This document applies to those who begin training on or after July 1, 2018.

Transcription

1 Objectives of Training in the Subspecialty of Pain Medicine This document applies to those who begin training on or after July 1, DEFINITION 2018 VERSION 2.0 Pain Medicine is a medical subspecialty concerned with the prevention, evaluation, diagnosis, treatment, and rehabilitation of patients with acute and chronic pain associated with cancer and non-cancer diagnoses. GOALS Upon completion of training, a resident is expected to be a competent subspecialist in Pain Medicine, capable of assuming a consultant s role in the subspecialty. The resident must acquire a working knowledge of the theoretical basis of the subspecialty, including its foundations in science and research, as it applies to medical practice. Only candidates certified by the Royal College in Anesthesiology, Emergency Medicine, Internal Medicine, Neurology, Pediatrics, Physical Medicine & Rehabilitation, Psychiatry, or Rheumatology may be eligible for certification in Pain Medicine. In addition, entry from the following Royal College accredited disciplines is possible in exceptional cases, with the approval of the Specialty Committee in Pain Medicine: Medical Oncology, Neurosurgery, Orthopedic Surgery, or Palliative Medicine. Residents must demonstrate the requisite knowledge, skills, and behaviours for effective patient-centred care and service to a diverse population. In all aspects of subspecialist practice, the graduate must be able to address ethical issues and issues of gender, sexual orientation, age, culture, beliefs, and ethnicity in a professional manner. PAIN MEDICINE COMPETENCIES At the completion of training, the resident will have acquired the following competencies and will function effectively as a: This document may be reproduced for educational purposes only provided that the following phrase is included in all related materials: Copyright 2018 The Royal College of Physicians and Surgeons of Canada. Referenced and produced with permission. Please forward a copy of the final product to the Office of Specialty Education, attn: Associate Director, Specialties. Written permission from the Royal College is required for all other uses. For further information regarding intellectual property, please contact: documents@royalcollege.ca. For questions regarding the use of this document, please contact: credentials@royalcollege.ca. Page 1 of 23

2 Medical Expert Definition: As Medical Experts, Pain Medicine specialists integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of patientcentred care. The core skill of the Pain Medicine physician is to synthesize available information in a manner which places the patient s clinical presentation in a bio-psychosocial framework, and to then advise as to the best method of pain management for that patient. Medical Expert is the central physician Role in the CanMEDS framework. Key and Enabling Competencies: Pain Medicine specialists are able to 1. Function effectively as consultants, integrating all of the CanMEDS Roles to provide optimal, ethical, and patient-centred medical care Perform a consultation effectively, including the presentation of well-documented assessments and recommendations in oral, written, and/or electronic form in response to a request from another health care professional Demonstrate use of all CanMEDS competencies relevant to Pain Medicine Practice Pain Medicine in the context of an interprofessional pain clinic setting Identify and appropriately respond to relevant ethical issues arising in patient care Demonstrate the ability to prioritize professional duties effectively when faced with multiple patients and problems Demonstrate compassionate and patient-centred care Recognize and respond to the ethical dimensions in medical decision-making Demonstrate medical expertise in situations other than patient care, such as providing expert legal testimony or advising governments, as needed 2. Establish and maintain clinical knowledge, skills and behaviours appropriate to Pain Medicine 2.1. Apply knowledge of the clinical, socio-behavioural, and fundamental biomedical sciences relevant to Pain Medicine: Describe the anatomy and neurophysiology of nociception Describe the pathophysiology of acute and chronic pain, including mechanisms, modulation, and associated physiologic consequences Define the disorder of chronic pain utilizing the International Association for the Study of Pain (IASP) Classification of Chronic Pain Describe current concepts of the placebo response and their implications for assessment and therapy Page 2 of 23

