Pain, 50 (1992) 251-256 25;

1992 Elsevier Science Publishers B.V. All rights reserved 0304-3959/92/$05.00

PAIN 02097

Clinical Section
Medical students' attitudes toward pain before and after a brief course
on pain

John F. Wilson a, Gene W. Brockopp b, Sandra Kryst a, Herbert Steger b and William O. Witt b
Departments of a Behal'ioral Science and b Anesthesiology, Unit'ersity of Kentucky College of Medicine, Lexington, ICY 40536-0086 (USA)
(Received 30 December 1991, accepted 7 February 1992)

Summary The effectiveness of a brief clinical and basic science seminar on pain for 1st year medical students
was examined by comparing attitudes about pain prior to the seminar to attitudes 5 months after the seminar. The
6-h course combined written materials conveying facts about behavioral, social and biological aspects of pain with
clinical observations of an acute and a chronic pain treatment team. Examination of responses to a questionnaire
assessing attitudes toward pain patients revealed that medical students have limited personal experience with pain
and medications for pain, and limited knowledge about pain. Pre-course attitudes toward pain patients were
dominated by perceived negative characteristics of pain patients and the belief that working with such patients is
difficult. Attitudes measured 5 months after the course reflected increased complexity, greater emphasis that pain is
real and not imaginary, and stronger belief that working with pain patients is rewarding. Five months after the
seminar, students reported more accurate estimates of the frequency of problems with addiction stemming from
acute pain treatment and exaggerated the prevalence of pain problems in the society. The importance of integrating
clinical and basic science experiences in order to influence long-term clinical attitudes and produce lasting changes
in clinically relevant knowledge is discussed.

