ANEU-4004 - Anesthesiology - Pain Clinic

ANEU-4004 - Anesthesiology - Pain Clinic

Elective Title: Anesthesiology - Pain Clinic
Course Number: ANEU-4004
Elective Type: clinical Duration/Weeks: 4 Max Enrollment: 3
Prerequisites: Successful completion of Year 2
Additional Requirements: N/A
Responsible Faculty Director: Adam Romman, MD Periods Offered: 1-7, 9-13 excluding holiday period 8 
Coordinator: Kathryn Gwinn Other Faculty:
Location to Report on First Day:
UTMB Health Pain Management, 2660 Gulf Freeway South - Entrance B, League City, TX 77573 at 7:45am

1. To learn the basic principles of chronic pain management including workup, diagnosis, and management.
2. Understand the role of pain practitioners in the treatment of chronic pain.

1. Learn to perform a focused history and physical examination pertinent to the chief complaint of pain.
2. Learn the basics of diagnosis and management for the following chronic pain conditions:
A. Radiculopathy (cervical and lumbar)
B. Facet arthropathy (cervical and lumbar)
C. Sacroiliac joint pain
D. Trochanteric bursitis
E. Knee and hip osteoarthritis
F. Rotator cuff tendinopathy
G. Painful diabetic neuropathy
H. Fibromyalgia
3. Understand role of radiology in workup of chronic pain and how to read and interpret basics of:
A. cervical and lumbar MRI
B. joint x-rays (knee, hip)
4. Learn the basics of anatomy, indication, and complications for the following interventional pain procedures:
A. Neck - Cervical epidural and Cervical medial branch block and radiofrequency ablation
B. Lower back/pelvis - Lumbar epidural; Lumbar medial branch block and radiofrequency ablation; Sacroiliac joint injection and Trochanteric bursa injection
C. Joint pain - Knee: Intra-articular injection and genicular nerve block; Hip: Intraarticular injection; Rotator cuff tendinopathy: Subacromial bursa injection
D. Larger pain procedures (basics of approach and indication) - spinal cord stimulation; kyphoplasty; intrathecal drug delivery system (IT pump); minimally invasive lumbar decompression (MILD) and Vertiflex Superion interspinous spacer
5. Learn the mechanism of action for the following types of medications along with basic indications, dosing, and side effects:
A. Gabapentinoids, gabapentin, pregabalin
B. NSAIDs: ibuprofen, meloxicam, ketorolac, celecoxib
C. Muscle relaxants: methocarbamol, tizanidine, cyclobenzaprine
D. SNRIs: duloxetine
E. TCAs: nortriptyline, amitriptyline
F. Opioids: hydrocodone (norco), oxycodone, buprenorphine
6. Understand the role of the following in multidisciplinary pain management: physical therapy; occupational therapy; pain psychology; pharmacologic agents; and interventional treatment
7. Understand the limitations of treatment of chronic pain and the role of counseling, education, and pain desensitization
8. Appreciate the major issues concerning opioids used for chronic pain including change in practice patterns over the past two decades, role in the opioid epidemic, and controversial role in modern chronic pain medicine.

Description of course activities
Welcome to the UTMB pain clinic! We are glad to have you rotate with us and hope you can learn a lot this rotation while being a contributing member of the team. My goal is for this course to be a low-stress learning environment where you will be active member of the chronic pain treatment team. Students rotate through the pain management service with the primary location at UTMB Multispecialty Center in League City. The goal of the Pain Medicine rotation is to provide experience and training in chronic pain management.

You will accompany a resident or fellow to see patients on your first day. Plan to shadow the first patients and by the afternoon work with the resident to participate in the history and physical and present to faculty. By the second day you should be seeing patients on your own. You will be expected to write the notes and input orders.

Interventional procedures are done in the clinic suite or at the League City Campus hospital. You will observe and work in procedures one day per week. Touch base with the senior resident or fellow to establish your procedure days.

Type of students who would benefit from the course
Chronic pain reaches practically all disciplines so this course may be of use for those interested in a variety of disciplines including: anesthesiology, PM&R, surgery, internal medicine, family medicine, rheumatology, psychiatry, neurology, and others.

Weekly Schedule
  Clinical Activities (estimated schedule)  
Day of Week   AM   PM
Monday 8:00am 4:30pm
Tuesday 7:00am 4:30pm
Wednesday 9:00am 4:30pm
Thursday 8:00am 4:30pm
Friday 8:00am 4:30pm

 Average number of patients seen per week: 16-24
 Call Schedule: no call duties

Research Activities (estimated schedule)
Activity Hours per Week
Faculty Contact-Time
Self-Directed Study

Method of Student Evaluation
1.  Clinical Observation
  A. Where are students observed on this elective?
    Inpatient Service   Ambulatory   Surgery   Standardized patients
Patients simulators   Other
  B. Frequency - How often are students observed clinically?
    Students are observed daily during patient assessments in the outpatient clinic.
  C. Format - What method(s) are used to document the student's clinical performance?
    Daily oral feedback   End of period oral feedback   Written feedback

