Background In Korea, anesthesiologists are expected to be mainstream pain medicine (PM) practitioners. However, anesthesiology and pain medicine (APM) residency programs mostly emphasize anesthesia learning, leading to insufficient PM learning. Therefore, this study evaluated the current status of PM training in APM residency programs in 10 Korean university hospitals.
Methods Overall, 156 residents undergoing APM training participated anonymously in our survey, focusing on PM training. We assessed the aim, satisfaction status, duration, opinion on duration, desired duration, weaknesses of the training programs and plans of residents after graduating. We divided the residents into junior (first and second year) and senior (third and fourth year). Survey data were compared between groups.
Results Senior showed significantly different level of satisfaction grade than did junior (p=0.026). Fifty-seven (81.4%) residents in junior and forty (46.5%) residents in senior underwent PM training for ≤2 months. Most (108; 69.2%) residents felt that the training period was too short for PM learning and 95 (60.9%) residents desired a training period of ≥6 months. The most commonly expressed weakness of the training was low interventional opportunity (29.7%), followed by short duration (26.6%). After residency, 80 (49.1%) residents planned to pursue a fellowship.
Conclusions Dissatisfaction with PM training was probably due to a structural tendency of the current program towards anesthesia training and insufficient clinical experience, which needs to be rectified, with a change in PM curriculum.
- resident education
- pain medicine
- clinical pain
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With a rapid growth in the field of pain medicine (PM), appropriate and adequate education of residents is important to produce competent PM practitioners. In Korea, the title anesthesiology was revised to anesthesiology and pain medicine (APM) in 2003, requiring anesthesiologists to be the mainstream PM practitioners. However, APM training is still focused on anesthesiology during the 4-year residency program, a program that follows the rules and decisions of the Ministry of Health and Welfare and that of the Korean Hospital Association. The APM training programs were updated in March 2018. The current training better reflects the needs of PM training than the previous program. The PM curriculum for the APM training program is composed of 50 cases of general postoperative pain management in the first year, 50 cases of regional anesthesia (including 10 cases of spinal or epidural anesthesia and 10 cases of nerve blocks) and learning pain pathophysiology in the second and third years and 100 cases involving pain management, with a new goal of 20 cases of ultrasound/fluoroscope-guided pain intervention in the fourth year. When an objective, recommended by the curriculum for a particular year is fulfilled inadequately, it should be completed before graduating from the residency program. This is an essential criterion to appear for the formal APM board examination. In general surgery, there is a concern that residents feel unprepared to practice independently after the residency training; and 70% of the graduating residents choose to pursue further fellowship training.1 2 Familiarity with developing surgical procedures is not being translated from senior to junior residents as a result of several factors including work-hour limitation and systemic diversity in training environments.1 Therefore, there are concerns that this trend has significant implications on resident education in general practice.1 In Korea, there are no published data regarding the current state of residency program in relation to PM training. Therefore, this study aimed to evaluate the current status of APM residency programs in 10 university hospitals in Korea.
Materials and methods
This survey was piloted with 184 APM residents in Korea in January 2017, by the Korean Pain Society. Two years later, we planned the survey to evaluate the PM training status. We conducted an anonymous survey with APM residents as participants from January 2019 to February 2019 at 10 university hospitals that were certified as official PM fellowship education institutions by the Korean Pain Society. All investigators from these 10 hospitals are members of the Korean Pain Society. Authors mailed the survey questionnaire to residents with an introduction to the research and a clarification stating the voluntary nature of the survey participation. The questionnaire included 13 questions. Eight were single-choice and five were multiple-choice questions. Fellows, education faculty and program directors were excluded. The completed surveys were then sent to the Korean Pain Society office via mail. After the survey, we divided the data into two groups depending on the residents’ year of program: first and second years (junior); and third and fourth years (senior).
All data were analyzed using SAS V.9.4 (SAS Institute). Data are expressed as numbers (with percentages), when appropriate. Responses to single-choice questions were compared between the two groups using a χ2 test or Fisher’s exact test. Level of satisfaction was categorized as very high, high, moderate, low and very low, and each proportions were analyzed with Fisher’s exact test. Responses to multiple-choice questions were compared between the two groups using a χ2 test. A p value less than 0.05 was considered statistically significant. This was an exploratory analysis; no adjustments were made for multiple comparisons.
In a total of 195 APM residents from 10 hospitals, 156 residents (80.0%) responded to the survey. Regarding satisfaction with the training, this was evaluated using a 5-point scale (very high, high, moderate, low, very low). Senior showed a significantly different level of satisfaction grade with the training program. Fifty-seven (81.4%) residents in junior and 40 (46.5%) residents in senior underwent pain training for≤2 months. Duration of training was significantly lower in junior, which is mostly attributed to a longer PM training duration during the third and fourth years of residency. One hundred and eight (69.2%) residents felt that the training period was too short for PM learning, and 95 (60.9%) residents desired a training period of ≥6 months (table 1). In terms of the responses to the multiple-choice questions, the number of residents who selected learning PM as the reason for pursuing fellowship was significantly different between the two groups, while responses to questions on aim of training, weaknesses of training, desired program and plan after residency were not different (table 2). The most commonly expressed weakness of the training program was low interventional opportunity (29.7%), followed by short duration (26.6%). After graduating from the residency program, 80 (49.1%) residents planned to pursue a fellowship in APM. The reasons for pursuing a fellowship were PM learning (48 residents, 42.5%), anesthesia learning (33 residents, 29.2%) and becoming a member of faculty (29 residents, 25.7%). A desire to learn PM was a significantly more common reason for pursuing a fellowship in senior (table 2).