3 Describe genetic influences on pain and pharmacotherapy for pain Describe the role of genomic techniques in investigating pain physiology Summarize the mechanism of action, pharmacology, side effects, and monitoring of the following drugs or drug classes: Acetaminophen Calcium channel blockers Cannabinoids N-Methyl-D-Aspartic acid (NMDA) receptor antagonists Opioid receptor agonists Opioid receptor agonists, antagonists, and mixed agonist-antagonists Prostaglandin inhibitors Serotonin/norepinephrine re-uptake inhibitors Sodium channel blockers Explain the administration, scoring, interpretation, limitations, and clinical utility of at least one validated outcome measures in each of the following domains: Pain Mood Function Sleep Quality of life and health care utilization Psychology of pain psychology List important psychological mechanisms involved in pain and suffering Describe how neuro-biologic predisposition, childhood and early life experiences, and cultural and societal environments may impact pain perception and experience using a bio-psycho-social model Identify characteristics of patients with pain who would benefit from a formal psychological assessment Outline indications, contraindications, benefits, and risks, and summarize the evidence that supports the following clinical treatments: Biofeedback Page 3 of 23

4 Cognitive Behavioural Therapy (CBT) Goal setting Hypnosis Imagery training Mindfulness Based Cognitive Therapy (MBCT) Mindfulness Based Stress Reduction (MBSR) Patient education programs Patient self-management techniques Define catastrophizing and kinesiophobia as predictors of chronic pain treatment outcomes Describe common assessment tools Outline interventions that reduce the severity of each condition Pain and psychiatric illness Describe how psychiatric illness relevant to pain medicine may be modulated through predisposing, precipitating, perpetuating, and protecting factors List diagnostic criteria, describe appropriate screening questionnaires, outline the fundamentals of treatment strategies and contraindications for other treatments, and state the indications for psychiatric or psychological assessment for the following psychiatric disorders Anxiety disorders Attention deficit/hyperactivity disorder Bipolar disorders Major depressive disorder Personality disorders Somatic symptom disorders Substance use disorders Trauma and stress-related disorders Explain the potential effect of pain treatments on psychiatric comorbidities Addiction medicine Define addiction, tolerance, and physical dependence Page 4 of 23

5 Describe the heterogeneity of opioid use in patients with pain and other diagnoses, including: Abuse Misuse Diversion Identify the health consequences of both untreated pain and opioid misuse or abuse Describe the core clinical features and treatment of patients with comorbid pain and addiction Describe the concept of "Universal Precautions" as it applies to treatment with opioids List aberrant drug-taking behaviours in patients prescribed opioids; identify which are predictive of abuse, misuse, or diversion; and describe differential diagnoses for these behaviours Describe a range of treatment strategies for pain management in patients with addiction, either active or in remission Describe appropriate withdrawal schedules and strategies for managing withdrawal symptoms for opioids and benzodiazepines Describe current national or widely recognized standards, such as Centers for Disease Control (CDC), or Canadian opioid guidelines, for the prescription of opioids in chronic pain Demonstrate knowledge of the scientific literature, identifying the benefits, risks, and shortcomings of opioids for chronic pain Demonstrate knowledge of current Canadian regulation of opioid prescribing Sleep medicine Describe how sleep disorders may affect patients with acute and chronic pain and may be modulated through predisposing, precipitating, perpetuating, and protecting factors Describe the interaction between pain, sleep, medications, nonprescribed substances, anxiety, and mood disorders Describe the basic classification of sleep disorders according to the International Classification of Sleep Disorders (ICSD) Identify the characteristics of patients who would benefit from referral to a sleep clinic List common assessment procedures used in the diagnosis of sleep disorders Page 5 of 23