2.  Oral Presentation
  A. Audience - To whom does the student present?
    You will give an informal presentation or article discussion toward the end of the month for approximately 10-15 minutes to the current residents, fellow, and faculty. It can be a PowerPoint presentation on any topic of your interest in chronic pain. Often these can be journal article presentations. You can discuss with a fellow or Dr. Romman for ideas.
  B. Frequency / Duration of Presentation(s)?
    One presentation for 10-15 minutes
  C. Format - What guidelines are set for the student's presentation?
    PowerPoint presentation on a topic of interest in chronic pain or a journal article discussion. Discuss with fellow or Dr. Romman for ideas.
  D. Assessment - Who assesses the student's presentation performance?
    Self-assessment   Peer assessment   Faculty assessment
  E. Method of content selection
    Current cases  Student-selected topic   Assigned topic

3.  Written Assignment (H&P's, notes, papers, abstracts, etc.)
  A. Frequency of written assignment(s)?
    Student will write clinic notes in the clinic under the direction of the supervising faculty. Expectation is two patients seen in the morning and two in the afternoon during the first week, and by the 2nd week seeing three in the morning and three in the afternoon.
  B. Format - What guidelines are set for the student's written work?
    Epic templates for clinic notes are available
  C. Length of written assignment(s)?
    Abstract   Annotated bibliography   1 - 2 page paper   3+ page paper
  D. Are recent references required?   No    If yes, how are they selected?
  E. Method of content selection - e.g. student-selected, relate to cases, etc.?
    Content selection made in discussion between student and faculty.
  F. Audience - Who assesses the student's written performance?
    Peer Assessment     Faculty Assessment     Other

4.  Examination
    Oral   Written multiple choice   Written essay / short answer   OSCE

5.  Extra Course Activities
  What expectations do you have for the student to demonstrate participation in the elective (e.g. small group activities, seminars, thoughtful questions, providing resources, journal club, resident lecture attendance)?
    Anesthesiology didactics on Wednesday mornings (7-9am) are optional and available on TEAMs.

6.  Additional Costs
  Please list any additional costs and/or purchases (books, materials, movies to watch, etc.) that are required for this course. Include an estimated total cost. If there are no additional costs, please enter "None".

7.  Other Modes of Evaluation
  Please explain below.
    Your evaluation will be based on your daily performance, case logs, and your presentation.

8.  If this course is an Acting Internship, please complete the following:
  A. Objectives for the AI should relate directly to the Entrustable Professional Activities (EPAs). Each AI should describe how the four key Year-4 EPAs that our school has identified as being Year-4 skills are assessed. The Year-4 objectives are:
1. Entering and discussing orders/prescriptions.
2. Give or receive patient handover to transition care responsibility.
3. Recognizing a patient requiring urgent or emergent care and initiating management.
4. Obtaining informed consent for tests and procedures.
Specify how the student will be given formative feedback on their clinical skills.

Year-4 students should demonstrate mastery of EPAs they developed in the clerkship year, including recommending and interpreting common diagnostic and screening tests, and performing general procedures of a physician. They should be able to demonstrate masterfully and independently skills they mastered in Years 2-3, including efficiently performing comprehensive admission-notes and succinct daily progress notes and perform accurate, concise, and hypothesis-driven clinical presentations, form clinical questions and retrieve evidence to advance patient care. They should be able to demonstrate basic understanding of and beginning mastery of collaborate as a member of the interprofessional team and identify system failures and contribute to a culture of safety improvement.

List advanced clinical skills that a student will be assured an opportunity to practice.

How specifically will this AI build on developing skills from the clerkship year to prepare students for internship?

What opportunities will typically be available to all students who take this AI (procedures, required presentations, etc.)? What opportunities may be available based on patient load/presentation or student initiative (ie. Writing a case report)?

An AI should have expectation of a minimum of 32 hours per week of clinical responsibilities. Duty hours should be capped at ACGME limits for an intern, thus up to 24 hours followed by 4 hours of activities related to patient safety, education, and handoff. Students cannot work more than 80 hours per week averaged over 4 weeks. They can only have 1 day off in a 7-day work week with 8 hours off between shifts.

Clinical responsibilities will vary depending on specialty, but how is the student functioning with work commensurate to a PGY1 with an appropriate level of training?

How is the student demonstrating drawing clinical conclusions and/or developing a management plan and documentation as an intern would do?

How and by whom will midpoint feedback be provided to the student? How will you remediate deficiencies identified at midpoint?

Acting Internship students often seek letters of recommendation following their experience. How many different Faculty will work directly with the student and have knowledge of the student's abilities to detail in a written evaluation? Describe the degree of supervision and interaction with faculty vs. residents or other providers and how feedback will be obtained if more direct work is with residents or other providers.