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Transcript – Programme 67: Biopsychosocial and Spiritual?

The place of faith in pain relief, plus phys­io­ther­a­py meets men­tal health, and edu­cat­ing doctors

To lis­ten to this pro­gramme, please click here.

It’s well estab­lished that pain needs to be under­stood and treat­ed as a biopsy­choso­cial prob­lem, but what about the spir­i­tu­al side of life? Pro­fes­sor of nurs­ing and Angli­can chap­lain Michelle Brig­gs speak to Paul Evans about how some peo­ple in pain can find relief and mean­ing in the prayer and com­mu­ni­ty engage­ment offered by their faith.

We’ve looked at the issue of pain edu­ca­tion before – Emma Brig­gs gives an update on the strug­gle to increase pain train­ing for doc­tors and improve its qual­i­ty. Her inter­dis­ci­pli­nary pain man­age­ment course brings health­care pro­fes­sion­als togeth­er with a focus on empa­thy, work­ing as a team and under­stand­ing the impor­tance of drug and non-drug treatments.

Phys­io­ther­a­py and men­tal health care might seem at oppo­site ends of the pain man­age­ment spec­trum, but phys­io­ther­a­pist Nathan Goss sets out why we have to see pain as a mind-body prob­lem and argues that men­tal health dif­fi­cul­ties are ‘some­thing we all experience’.

Issues cov­ered in this pro­gramme include: Mul­ti­dis­ci­pli­nary approach, the biopsy­choso­cial mod­el, men­tal health, edu­cat­ing health pro­fes­sion­als, reli­gion, faith, phys­io­ther­a­py, research, psy­chol­o­gy, com­mu­ni­cat­ing pain and empathy.

Paul Evans: Hel­lo, I’m Paul Evans and wel­come to Air­ing Pain, a pro­gramme brought to you by Pain Con­cern, the UK char­i­ty pro­vid­ing infor­ma­tion and sup­port for those of us liv­ing with pain and health­care pro­fes­sion­als. This edi­tion has been fund­ed by dona­tions from res­i­dents at Fal­con House, Edinburgh.

The biopsy­choso­cial approach to man­ag­ing chron­ic pain is well estab­lished. It acknowl­edges that thoughts, emo­tions, eco­nom­ics, envi­ron­men­tal, cul­tur­al and bio­log­i­cal fac­tors all con­tribute to our well­be­ing. But could the word ‘spir­i­tu­al’ be added to that description?

‘Towards cul­tur­al­ly com­pe­tent pain assess­ment was a research project fund­ed by the Nation­al Insti­tute for Health Research. It explored the expe­ri­ence, expres­sion and man­age­ment of chron­ic pain across the five [most] com­mon faith com­mu­ni­ties in the UK – Jew­ish, Hin­du, Sikh, Mus­lim and Chris­t­ian. Forty-four par­tic­i­pants aged 65 and above were asked about their expe­ri­ences of pain, their choic­es around self-man­age­ment, their inter­ac­tions with health pro­fes­sion­als and whether or not faith had influ­enced the way they man­aged their pain.

Michelle Brig­gs was one of the research team. She’s Pro­fes­sor of Nurs­ing at Leeds Met­ro­pol­i­tan Uni­ver­si­ty and she’s an Angli­can chaplain.

Michelle Brig­gs: We could not see any spe­cif­ic pat­tern of a Chris­t­ian way of deal­ing with our faith or an Islam­ic way of deal­ing with the faith. What we found more inter­est­ing­ly is that the major­i­ty of peo­ple found faith as an incred­i­bly pos­i­tive resource to help them with their pains, so they talked about their [faith] pro­vid­ing solu­tions to help them live pos­i­tive­ly with their pain, in terms of prayer, in terms of com­mu­ni­ty engage­ment, the sup­port that they got from oth­er mem­bers of their Faith com­mu­ni­ty. They talked very pos­i­tive­ly about how their Faith had helped them cope and live with their pain and also not only cope and live with their pain but a way of under­stand­ing what their pain meant for them – their faith helped them have a sense of why we have pain in the world.