6 Outline non-pharmacologic and pharmacologic treatment options for the common sleep problems that occur in association with chronic pain disorders Musculoskeletal (MSK): Describe the epidemiology, pathophysiology, natural history, diagnosis, treatments, and prognosis of common painful musculoskeletal diseases, including inflammatory and degenerative joint disease, soft tissue rheumatism, and diffuse body pain Demonstrate knowledge of diagnosis, appropriate investigations and management of common rheumatic conditions Describe specific pain syndromes that may occur following spinal cord injury, stroke, and limb amputation Demonstrate knowledge of the diagnosis and management of common pathologies of the spine that may cause pain, including mechanical back pain, intervertebral disc herniations with radiculopathy, spinal stenosis, and whiplash associated disorders Demonstrate knowledge of diagnosis and management of emergency conditions of the spine, including cauda equina syndrome, tumour, fracture, myelopathy, and infection Describe the indications for the various modalities of diagnostic imaging specific to MSK assessment; Describe injection formulations and techniques that may be used to treat painful soft tissue and joint disorders Describe the principles, indications, and limitations of physical treatments, including exercise based treatment, and active and passive physical therapies Describe the principles, indications, and limitations of occupational therapy management Describe the principles, indications, and limitations of evidence for complementary and alternative medicine commonly used in managing musculoskeletal pain Describe functional domains as outcome measures for pain Describe the principles of functional restoration in individuals with pain and the evidence supporting different types of chronic pain activation programs Describe the current World Health Organization Disability Assessment Scale (WHO-DAS), the concepts of impairment, ability and participation, and how these apply to individuals with pain Page 6 of 23

7 Neurology and neuropathic pain Describe the epidemiology, pathophysiology, natural history, diagnosis, treatments, and prognosis of common conditions causing neuropathic pain Describe the features of neuropathic pain including peripheral and central sensitization List the common symptoms and signs Explain their role in the persistence of pain Demonstrate knowledge of diagnosis, appropriate investigations, and management of common painful peripheral nervous system disorders, including Compression and entrapment syndromes Diabetic neuropathy Infectious lesions including herpes zoster Post-herpetic neuralgia Ischemic nerve injuries Demonstrate knowledge of diagnosis, appropriate investigations and management of common painful central nervous system disorders including post-stroke pain, spinal cord injury, and multiple sclerosis Explain the appropriate use of clinical tests used to diagnose neuropathic pain Describe the indications for and limitations of medical imaging, nerve conduction studies, electromyography and quantitative sensory testing in the diagnosis of neuropathic pain Describe common validated tools to assess neuropathic pain; identify their purpose, scoring, interpretation, and limitations Headache and craniofacial pain Anatomy and physiology of craniofacial pain pathways Classification of headache Pathophysiology, clinical features, and management of headache and craniofacial pain disorders, including Primary headaches Migraine and chronic migraine Tension-type headache and chronic tensiontype headache Page 7 of 23

8 Secondary headaches such as medication overuse headache and cervicogenic headache Identify the critical factors for assessing life-threatening headache including early morning nausea and vomiting and focal neurological signs and symptoms Pediatrics Explain the common acute and chronic pain syndromes unique to pediatric patients, their epidemiology, pathophysiology, natural history, symptoms, signs, treatment, and prognosis Describe how developmental, psychosocial, family, and cultural factors affect the assessment of pain in pediatric patients and formulation of a treatment plan Describe the use of common validated tools to measure pain in neonates, children, and youth, including those with intellectual disability Identify their purpose Explain their administration, scoring, interpretation, and limitations Define their clinical utility Describe the differences between adults and children with regards to common analgesic pharmacotherapy Describe approved strategies for safe prescribing and monitoring of off-label pain therapies Describe non-pharmacologic approaches reduce procedural pain and to treat pain Outline the evidence regarding adverse physiological and psychological effects of inadequate pain management in neonates and infants Describe the assessment and management of a child or youth who experiences pain sensitization following repeated or prolonged exposure to acute pain episodes Acute pain List common acute pain conditions, their epidemiology, pathophysiology, natural history, treatment, and prognosis Describe the elements of an acute pain assessment and explain how it may differ from a chronic pain assessment Describe how specific patient characteristics such as culture, age, cognitive impairment, language barrier, or Page 8 of 23

9 level of consciousness might affect acute pain assessment Describe the adverse physiological and psychological effects, both immediate and long term, of inadequate pain management in the acute care setting Identify patients whose injury, disease, or surgery, in combination with their psychological characteristics, may put them at risk of developing chronic pain Describe treatments which might decrease that risk Describe the indications, contraindications, delivery routes, side effects, and complications of specific pharmacological interventions used for acute pain management including medications from the following classes: Acetaminophen Calcium channel blockers Cannabinoids N-Methyl-D-Aspartic acid (NMDA) receptor antagonists Opioid receptor agonists Opioid receptor agonists, antagonists, and mixed agonist-antagonists Prostaglandin inhibitors Serotonin/norepinephrine re-uptake inhibitors Sodium channel blockers Demonstrate an understanding of a multimodal pain management plan for the highly opioid tolerant patient experiencing an acute process such as surgery or trauma Describe the evidence for non-pharmacological techniques used for acute pain relief and describe how they can be successfully utilized in acute pain management Identify factors that complicate treatment of a patient with acute pain including previous chronic pain conditions, opioid tolerance, substance abuse, and psycho-social factors Page 9 of 23