Key words: Pain attitudes; Medical students

Introduction the treatment of pain remains a minor educational

Despite the frequency of pain problems in Ameri-
can society, pain and the treatment of people in pain
have not been major components of medical education.
The IASP noted this deficit and appointed a subcom-
mittee on Medical School Courses and Curriculum in
1985. A report of this committee concluded that little
is taught about pain to either clinical or preclinical
students and that information about pain is not well
integrated into the medical curriculum (Pilowsky 1988).
Others have reported similar findings. Oden (1989) has
noted that in reviewing more than 10,000 pages of
surgical text, only 7 pages are devoted to postoperative
treatment for pain. Even in specialty areas in which
pain relief might be seen as crucial, such as oncology,
Correspondence to: J.F. Wilson, Department of Behavioral Sci-
ence College of Medicine, Lexington, KY 40536-0086, USA. Tel.:
(606) 233-6257; FAX: (606) 233-5350.
issue (Bonica 1987).
The lack of emphasis on pain in the medical curricu-
lum is surprising considering that pain is a major
presenting complaint in medical institutions. Problems
of chronic pain are widespread (Von Korff et al. 1988)
and acute pain is seriously undertreated (Sriwatanakui
1985; Edwards 1990). It is essential that existing knowl-
edge about treatment of pain be integrated into the
usual and customary medical practice of physicians.
We believe this process would be facilitated if medical
students obtained adequate knowledge about pain and,
in addition, developed attitudes toward acute and
chronic pain patients devoid of stereotypes. To address
this need, the IASP has outlined a model curriculum
on pain, focusing on both basic and clinical sciences
(Pilowsky 1988). Unfortunately, factual elements of the
medical curriculum are often lost by students after
examinations. We believe a curriculum on pain should
include not only factual material about pain but also
educational experiences that reinforce facts and help
252
s t u d e n t s f o r m positive a t t i t u d e s t o w a r d p a t i e n t s in pain.
I n i t i a t i o n o f t h e p a i n c u r r i c u l u m early in m e d i c a l e d u -
c a t i o n may be crucial. P r e v i o u s w o r k has d e m o n s t r a t e d
the usefulness of introducing curricular material about
g e r i a t r i c s a n d t h e e l d e r l y early in m e d i c a l e d u c a t i o n to
preclude the formation of negative attitudes during the
clinical years ( W i l s o n a n d H a f f e r t y 1980, 1983). O u r
g o a l was to d e v i s e a b r i e f c o u r s e in t h e first y e a r o f
m e d i c a l school t h a t w o u l d p r o v i d e s t u d e n t s w i t h an
i n t r o d u c t i o n to basic s c i e n c e c o n c e p t s o f p a i n , p r o v i d e
c o n t a c t with p a t i e n t s in p a i n , a n d allow o b s e r v a t i o n o f
clinical p r a c t i t i o n e r s p r o v i d i n g a p p r o p r i a t e t r e a t m e n t .
In this r e p o r t , w e d e s c r i b e o u r initial e x p e r i e n c e in
d e v e l o p i n g such a p a i n s e m i n a r . W e d i s c u s s q u a n t i t a -
tive a n d q u a l i t a t i v e d a t a d e r i v e d f r o m p r e - a n d post-
c o u r s e a s s e s s m e n t s o f m e d i c a l s t u d e n t s ' a t t i t u d e s to-
w a r d p a t i e n t s e x p e r i e n c i n g pain.
Method
Health and Society is a 40-h required course for 1st year medical
students at the University of Kentucky College of Medicine, taught
primarily by faculty in the Department of Behavioral Science. For
the class of 1994, a 6-h segment of this course constituted a pain
seminar taught jointly by faculty from the Department of Behavioral
Science, a basic science department, and faculty and staff from the
Pain Management Center, a division of the Department of Anesthe-
siology, in groups ranging in size from 18 to 20. 95 lst-year students
studied pain for 6 course hours spread over a 2-week rJeriod. The
course's primary objectives were to provide introductory information
about pain and to provide the opportunity to observe the ftmctioning
of a modern multi-disciplinary pain treatment team.
Factual information was provided through 5 learning modules
written or compiled by course instructors. These modules addressed
Pain Theories and Concepts, Treatment of Acute Pain, Biobehav-
ioral Treatments for Pain, Cancer-related Pain, and Pain in Chil-
dren. The curriculunl consisted of 45 pages of written material and
35 learning objectives. Learning objectives addressed specific basic
concepts (e,g., be able to define and distinguish between specificity,
pattern, and gate-control theories of pain) as well as applied social
and behavioral aspects of pain treatment (e.g., be able to discuss why
health care providers have been reluctant to give adequate doses of
pain medication for acute pain).
The seminars began with a l-h orientation and description of the
Acute Pain Management Service, a liaison service that provides
consults for patients being treated at University Hospital. This ser-
vice provides a variety of pain management procedures and tech-
niques, including i.v. and epidural PCA, and regional anesthesia.
Groups of 3 or 4 students accompanied the Acute Pain Management
Team on afternoon rounds. Attendance at these rounds constituted
a 2nd course hour. Students were required to submit a 1-page report
of their experiences that focused on what they had learned about
pain and pain treatment from observation of patients and staff.
Instructors devoted a 3nd hour to the multidisciplinary approach
to treatment of chronic pain. They detailed the different disciplines
in the treatment of chronic pain and described the functioning of the
Chronic Pain Clinic. A brief introduction to pain was also provided
by demonstrating a laboratory pain stimulus (the Barber-Forgione
finger pressure pain stimulator) with student volunteers.
The 4th contact hour consisted of students' attendance at a
regularly scheduled chronic pain patient case management confer-
ence, typically staffed by an attending medical faculty member, a
medical resident, a psychologist, a registered nurse, and a physical
therapist. These conferences provided students with a realistic pic-
ture of the complexity of chronic pain treatment. Although explana-
tions of terminology and questions from students to some degree
altered the flow of the conference, the case conferences were not
edited in any way to eliminate differences of opinion among staff or
to select only ideal patients.
Demonstrations of biofeedback techniques for pain assessment
and treatment and an example of systematic muscle relaxation tech-
niques comprised the 5th contact hour. The 6th contact hour was
devoted to a group discussion of seminar experiences, including
students' questions about factual material in the learning modules
and students' reactions to observations of the chronic pain case
conference and of patients and staff during acute pain treatment
rounds. Grading; for the seminar was based on the 1-page write-up of
pain rounds (15%t, a written examination based on learning objec-
tives (65%), and an essay question based on a case study of a chronic
pain patient (20%).
Course et~ahtation instrument
The standard course evaluation consisted of six 5-category
Likert-type questions with response categories ranging from 'strongly
agree' to 'strongly disagree'. Students were asked to rate whether (1)
study questions were useful guides to learning, (2) seminar content
was well organized, (3) an appropriate mix of teaching methods was
used, (4) seminar material was relevant to the profession of medicine,
(5) seminar atmosphere was stimulating and encouraging to learning,
and (6) the instructors had a positive attitude toward students.
These questions were administered and collected anonymously at
the conclusion of each 2-week seminar, at a time apart from course
examinations.
Assessment of attitudes toward pa#l
An 8-item questionnaire administered at the beginning of the
pain seminar and again 5 months after completion of the seminar,
assessed students' attitudes al~out pain. The time of the re-testing
was chosen in order to determine what elements of knowledge and
attitude change remained after the effects of cramming for examina-
tions and recency of learning had diminished. Four questions were
asked to assess knowledge of the frequency of pain problems. (1)
Post-operative pain: what percentage of surgery patients experience
significant amounts of postoperative pain despite usual treatments
for pain? (answer from course materials: 33%). (2) Chronic pain:
what percentage of people in the United States experience pain
more than 50e~ of the time? (answer from course materials: 25%).
(3) Narcotic addiction: what percentage of patients who do not have
an existing drug problem become dependent or addicted after being
treated with narcotic medications for pain? (answer from course
materials: < 1%). (4) Infants' pain: what percentage of infants expe-
rience pain from surgical procedures such as circumcision? (answer
from course materials: > 99%).
One item was used to assess students' assessment of how difficult
it will be to work with patients in pain. (5) Clinical difficulty: on a
scale of 0-100, with 0 being 'not difficult at all' and 100 being 'as
difficult as you can imagine', indicate how difficult you think it will
be to work with patients in pain.
A modified open-ended sentence-stem format was used to gather
qualitative data about students' attitudes toward pain patients. Stu-
dents were asked to complete 2 open-ended sentence-stems: (6)
"people in pain are ...", and (7) "working with patients in pain will
be...".
Students were given the opportunity to provide 3 responses to
each sentence-stem. (8) On the pre-course assessment students were
also asked to describe the worst pain they could remember and also
to indicate any treatment or medications that they received for this
pain,
 253

