Rotation: Pain Management

• The fellow will spend two weeks with the pain service at Texas in outpatient pain clinic.
• Participate in outpatient consultation and follow up visits in ambulatory pain clinic.

Rotation coordinator: Dr. Evelyn Monico. Contact: ecmonico@texaschildrens.org.

Clinical experience: Bedside teaching from pain team faculty in the outpatient setting.

Didactic experience: Directed readings from pain team clinicians. Online modules from End of Life Education Curriculum Pediatrics on Opioids, Neuropathic Pain and Acute Pain Management.

Daytime: Fellows will assist pain team clinicians in patient care, in the ambulatory outpatient pain clinic.

Call: No overnight weekday and one weekend per month. Weekend calls include daytime rounding as well as overnight home call.

• Timely verbal feedback provided by faculty throughout rotation.
• Structured written evaluation of fellow by rotation director using American Academy of Hospice and Palliative Medicine tools at end of rotation.
• Fellow provides feedback to program director about rotation at end of rotation.

Goals and objectives based on Pediatric Hospice and Palliative Medicine Competencies, version 2.0

The fellow should demonstrate compassionate, appropriate, and effective care based on existing evidence base in pediatric palliative medicine and aimed at maximizing the well-being and quality of life for patients with chronic, complex, and/or life-threatening conditions and their families. The fellow should provide care in collaboration with other subspecialists and within an interdisciplinary team.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Obtain a comprehensive pain history and exam including:
  • Physical pain
  • Psychological pain
  • Social pain
  • Spiritual pain
• Formulate a complete care plan utilizing evidence -based palliative medicine and including all members of an interdisciplinary team.
  • Use both pharmacologic and non-pharmacologic pain management interventions.
  • Understand and address the interplay between physical symptoms and psychosocial and spiritual distress.
• Construct plans that balance a patient’s level of function and quality of life with concerns for longevity.

The fellow should demonstrate knowledge about established and evolving biomedical, clinical, population, and social-behavioral sciences relevant to the care of patients with life-threatening conditions and to their families, and relate this knowledge to the hospice and palliative care practice.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Explain principles of assessing and treating pain including the concept of total pain.
• Demonstrate understanding of mechanism, indication, and dosing of pain medications including opioids and non-opioids.
• Demonstrate understanding and indication of common non-pharmacologic pain management modalities.
• Demonstrate understanding of options and indications for interventional pain management strategies.
• Demonstrate understanding of factors influencing opioid dependence.

The fellow should be able to investigate, evaluate, and continuously improve personal practices in caring for patients and families and appraise and assimilate scientific evidence relative to palliative care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Utilize self-evaluation and feedback from pain management experts in order to assess efficacy of pain management practices as patients are followed longitudinally.
• Demonstrate a habit of critical thinking, evidence-based decision-making, and continuous quality improvement.
• Identify knowledge gaps in the course of providing patient care and cultivate the habit of continuous inquiry to expand one’s knowledge base.

The fellow should be able to demonstrate interpersonal and communication skills that result in effective relationship building, information exchange, emotional support, shared decision making, and collaboration with patients, patients’ families, and professional associates.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Utilize compassionate, effective communication skills to enhance interactions with patients and families centered around topics of pain and pain management.
• Utilize learned communication skills to effectively navigate interactions with patients and families including information sharing, discussing concept of palliative care, discussing advance care planning and resuscitation status, discussing goals of care, and discussing symptoms and suffering.
• Demonstrate knowledge of the unique language of hospice and palliative medicine and effectively use this language in conversation.
• Demonstrate ability to talk with patients and families about concepts of tolerance, withdrawal, and addiction.

The fellow should be able to demonstrate a commitment to carrying out professional responsibilities, awareness of his or her role in reducing suffering and enhancing quality of life, adherence to ethical principles, sensitivity to a diverse patient population, and appropriate self-reflection.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Demonstrate care that shows respectful attention to age/developmental stage, gender, sexual orientation, culture, religion/spirituality, disability, and family interactions.
• Demonstrate ability to balance the needs of patients, families, and team members with one’s own need for self-care.
• Demonstrate accountability and ownership in interactions with patients, families, and colleagues.
• Recognize the role of self and the role of the system in prevention of opioid abuse and diversion.

The fellow should be able to demonstrate an awareness of and responsiveness to the larger context and system of healthcare, including hospice and other community-based services for patients and families, and the ability to effectively call on system resources to provide high-quality care.

Objectives: At the completion of this rotation, the palliative care fellow will be able to:

• Demonstrate understanding of the importance of a team-based approach to management of chronic pain.
• Describe the challenges inherent in effectively treating pain within a larger healthcare system that is wary of opioid use and in which there are true risks that come with availability of opioids in a general population.
• Collaborate effectively with colleagues spanning the palliative care continuum including hospitals, nursing homes, long-term care facilities, and hospice agencies.