Scope and Nature of Pain- and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE)

Abstract

Background“The ongoing opioid crisis lies at the intersection of two substantial public health challenges—reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications” [1]. Improved pain education for health care providers is an essential component of the multidimensional response to both still-unmet challenges [2,3]. Despite the importance of licensing examinations in assuring competency in health care providers, there has been no prior appraisal of pain and related content within the United States Medical Licensing Examination (USMLE).MethodsAn expert panel developed a novel methodology for characterizing USMLE questions based on pain core competencies and topical and public health relevance.ResultsUnder secure conditions, raters used this methodology to score 1,506 questions, with 28.7% (432) identified as including the word “pain.” Of these, 232 questions (15.4% of the 1,506 USMLE questions reviewed) were assessed as being fully or partially related to pain, rather than just mentioning pain but not testing knowledge of its mechanisms and their implications for treatment. The large majority of questions related to pain (88%) focused on assessment rather than safe and effective pain management, or the context of pain.ConclusionsThis emphasis on assessment misses other important aspects of safe and effective pain management, including those specific to opioid safety. Our findings inform ways to improve the long-term education of our medical and other graduates, thereby improving the health care of the populations they serve.

Systematic Review of Pain Medicine Content, Teaching, and Assessment in Medical School Curricula Internationally

“…However, competencies that specifically identify pain medicine-related skills, knowledge, or attitudes are minimal or mostly absent in regulatory requirements for medical graduates in Canada and the UK. A recent review of the United States Medical Licensing Examination found that 15% of questions reviewed (40% of total examination questions) were identified as being fully or partially related to pain [ 71 ]. However, these questions were predominantly focused on assessment of pain rather than knowledge of the nature and context of pain, or implications for safe and effective treatment [ 71 ].…”

Self-Administered Skills-Based Virtual Reality Intervention for Chronic Pain: Randomized Controlled Pilot Study

“…Second, access to effective pain management treatments must be improved through adoption of clinical best practices in medical and dental practice and clinical health systems. 28 Third, clinical best practices for pain management should be better incorporated into the routine training of clinicians, 29 with special attention to residency training to meet the needs of patients treated in each specialty. 8,15 Finally, quality care must be adequately reimbursed.…”

“…15 Encouraging licensing and education practices that do more to emphasize safe and effective pain assessment and management has the potential to improve pain management and mitigate factors that contribute to the current opioid crisis. 26,441 Health care professionals who prescribe opioids are in a key position to balance the benefits of analgesics against the risk of adverse clinical outcomes. It is estimated that "apart from federal prescribers who are required to be trained, fewer than 20% of the over one million health providers licensed to prescribe controlled substances have training on how to prescribe opioids safely and effectively."…”

“…26 Provider education research specific to patient outcomes is limited, but systematic reviews on continuing medical education (CME) programs indicate that interventions that include multimedia, multiple instructional techniques, and multiple exposures are associated with improved provider knowledge outcomes compared with alternatives (e.g., print materials, one-time interventions). [443][444][445] Likewise, regardless of whether educational interventions are targeted at clinicians in training or in practice, aligning educational interventions with core competencies (i.e., outcomes) for pain care education 15,441 is a best practice. 49 In addition, although Frank et al 446 demonstrated the effectiveness of a longitudinal distance learning approach that uses telemedicine to change clinical pain practice in primary care (e.g., Extension for Community Healthcare Outcomes [Project ECHO]), a recent systematic review by Rochfort et al 447 found a scarcity of studies on the effectiveness of educational interventions implemented by a PCP designed to promote optimal patient outcomes.…”

Palliative Care Competencies and Readiness for Independent Practice: A Report on the American Academy of Hospice and Palliative Medicine Review of the U.S. Medical Licensing Step Examinations

“…In addition, we were not able to compare the extent to which our assessment of PC items agreed with that of NBME, because the specific percentage of questions within any category is proprietary information. 25 Finally, we made a deliberate decision to focus our recommendations on enhancing the quality of PC content across the step examinations instead of the quantity, both because the optimal amount of content is unknown (e.g., to generate a reportable subscore domain for a given examination) and because multiple specialty and stakeholder societies have advocated for their own interests being represented in the examination series over the years, 26,27 yet the USMLE is structurally limited in how much of any content area can be delivered during an examination period. We hope that our recommendations will allow for integration of PC concepts across a breadth of organ systems and patient populations in a manner that improves the examinations themselves and ultimately medical student and resident PC knowledge and skills.…”