TABLE I
MEAN VALUES, S T A N D A R D DEVIATIONS AND F RATIOS FOR PRE- AND POST-COURSE PAIN KNOWLEDGE SCORES

Knowledge Pre-course Post-course F(I, 33) b p

Mean a S.D. Mean S.D.
Post-op pain 57.1 25.1 66.6 18.8 3.30 0.09
Chronic pain 33.3 23.0 49.4 19.2 10.37 0.003
Narcotic addiction 20.6 20.8 9.1 13.9 13.61 0.001
Infant pain 75.0 33.4 82.4 28.0 1.42 ns
Clinical difficulty 65.9 22.1 61.6 22.8 1.56 ns

Total accuracy 22.7 13.1 21.6 9.6 < 1 ns

a All scores can range from 0 to 100, n = 35.

h F ratios represent repeated measures ANOVA values for within-subjects changes.

A measure of accuracy of knowledge about the frequency of pain
problems was constructed from the 4 knowledge items by taking the
absolute value of the difference between the student's response and
the 'correct' response as provided in course materials. The 4 accu-
racy items were averaged to yield a total accuracy score, with smaller
numbers reflecting greater accuracy and larger numbers reflecting
greater deviation from accurate knowledge.
Initial questionnaires were obtained from 93 students. Approxi-
mately 5 months after the course, follow-up questionnaires were sent
to the 88 students still available for testing. Questionnaires were
returned by 36 students (41%). One question was unusable due to
lack of identification. Differences between respondents and non-re-
spondents to the follow-up questionnaire were examined for age,
gender, and all pre-course knowledge and attitude measures. Re-
spondents did not differ significantly from non-respondents in age,
gender or any of the ore-course attitude items ( P > 0.10).
Responses to the open-ended sentence-stems were thematically
analyzed and then assigned quantitative ratings according to the
tbllowing procedure. Verbatim transcripts of students' responses
were thematically analyzed by course instructors, who constructed
themes reflected in students' responses to the 2 open-ended ques-
tions. Analysis of responses to "people in pain a r e . . . " yielded 4
themes: (1) negative mood state (e.g., miserable, unhappy); (2) nega-
tive trait or characteristic (bitter, selfish, wimpy, uncooperative); (3)
needy (in need of help, treatment, medication); and (4) having real
problems (actually in pain, not faking, not hypochondriacs).
Analysis of responses to the question "working with patients in
pain will b e . . . " also yielded 4 thematic areas: (1) intellectually or
educationally stimulating (educational, interesting, informative); (2)
pleasant or worthwhile (rewarding, worthwhile, gratifying, fulfilling);
(3) unpleasant and difficult (stressful, difficult, frustrating, unpleas-
ant); and (4) challenging (challenging, complex, demanding).
Four raters (faculty or advanced graduate students in the Depart-
ment of Behavioral Science) then independently rated each unique
response to the 2 questions, indicating which of the 4 them,~s "'
reflected. A 5th (not applicable) category was available if the rater
felt that the response did not fit any of the thematic categories.
Raters did not know whether the response they were rating was
given before or after the course. Ratings for each item were then
collated. If a response was rated as fitting a thematic category by at
least 3 of 4 raters, it was assigned to that category. Raters showed a
high degree of agreement on the 134 unique responses generated by
the students. At least 3 of 4 raters agreed on placement for 88c~ of
the unique categories, which accounted for 97% of all responses. On

