the UC Davis Pain Medicine Clinic.

Format

The course is conducted using a hybrid of in-person and online teaching with self-study. Students watch and learn from six hours of recorded content introduction alongside two in-person days observing in the Division of Pain Medicine’s outpatient clinic and procedure suites. Students also read relevant published literature and respond to discussion questions.
Trainees begin the course by taking a pre-test that folds in content that they already should have learned from the pre-clinical and clinical years. The course concludes with a multiple-choice examination that incorporates concepts in the pre-clinical and clinical years while including new content from this course. Students’ discussion questions are graded for completion and clarity.

Objectives

Each topic is aligned with three objectives:

1. Understand the history, physical examination, pathogenesis, and treatment of X type of pain using recorded lecture material.
2. Demonstrate knowledge attainment of the objective 1 criteria through multiple choice pre-testing and post-testing demonstration and journal article review.
3. Apply knowledge of topics to clinical practice, through direct observation in clinical practice.

These objectives correspondingly constitute four Liaison Committee on Medical Education (LCME) milestones:

1. Knowledge — This course is designed to impart and expand knowledge about common conditions that many types of providers will see in clinical practice.
   •    Example/Objective 1: Understand the history, physical examination, pathogenesis, and treatment of lumbar spinal pain.
   •    Example/Objective 2: Understand the history, physical examination, pathogenesis, and treatment of sacroiliac joint and hip joint pain as the differential for lumbar spinal pain.
   •    Example/Objective 3: Understand the history, physical examination, pathogenesis, and treatment of cervical spinal pain.
   •    Example/Objective 4: Understand the history, physical examination, pathogenesis, and treatment of shoulder pain as the differential for cervical spinal pain.
2. Lifelong Learning — This course will foster skills in lifelong learning by use of evidence-based medicine.
   •    Example/Objective: Critically analyze and interpret evidence-based articles (and answer corresponding questions) on spinal pain.
3. Patient Care — The in-person clinical time gives students the chance to apply clinical knowledge to patient care.
   •    Example/Objective: Apply the above knowledge in the care of outpatient chronic pain patients by taking an active role in history-taking and physical examinations and via supervision by pain medicine faculty and fellows.
4. Professionalism — Because this is an asynchronous course, students have responsibility for completing coursework on their own.
   •    Participate in the outpatient clinic in a respectful, team-based manner.

Course requirements

• In good standing at UC Davis School of Medicine.
• In the clerkship years.
• Completion of a pre-test (may be completed up to one week prior to beginning of the course, not graded and for self-assessment only). This is intended to be self-study and covers a wide array of topics touched upon in the previous years of medical training. Ideally, this would be taken as “closed book” to assess baseline knowledge.
• Completion of a post-course assessment (may be completed up to one week after the end of the course), with a 50% pass rate for 30 questions). This is intended to consolidate knowledge across this course and multiple other medical specialties, including the pre-clerkship years. Students are allowed three attempts to meet the 50% cutoff in the open-source exam.
• Watch four pre-recorded lectures (6+ hours) on lumbar spinal pain, cervical spinal pain (including shoulder pain), sacroiliac joint and hip pain, and myofascial pain (including fibromyalgia). PDFs of the recorded lectures are uploaded to Canvas under “Files” while the recording can be viewed in the PANOPTO link.
• Review, analyze, and submit (via Canvas) answers to three to four questions per article from a total of four journal articles on the following topics:

1. Chronic low back pain
2. Hip pain
3. Sacroiliac joint pain
4. Whiplash 
   
   Questions and articles also are uploaded to Canvas under “Files” and can be found under “Assignments.” Grading for this course is on a pass/fail (P/F) basis (18 hours).

• Completion of two days of direct observation in the UC Davis Pain Medicine clinic (to be done ideally during the two-week time frame of the rotation) on the third floor of the Tschannen Eye Institute at 4860 Y Street in Sacramento, California. Clinic begins at 8:00 a.m. and ends at approximately 5:00 p.m. (16 hours).
  
  As an example, students can plan on doing the following:
  
  Week 1: Complete pre-test, watch pre-recorded lectures, read journal articles and start answering related questions.
  
  Week 2: Complete journal article answers and submit to Dr. Sanghvi for grading, come for in-person direct observation at the Pain Clinic in the Lawrence J. Ellison Ambulatory Care Center, and complete the post-test.

Evaluation

1. MedHub evaluation of the trainee along with any necessary face-to-face feedback regarding knowledge, lifelong learning, patient care or professionalism.
2. Grading of journal article discussion questions (lifelong learning) on a pass/fail basis with narrative feedback.
3. Clinical feedback during bedside teaching opportunities (patient care).

Final Grade

1. 50% passing on end-of-course final examination (post-test)
2. Completion of discussion questions (P/F grading)
3. Completion of pre-test (self-assessment only)
4. Completion of in-person clinical experiences
5. Adequate evaluation will reflect pass or fail (P/F) only