In this study, we aimed to evaluate the current status of PM training on the basis of feedback from APM residents of 10 university hospitals in Korea. Senior residents expressed a significantly lower level of satisfaction grade with PM training. The most commonly expressed weakness of the training program was low interventional opportunity, followed by short training duration. Current PM training duration was 1 month in junior and ≥3 months in senior. Most residents desired a training period of 3–6 months in junior and 6–12 months in senior. Senior residents, who received more PM training than the junior residents, felt a higher need for PM learning, presumably because sufficient time, effort and clinical experience are necessary to gain confidence. Inadequate exposure and lack of training may be linked to independent practice failure after graduation and/or quality decline of practice.3 4 According to educators of surgical residency, observation style of learning is at risk with both a less robust operative experience and non-completion of resident’s surgical training.5 We suspect that low interventional learning and short training duration are associated with each other. Current structural tendency toward anesthesia training and insufficient clinical experience based on present PM curriculum may have led to this outcome.
Until now, APM residency programs have mostly emphasized on anesthesia learning, and there is a continuous need for sufficient PM learning. To produce qualified PM practitioners, educator should provide balanced education on anesthesia and PM. In the USA, the focus of training in regional anesthesia and PM has rapidly changed over the past 15 years by shifting from neuraxial block to peripheral block techniques.4 An analysis of 129 US anesthesiology training programs, with a duration of 3 years (that is, 1 year shorter than the Korea APM training period), revealed that almost one-third of the residency training period is dedicated for regional anesthesia and acute, chronic and cancer pain management.4 The US anesthesiology committee of the Accreditation Council for Graduate Medical Education (ACGME) established core competency for patient care and procedural skill in regional anesthesia and PM. It included at least 1 month exposure to each of regional anesthesia, acute perioperative PM and chronic PM in rotation.4 Mariano and colleagues reported that despite widespread adoption of ultrasound in regional anesthesia and PM in the past 10 years, the core residency curriculum is limited to teaching the residents only basic practices, and this motivates them to pursue a fellowship after residency in the USA.6 In Korea, according to a survey of 51 PM fellows in 2017, there was a need for ultrasound-related training; however, there was no standardized curriculum to meet this learning desire.7
Moreover, 80 hours work/week restriction for residency may accelerate PM curriculum shortage. The work-hour limitation was designed to standardize residents’ duty hour among all accredited programs, to promote high-quality learning and safe care in teaching institution. It was implemented by the ACGME in the USA from 2003.8 In Korea, this policy has been adopted for a balance between wellness and proper training experience among residents since the end of 2015. However, there are some concerns, such as the negative effects due to significant reduction in case volume and inadequate training experience.1 9 10 Swide and colleagues reported that work-hour restriction improves resident’s wellness, but improvement in patient safety or residents’ quality of education remained unclear based on a survey conducted by the US anesthesiology residency program.11 In emergency medicine, educators reported that work-hour restriction has a negatively impact on the educational environment.10 In the fields of obstetrics and gynecology in the USA, work-hour restriction led to a decline in the quality of the residency program, and it did not improve communication skills or patient care.9 In the fields of otolaryngology and neurosurgery, residents reported negative impact of work-hour restriction on training experience and patient care.12 13 Considering the variation in educational environments and each specialty’s characteristics, changes to the educational programs will be needed in the future.14 To provide better opportunities for learning interventional techniques, alternative training methods, including simulation program, bench models, virtual tools, phantom models and live animal models will be needed to improve basic skills.1 15–20 In addition, we suggest that the current PM training goal be changed to reflect the residents’ opinions of low interventional opportunity and more ultrasound block learning. The curriculum should be focused on new goals to ensure a success rate of over 90% of the block by residents, independently. To back up this, increasing cases of regional block with increasing portion of peripheral nerve block, rather than spinal or epidural anesthesia, and increasing portion for ultrasound and fluoroscopic-guided intervention in total pain management cases are needed.
Our study has several limitations. First, the survey was carried out at 10 APM training hospitals in Korea. Second, we did not compare the opinion on PM training before and after the enforcement of work-hour restriction; thus, we cannot rule out work-hour limitation as an exact cause of dissatisfaction with PM training. Third, the starting point of PM program varied among hospitals; this could have affected resident’s satisfaction. Fourth, before asking the participants what the weaknesses of PM program were (question number 10), we did not ask whether there were weaknesses or not.
Lack of satisfaction with PM training was observed among residents, which is probably due to structural tendency of the current program toward anesthesia training and shortage of clinical experience. Increased and early participation in the PM training, determination of practical and detailed educational objectives for improving interventional skills and use of supplementary program will be needed to improve the APM residency program. We recommend a change in the learning objectives of the PM curriculum to ensure the competency of physicians on pain treatment. Furthermore, future studies are required to determine whether work-hour restriction can affect PM training quality and satisfaction.
The authors would like to thank to SMC biostatistics team for their statistical assistance and supervision.
Correction notice This article has been corrected since it published Online First. The affiliation details for Jia Kim and Min Ju Kim have been corrected.
Contributors JYL and HJP: conceptualization, data curation, formal analysis, investigation, methodology, writing, review and editing; ShHK, YY, SSC, SaHK, YJP, GJB, YDK, JEK, SeHK, JK, MJK: data curation and investigation.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Ethics approval This study was approved by our departmental ethics committee (ref: SMC 2019-08-136) and registered with Clinical Research Information Service of the Korea National Institute of Health, ref: KCT0004274 (http://cris.nih.go.kr/cris/index.jsp).
Provenance and peer review Not commissioned; externally peer reviewed.
Data availability statement No data are available.