TABLE II
MEAN VALUES, S T A N D A R D DEVIATIONS, PERCENTAGES OF T O T A L RESPONSES AND F RATIOS FOR PRE- AND POST-
C O U R S E MEASURES O F ATTITUDES T O W A R D PAIN PATIENTS

Pre-test Post-test F P
% of all Mean S.D. % of all Mean S.D.
responses responses

"People in pain are . . . "

Negative mood 48 1.14 1.00 49 1.26 1.01 < 1 ns

Negative trait 30 0.71 0.79 19 0.48 0.66 2.37 ns

Need help 16 0.37 0.60 18 0.46 0.61 < 1 ns

Have 'real' problems 6 0.14 0.36 14 0.37 0.65 4.37 < 0.05
ns
Complexity 2.14 0.73 2.14 0.65 < 1

"Working with pain patients will be . . . "

Educational/informative 28 0.77 0.97 11 0.31 0.53 10.95 < 0.01
Worthwhile/rewarding 15 0.43 0.56 30 0.83 0.45 13.25 < 0.01
ns
Difficult unpleasant/different 38 1.08 0.95 37 1.00 0,73 < 1
as
Challenging 19 0.54 0.56 21 0.57 0.50 < 1
Complexity 2.20 0.71 2.60 0.55 8.52 < 0.01

a All scores can range from 0 to 3, n = 35.