10 Cancer pain Describe the epidemiology, pathophysiology, natural history, treatment, and prognosis of common cancers Explain how cancer cycles of recurrence and remission might affect pain assessment and treatment Identify acute and life threatening complications of cancer that can present with pain, including raised intracranial pressure, spinal cord compression, and hypercalcemia Outline common pain management problems that are unique to cancers Describe the pain-related complications of chemotherapy, radiotherapy, and surgery, and their management Describe the psychological, social, cultural, and spiritual effects of a life threatening disease on pain assessment and treatment Demonstrate knowledge of guidelines for the pharmacologic management of cancer pain Identify the differences with regard to utilizing opioids and coanalgesics in a variety of administration routes Describe the indications, contraindications, risks and benefits of anesthetic and neurosurgical procedures to control cancer related pain, including local anesthetic and neurolytic blocks and neuraxial drug delivery systems Describe the elements of both an outpatient and inpatient cancer pain service Identify characteristics of patients who would benefit from psychosocial intervention, home care, and palliative care Anesthesia Describe the mechanism of pain relief from general, neuraxial, and regional anesthesia Describe the role of the sympathetic nervous system in cardiovascular homeostasis and the effect of drugs on these parameters Demonstrate knowledge of plans other than Advanced Cardiovascular Life Support (ACLS) algorithms for management of over-sedation, partial or complete airway obstruction, bradycardia, hyper- or hypo-tension, seizure, and local anesthetic toxicity Demonstrate knowledge of paravertebral and neuraxial anatomy, physiology, and pharmacology Page 10 of 23

11 Describe current methods of interventional techniques in acute pain management including their indications, contraindications, side effects, and complications including: Neuraxial block Plexus block Peripheral nerve block Intravenous infusion therapies Demonstrate understanding of the risks of interventions in the neuraxis, including epidural hematoma, post-dural puncture headache, meningitis, arachnoiditis, and discitis, and describe strategies to deal with these events Interventions for chronic pain Demonstrate an understanding of patient factors that influence selection for and response to interventions Demonstrate knowledge of interventions for chronic pain management Neuraxial block, plexus, peripheral, sympathic, and myofascial injections Neuromodulation procedures Intravenous infusions such as ketamine, lidocaine, and dexmedetomidine Neuroablative procedures including radiofrequency, cryotherapy, and chemical neurolysis Epidural and intrathecal drug delivery Fluoroscopic techniques, including radiation safety Ultrasound physics and the role of ultrasound in interventional treatments Demonstrate knowledge of the prevention of infectious complications, including sterile technique, sterilization of equipment and supplies, and indications for antibiotic prophylaxis Demonstrate knowledge of the management of emergencies that might arise in a pain clinic, including: Acute spinal cord compression Cardiovascular collapse Local anesthetic systemic toxicity Loss of airway Page 11 of 23