b F ratios represent repeated measures ANOVA values for within-subjects changes.
254
14 responses(3% of total responses) agreementcould not be reached.
These were placed into the not applicable category. A score of 1 was
assigned to each student's response for each thematic category,
yielding scores for each of the 8 thematic categories that could range
from 0 to 3 for each student.
Because we expected that educational experiences not only
change the direction of a student's attitude but also increase the
complexity of a student's thinking, we created 2 complexityvariables
based on the total number of thematic categories represented by a
student's open-ended responses. The complexity variables could
range from 1 to 3 for each of the 2 open-ended questions, with larger
numbers reflecting greater levels of complexity.
Results
Measures of accuracy of knowledge
Mean values for pre-course and 5-month post-test
assessment scores for the measures of knowledge about
prevalence of pain problems can be found in Table I.
Students overestimated the percentage of people with
acute and chronic pain problems, the percentage with
problems of addiction after treatment with narcotic
medications, and underestimated the number of in-
fants who react to painful stimuli. When measured 5
months after the course, students' estimates of the
percentage of individuals in chronic pain and in acute
post-surgical distress had increased, and estimates of
narcotic addiction problems in acute pain patients had
decreased. Their estimates of the clinical difficulty of
treating pain patients had not changed significantly.
Although the total index of accuracy had also not
changed, students were now less accurate on the index
of chronic pain sufferers (F(I, 33) = 4.67, P < 0.05)
and more accurate on the index of narcotic addiction
problems (F(I, 33)= 13.17, P < 0.001). Scores on the
objective examination administered at the conclusion
of the course averaged 92% correct. This examination
discussed basic science knowledge (e,g., gate-control
theory, endorphin mediation of pain inhibition).
Measures of attitudes toward pain patients
Mean values for pre-course and 5-month post-course
assessment scores for the measures of attitudes derived
from the 2 open-ended questions about pain and pain
patients can be found in Table If. Pre-course responses
to the "people in pain are . . . " prompt are dominated
by themes related to negative mood state and negative
characteristics of pain patients. Post-course responses
still emphasize negative mood but show a statistically
significant increase in themes emphasizing the non-
imaginary nature of pain p, oblems ( P < 0.05). On a
numerical level, negative trait responses declined from
30% to 19%, whereas responses relating to the needs
of pain patients and the real nature of their pain
increased from 22% to 32%. The index of response
complexity showed no change from pre- to post-course
assessment for this question.
Pre-course responses to the "working with pain
patients will be . . . " prompt were dominated by themes
suggesting that working with pain patients will be diffi-
cult (38% of responses) but educational (28%). Post-
course assessments retain a predominance of themes
related to difficulty but show significant decreases in
the educational dimension and an increase in themes
reflecting the rewarding and worthwhile nature of this
work (both P < 0.01). The index of complexity showed
a significant increase on the post-course assessment,
with students using a significantly greater number of
themes on the post-course assessment ( P < 0.01).
Medical students' prior experiences with pain and nar-
cotic medications
In an attempt to define correlates of attitudes to-
ward pain we examined the worst pain experiences of
medical students and their prior experience with nar-
cotic medications for pain. Ninety responses to the
open-ended question about worst pain experience were
coded into types of pain experience. The most frequent
category consisted of athletic injuries (knee ligaments,
shoulder separations, ankle sprains) described as their
worst pain by 28% (25 of 90) of the respondents to this
question. Dental pain (wisdom tooth removal, tooth
abscess, oral surgery)was the next most frequent cate-
gory noted as the worst pain by 16% (15 of 90). A
variety of medical complaints (ear infections, menstrual
cramps, gastritis, mononucleosis) was reported by 14%
(13 of 90). Accidents involving moving vehicles or power
equipment constituted the worst pain experiences of
16% (15 of 90). Eleven students (12%) reported either
migraine or tension headaches as their worst pain.
Only 9 students (10%) had experienced non-dental
surgical procedures (appendectomy, tonsillectomy, C-
section). One student reported sun poisoning and an-
other grief as their worst pain experiences.
Use of some form of narcotic medications for these
worst pain experiences was reported by 26 of 80 re-
spondents (32%) which could be categorized for medi-
cation use. Seventeen students (21%) reported use of
acetaminophen with codeine or acetaminophen with
oxycodone. Only five (6%) reported use of morphine or
meperidine for their worst pain experience. Two re-
ported use of percocet, and one each said they had
used fiorinal and dilaudid. Reported use of narcotic
medications for the worst pain experience was unre-
lated to initial knowledge or attitudes toward pain. The
small number of students reporting use of morphine or
meperidine precludes analysis of this variable in terms
of its effect on attitudes or knowledge.
Student ecah~ations
Student evaluations of the course were overwhelm-
ingly positive. Seminar ratings for the average of the 6
evaluation questions showed that 66% of the class

endorsed the most positive (strongly agree rating), 30%
the agree category, 3% a neutral category, and less
than 1% selected either of the 2 negative categories
(disagree or strongly disagree). Open-ended comments
on evaluations focused on the usefulness of the clinical
experiences and the demonstrations of biofeedback
and relaxation techniques.
Discussion
Although data from this pilot course must be con-
sidered preliminary, we believe three findings are im-
portant for devising effective medical curricula about
pain. First, students enter medical school with little
academic or personal knowledge of pain. Students did
not have an accurate picture of the scope of pain
problems, the reality of pain for infants, and the likeli-
hood of addiction after treatment of acute pain with
narcotics. Students also had little personal experience
with pain. Only a small minority had experienced non-
dental surgery or hospitalization involving pain, and
less than one-third had experienced treatment with any
type of narcotic medication for pain.
Set3nd, students' knowledge of pain problems
chaag~:d in a complex fashion, sometimes becoming
less accurate and sometimes more accurate. Students
became less accurate in their estimates of the preva-
lence of acute and chronic pain problems in society but
became more accurate in their estimation of problems
of addiction following treatment for acute pain. One
factor that would contribute to lack of accuracy in
students' estimates is the timing of the post-course
questionnaire 5 months after the course. The decline in
ability to remember facts following examination cram-
ming is well documented (Levine and Forman 1973;
Miller 1978). One explanation consistent with our find-
ings is that students may selectively remember clini-
cally relevant as opposed to clinically irrelevant facts.
The percentage of people who have pain problems may
be seen as only exam relevant, whereas the likelihood
of narcotic addiction may be viewed as clinically rele-
vant.
This explanation, however, does not account for
students' actual decline in accuracy in the measures of
the frequency of pain problems. We believe that stu-
dents' responses 5 months after the exam do not reflect
their memory for facts as much as their attitude about
how clinically import:ant pain problems are. After the
pain seminar, students felt that pain problems are
more important than they did previously, and this is
reflected in increased estimates of the prevalence of
such problems. We did not measure these variables
immediately after the course, but we wo~J!d hypothe-
size that students' accuracy on the epidemiological
prevalence questions would have temporarily im-
255
proved, and then would have declined as memory
faded and attitude about the importance of pain be-
came the primary determinant of their estimates of
pain problems. As one student wrote in the course
paper:
"I came away from my experience of rounds with
the notion that unregulated pain is the enemy of
everyone, patient, family and physician. It be-
comes the focus of attention when not under
control and thereby takes control of all those
involved."
Third, use of open-ended questions to assess atti-
tudes allowed examination of subtle but important
changes in how students think about pain and pain
patients. After the course, students' responses to
open-ended questions reflected greater awareness that
pain problems are not imaginary and that working with
pain patients can be worthwhile and rewarding. At the
same time, students' responses became significantly
more complex, reflecting themes about both the re-
warding nature of working with pain patients and the
complexity and difficulty of working with pain patients.
We believe these findings reflect two important as.-
pects of attitude formation in medical education. First,
we believe that if attitude change in students is to
persist beyond the typically short half-life of didactic
teaching, medical curricula should include realistic rep-
resentations of the difficulties as well as the joys of
clinical practice. Otherwise, students' confrontation
with clinical realities may lead more easily to stereotyp-
ing and disillusionment if expectations do not match
reality. A quote from one student's report about his
observation of team conferences about chronic pain
patients exemplifies this theme.
"The reality that health care providers cannot
help all patients came as the biggest surprise. As
an idealistic second week medical student !
thought naively that medicine could help, but not
necessarily cure, all those in need. I benefitted
from the conference because it made clear the
patient's needs must be balanced with the ability
of the team to provide adequate treatment."
Second, inclusion of clinical material and clinical role
models within basic science education provides a more
meaningful context for basic science information about
pain, underscoring clinical significance at the time of
learning. One student's course evaluation illustrated
this issue.
"Prior to this seminar, my ideas about pain and
how it affects people were very limited. The op-
portunity to go on pain rounds proved to be both
interesting and educational. By observing other
people that were experiencing varying dcgrces of
256
acute pain, 1 was able to gain new insights on
what pain is, how pain varies in different people,
and the treatment of pain."
The report from this pilot project must be consid-
ered a preliminary finding due to the relatively small
sample size and the relatively short-term follow-up
period. We believe, however, that the complexity of
pain requires the integration of behavioral and biologi-
cal knowledge within a learning medium enriched by
both basic scientists and clinical role models from
several disciplines. This mixture can produce a realistic
enthusiasm for treatment of pain problems that has a
greater chance of lasting into clinical practice than
other more didactic approaches to pain education. Two
students' responses reflect a degree of enthusiasm that
goes beyond factual comprehension.
"I think pain treatment will be one of the greater
LEAPS in medicine, right up there with the dis-
covery of penicillin." "I agree with the idea that
aggressive pain treatment represents something
which medicine can return to the patient. I be-
lieve this embodies the compassion and consider-
ation which medicine must have for its patients"
Although we agree that factual learning is an inte-
gral component of a medical curriculum about pain
,,nd pain treatment, the attitudinal dimension of medi-
cal educati,m emphasized in this article represents a
necess: W i:lgredient if factual knowledge about pain is
to be t~,aAated into clinical action. Exposure to clini.
cal role models from the several disciplines involved in
acute and chronic pain treatment can provide a mean.
ingful context for learning basic science material and
forming positive attitudes toward treatment of patients
in pain.
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