12 Seizure Vasovagal syncope Describe the CanMEDS framework of competencies relevant to Pain Medicine Apply lifelong learning skills of the Scholar Role to implement a personal program to keep up to date and enhance areas of professional competence Integrate the available best evidence and best practices to enhance the quality of care and patient safety in Pain Medicine 3. Perform a complete and appropriate assessment of a patient 3.1. Identify and effectively explore issues to be addressed in a patient encounter, including the patient s context and preferences Perform an appropriate clinical assessment, including a directed history and examination, in order to identify the etiology of the acute or chronic pain condition Perform an assessment of the presenting complaint and relevant comorbidities utilizing a biopsychosocial framework and appropriate to the patient s age and developmental stage 3.2. Elicit a history that is relevant, concise, and accurate to context and preferences for the purposes of diagnosis, management, health promotion, and disease prevention Demonstrate appropriate use of at least one validated pain outcome questionnaire chosen from each of the six domains in the Initiatives on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT) guidelines 3.3. Perform a focused physical examination that is relevant and accurate for the purposes of diagnosis, management, health promotion, and disease prevention Perform a directed musculoskeletal and/or neurological physical examination in order to differentiate painful processes arising from bones, joints, soft tissues, or the peripheral or central nervous system Perform a directed history and physical examination specific to the assessment of the patient with cancer in order to differentiate painful processes arising from the primary cancer or metastases, a complication from cancer or its treatment, or a preexisting chronic pain condition Conduct an appropriate assessment of oncologic emergencies, including raised intracranial pressure, spinal cord compression, and hypercalcemia Page 12 of 23

13 3.4. Select medically appropriate investigative methods in a resource-effective and ethical manner Identify expected imaging abnormalities for common pain diagnoses Explain the relationship between imaging findings and pain 3.5. Demonstrate effective clinical problem solving and judgment to address patients problems, including evidence-based examination techniques, interpreting available data, and integrating information to generate differential diagnoses and management plans Identify whether a given pain complaint arises from an inflammatory or degenerative musculoskeletal condition and generate a differential diagnosis using anatomical knowledge and, if applicable, evidence-based examination techniques Devise, as resources allow, an appropriate integrative, interdisciplinary management plan utilizing all appropriate interventions (preventative, psychological, non-pharmacologic, pharmacologic, interventional) based on the individuals specific pain, co-morbidities, goals, and other relevant factors to provide maximal functional restoration Formulate a step-wise approach to pharmacotherapeutics and pain interventions for a patient with neuropathic pain, applying published consensus guidelines and taking into consideration the patient s individual medical complexity Identify patients with co-morbid psychiatric and coping difficulties and select appropriate therapeutic strategies for pain management Utilizing the Universal Precautions risk stratification, and in accordance with Canadian Guidelines for Safe and Effective use of Opioids for Chronic Noncancer Pain, develop and implement an appropriate management and follow up plan for a patient who requires opioids Stratify patients into categories of low, moderate, or high risk for addiction, and identify patients who should be referred for addiction consultation prior to or during opioid therapy Employ validated risk assessment tools and interviewing techniques to perform an appropriate risk assessment for a patient in whom opioids or cannabinoids are being considered Identify strategies to reduce opioid diversion, including health provider education, patient education regarding safe storage, improved treatment resources for patients with pain, government collaboration regarding surveillance and regulations, and abuseresistant formulations Page 13 of 23

14 4. Use preventive and therapeutic interventions effectively 4.1. Implement a management plan in collaboration with a patient and the patient s family Demonstrate appropriate and timely application of preventive and therapeutic interventions relevant to Pain Medicine Identify treatment and monitoring strategies for patients with emerging aberrant drug-taking behaviours Use reversal agents appropriately, such as naloxone and flumazenil Apply evidence-based therapeutic measures that can be used for prevention of: Post-surgical pain Musculoskeletal pain Neuropathic pain Pain-related crises in cancer pain syndromes Pain related disabilities Medication and substance abuse disorders Obtain appropriate informed consent for procedures and/or therapies Perform common image-guided procedures, taking into account their limitations and risks: Peripheral nerve block Lumbosacral spine and sacroiliac (SI) joint block Sympathetic chain block Common musculoskeletal and joint injections 4.5. Perform the following procedures: Insertion of intravenous vascular access ACLS Administration of sedation with appropriate monitoring, as indicated by the Canadian Anesthesiolgists Society standards Management of an obstructed airway with jaw thrust, oral airway, laryngeal mask airway, and orotracheal intubation Management of moderate hypotension and hypertension, including vasovagal bradycardia 1 Throughout this document, references to the patient s family are intended to include all those who are personally significant to the patient and are concerned with his or her care, including, according to the patient s circumstances, family members, partners, caregivers, legal guardians, and substitute decision-makers. Page 14 of 23

15 Identify procedures that require the use of appropriate image guidance including ultrasound, fluoroscopy, computed tomography (CT), or endoscopy, and plan referrals accordingly Document and disseminate information related to procedures performed and their outcomes Ensure adequate follow-up is arranged for procedures Ensure patients receive appropriate end-of-life care 5. Seek appropriate consultation from other health professionals, recognizing the limits of their own expertise Demonstrate insight into their own limits of expertise Demonstrate effective, appropriate, and timely consultation of another health professional as needed for optimal patient care and specifically in situations where: An emergency referral to another specialist is required Consultation with another medical specialist would be beneficial (including for diagnostic or treatment-related interventional procedures) Consultation with other health professionals, including occupational or physical therapists, would be beneficial Adapt the referral request to individual situations and consider, where possible, telephone or video consultation Arrange appropriate follow-up care services for patients and their families, with the most responsible physician, to facilitate longitudinal coordinated care, after consultation with others Communicator Definition: As Communicators, Pain Medicine specialists effectively facilitate the doctor-patient relationship and the dynamic exchanges that occur before, during, and after the medical encounter. Key and Enabling Competencies: Pain Medicine specialists are able to 1. Develop rapport, trust, and ethical therapeutic relationships with patients and families 1.1. Recognize that being a good communicator is a core clinical skill for physicians, and that effective physician-patient communication can foster patient satisfaction, physician satisfaction, adherence, and improved clinical outcomes Page 15 of 23

16 1.2. Establish positive therapeutic relationships with patients and their families that are characterized by understanding, trust, respect, honesty, and empathy Communicate with patients in a way that is appropriate to their individual circumstances, including cultural differences Engage the pediatric patient in developmentally appropriate discussions with his/her parents while providing appropriate opportunities for both the patient and family to meet with the team separately Display high levels of communication skills by using a variety of techniques Practise the assessment and care of pain patients in a manner that validates the individual patient s subjective experience of pain Respect patient privacy, confidentiality, and autonomy Listen effectively Be aware of and responsive to nonverbal cues Facilitate a structured clinical encounter effectively 2. Accurately elicit and synthesize relevant information and perspectives of patients and families, colleagues, and other professionals Gather information about a disease and about a patient s beliefs, concerns, expectations, and the impact of pain on their life Seek out and synthesize relevant information from other sources, such as a patient s family, and other professionals, while respecting individual privacy and confidentiality 3. Convey relevant information and explanations accurately to patients and families, colleagues, and other professionals 3.1. Deliver information to a patient and family, colleagues and other professionals in a humane manner and in such a way that it is understandable and encourages discussion and participation in decision-making 4. Develop a common understanding on issues, problems, and plans with patients, families, and other professionals to develop a shared plan of care Identify and effectively explore problems to be addressed from a patient encounter, including the patient s context, responses, concerns, and preferences Respect diversity and difference, including the impact of gender, religion, and cultural beliefs on decision-making Encourage discussion, questions, and interaction in the encounter Engage patients, families, and relevant health professionals in shared decisionmaking to develop a plan of care Page 16 of 23

17 Address challenging communication issues effectively, including obtaining informed consent, delivering bad news, and addressing anger, confusion, and misunderstanding Consult with patients and their families to develop a patient-centred end-of-life care plan 5. Convey oral, written, and/or electronic information effectively about a medical encounter 5.1. Maintain clear, concise, accurate, and appropriate records of clinical encounters and plans Use appropriate documentation and strategies to deal with behaviours possibly associated with opioid misuse, abuse, diversion, or addiction Present oral reports of clinical encounters and plans Convey medical information appropriately to ensure safe transfer of care 6. Present medical information effectively to the public or media about a medical issue Collaborator Definition: As Collaborators, Pain Medicine specialists effectively work within a health care team to achieve optimal patient care. Key and Enabling Competencies: Pain Medicine specialists are able to 1. Participate effectively and appropriately in an interprofessional health care team Describe the Pain Medicine specialist s roles and responsibilities to other professionals Describe the roles and responsibilities of other professionals within the health care team Recognize and respect the diverse roles, responsibilities, and competencies of other professionals in relation to their own Work with others to assess, plan, provide, and integrate care for individuals and groups of patients Work collaboratively in other activities and tasks; examples are research, educational work, program review, and/or administrative responsibilities Participate in interprofessional team meetings Page 17 of 23

18 Enter into interdependent relationships with other professions for the provision of quality care Describe the principles of team dynamics Respect team ethics, including confidentiality, resource allocation, and professionalism Demonstrate leadership in a health care team, as appropriate 2. Work with other health professionals effectively to prevent, negotiate, and resolve interprofessional conflict Demonstrate a respectful attitude towards other colleagues and members of an interprofessional team Work with other professionals to prevent conflicts Respect differences and the scopes of practice of other professions Reflect on their own differences, misunderstandings, and limitations that may contribute to interprofessional tension Reflect on interprofessional team function Employ collaborative negotiation to resolve conflicts and address misunderstandings Manager Definition: As Managers, Pain Medicine specialists are integral participants in health care organizations, organizing sustainable practices, making decisions concerning the allocation of resources, and contributing to the effectiveness of the health care system. Key and Enabling Competencies: Pain Medicine specialists are able to 1. Participate in activities that contribute to the effectiveness of their health care organizations and systems Work collaboratively with others in their organization to promote an interdisciplinary team approach in the management of pain Participate in systemic quality process evaluation and improvement, including patient safety initiatives, organization of delivery of new therapies, services, and programs, and their evaluation Describe the structure and function of the health care system as it relates to Pain Medicine, including the roles of physicians Page 18 of 23

19 1.4. Describe the principles of health care financing, including physician remuneration, budgeting, and organizational funding Demonstrate knowledge of components of health administration required to establish pain management services, either at a secondary communitybased facility or in a tertiary university-affiliated clinic Describe the components of a safe, effective, and efficient acute pain service; describe its impact on health resource utilization Describe the components of a safe, effective, and efficient chronic noncancer pain service; describe its impact on health resource utilization Describe the components of a safe, effective, and efficient cancer pain and symptom management service; describe its impact on health resource utilization 2. Manage their practice and career effectively 2.1. Set priorities and manage time to balance patient care, practice requirements, outside activities, and personal life 2.2. Manage a practice, including finances and human resources 2.3. Implement processes to ensure personal practice improvement 2.4. Employ information technology appropriately for patient care 3. Allocate finite health care resources appropriately 3.1. Demonstrate an understanding of the importance of just allocation of health care resources, balancing effectiveness, efficiency, and access with optimal patient care 3.2. Apply evidence and management processes for cost-appropriate care 4. Serve in administration and leadership roles 4.1. Participate effectively in committees and meetings 4.2. Lead or implement change in health care 4.3. Plan relevant elements of health care delivery, such as work schedules Health Advocate Definition: As Health Advocates, Pain Medicine specialists use their expertise and influence responsibly to advance the health and well-being of individual patients, communities, and populations. Page 19 of 23

20 Key and Enabling Competencies: Pain Medicine specialists are able to 1. Respond to individual patient health needs and issues as part of patient care 1.1. Identify the health needs of an individual patient 1.2. Identify opportunities for advocacy, health promotion, and disease prevention with individuals to whom they provide care Advocate for the needs of individual patients with acute or chronic pain Assist individual patients with pain to access appropriate diagnostic modalities and treatment in a timely fashion Promote patient self-advocacy to improve their pain, quality of life, and access to health related resources Provide patients with appropriate resources, including books, online information, support groups, and patient advocacy groups 1.3. Demonstrate an appreciation of the possibility of competing interests between advocacy for an individual and for the community at large 2. Respond to the health needs of the communities that they serve 2.1. Describe the practice communities that they serve 2.2. Identify opportunities for advocacy, health promotion, and disease prevention in the communities that they serve, and respond appropriately Advocate for improvements in service for acute or chronic pain within institutions and communities 2.3. Demonstrate an appreciation of the possibility of competing interests between the communities served and other populations 3. Identify the determinants of health for the populations that they serve 3.1. Identify the determinants of health of the population, including barriers to access to care and resources 3.2. Identify vulnerable or marginalized populations within those served and respond appropriately 4. Promote the health of individual patients, communities, and populations 4.1. Describe an approach to implementing a change in a determinant of health of a population they serve Advocate for improvements in service for acute pain, cancer pain, and chronic pain within populations and political jurisdictions Page 20 of 23

21 Identify the opportunity to shape public policy related to access to pain management services Identify points of influence in the health care system and its structure Describe the ethical and professional issues inherent in health advocacy, including altruism, social justice, autonomy, integrity, and idealism Demonstrate an appreciation of the possibility of conflict inherent in their role as a health advocate for a patient or community with that of manager or gatekeeper Describe the role of the medical profession in advocating collectively for health and patient safety Demonstrate awareness of regional, national, and international advocacy groups for persons living with pain Scholar Definition: As Scholars, Pain Medicine specialists demonstrate a lifelong commitment to reflective learning, and the creation, dissemination, application, and translation of medical knowledge. Key and Enabling Competencies: Pain Medicine specialists are able to 1. Maintain and enhance professional activities through ongoing learning related to Pain Medicine Describe the principles of maintenance of competence Describe the principles and strategies for implementing a personal knowledge management system Recognize and reflect on learning issues in practice Conduct personal practice audits Pose an appropriate learning question Access and interpret the relevant evidence Integrate new learning into practice Evaluate the impact of any change in practice Document the learning process 2. Critically evaluate medical information and its sources, and apply this appropriately to practice decisions Describe the principles of critical appraisal Critically appraise retrieved evidence in order to address a clinical question Integrate critical appraisal conclusions into clinical care Page 21 of 23

22 3. Facilitate the learning of patients, families, students, residents, other health professionals, the public, and others Describe principles of learning relevant to medical education Identify collaboratively the learning needs and desired learning outcomes of others Provide assistance to members of the team with respect to their professional development Select effective teaching strategies and content to facilitate others learning Deliver effective lectures or presentations Contribute to the education of all health disciplines in the principles and necessity of effective pain management Assess and reflect on teaching encounters Provide effective feedback Describe the principles of ethics with respect to teaching 4. Contribute to the development, dissemination, and translation of new knowledge and practices Describe the principles of research and scholarly inquiry Describe the principles of research ethics Pose a scholarly question Conduct a systematic search for evidence Select and apply appropriate methods to address the question Disseminate the findings of the study, audit, or education project Complete a scholarly research, quality assurance, or educational project relevant to Pain Medicine that is suitable for peer-reviewed publication or presentation at an academic meeting Professional Definition: As Professionals, Pain Medicine specialists are committed to the health and well-being of individuals and society through ethical practice, profession-led regulation, and high personal standards of behaviour. Page 22 of 23

23 Key and Enabling Competencies: Pain Medicine specialists are able to 1. Demonstrate a commitment to their patients, profession, and society through ethical practice Exhibit appropriate professional behaviours in practice, including honesty, integrity, commitment, compassion, respect, and altruism Demonstrate a commitment to delivering the highest quality care and maintenance of competence Recognize and appropriately respond to ethical issues encountered in practice Identify, declare, and manage perceived, potential, and actual conflicts of interest Recognize the principles and limits of patient privacy and confidentiality, as defined by the law and professional practice standards Maintain appropriate boundaries with patients 2. Demonstrate a commitment to their patients, profession, and society through participation in profession-led regulation Demonstrate knowledge and understanding of professional, legal, and ethical codes of practice Fulfil the regulatory and legal obligations required of current practice Prescription of opioids, including methadone and buprenorphine Prescription of medical marijuana Demonstrate accountability to professional regulatory bodies Recognize and respond appropriately to others unprofessional behaviours in practice Participate in peer review 3. Demonstrate a commitment to physician health and sustainable practice 3.1. Balance personal and professional priorities to ensure personal health and sustainable practice 3.2. Strive to heighten personal and professional awareness and insight 3.3. Recognize other professionals in need and respond appropriately This document is to be reviewed by the Subspecialty Committee in Pain Medicine by December APPROVED Specialty Standards Review Committee February 2013 APPROVED Specialty Standards Review Committee March 2018 Page 23 of 23