And that, as a pain com­mu­ni­ty, what we saw was, cer­tain­ly with­in the pal­lia­tive med­i­cine field – Dame Ceci­ly Saun­ders was a pio­neer in that area – and she talked about pain being a total pain expe­ri­ence, where­by we have phys­i­cal pain, we have psy­cho­log­i­cal, social and spir­i­tu­al ele­ments to our pain. And, that actu­al­ly, that’s one of the things we think – that we have pain because our bod­ies are bro­ken, we have pain because the way we are think­ing about pain might help, so our thoughts are bro­ken or need fix­ing or we have pain because maybe our rela­tion­ships break down or that there are issues around our rela­tion­ships – and one of those rela­tion­ships could be our rela­tion­ship with God or with­in our faith.

And cer­tain­ly with­in the pal­lia­tive care field, one could argue that the pain man­age­ment with­in that area is opened up because we are able to talk about all of those aspects, in a way that we don’t nec­es­sar­i­ly talk, when we are talk­ing about chron­ic pain man­age­ment, where we focus some­times pre­dom­i­nant­ly on the bro­ken bod­ies and maybe we talk about the psy­chol­o­gy, but don’t nec­es­sar­i­ly talk about the social fac­tors that can help.

Evans: Are there any instances where our con­cept of God might get in the way of us man­ag­ing our pain?

M Brig­gs: I think some­times that might be – in the same [way] as any­thing can be a bar­ri­er to get­ting good pain relief: the way we work with our fam­i­lies; the way that we work with our health pro­fes­sion­als; the way that we see God; the way that we’re work­ing with our faith com­mu­ni­ty… some­times that can be a dif­fi­cul­ty and it’s why with­in the research what we’ve come up with is a series of ques­tions that, actu­al­ly from a pain con­sul­tant point of view, or if you’re going to a pain clin­ic, you may think about… one of the ques­tions that we’re ask­ing is ‘Does your reli­gion influ­ence how you under­stand your pain and it’s cause?’

And of course there’s the poten­tial there for that influ­ence to be a pos­i­tive influ­ence, because it helps me under­stand why I have my pain, but it could be that it’s a neg­a­tive influ­ence, and that actu­al­ly it’s get­ting in the way of me access­ing pain treat­ment or think­ing about pain. Or, indeed, what we’re ask­ing is ‘Can you tell me if aspects of your reli­gion make your pain bet­ter or worse?’

One exam­ple that was giv­en was some­body who felt that they would like to con­tin­ue with their prayer, but the pain that they had made the prayer posi­tions par­tic­u­lar­ly dif­fi­cult, so there was a real ten­sion there. And one way their pain con­sul­tant helped them was to find a way to per­form their prayers in a way that helped their pain. So that there were dif­fer­ent ways to say the prayers and do the prayers, that com­bined their phys­io­ther­a­py and their prayers.

So there are ways that when you ask those ques­tions and you give peo­ple per­mis­sion to talk about it, that we can find ways of improv­ing people’s pain man­age­ment in com­bi­na­tion with their faith community.

Evans: That’s incred­i­bly impor­tant, isn’t it?

M Brig­gs: I believe so. I think some­times we talk about being able to see all aspects of some­body’s life and being able to work out how the pain can some­times be in the dri­ving seat of that per­son­’s life. They can be think­ing about how the pain is stop­ping them doing things, and one area of their life can be their par­tic­i­pa­tion in their faith com­mu­ni­ty, but it’s an area of life we don’t nec­es­sar­i­ly talk about. But there’s a lot of evi­dence to sug­gest that prayer can help some peo­ple if it’s an impor­tant part of their reli­gious life or that oth­er aspects of being able to par­tic­i­pate in their faith can help their pain experience.

So being able to facil­i­tate that as pain spe­cial­ists, is an impor­tant area for some peo­ple. The impor­tant thing is that what we need to make sure when we’re help­ing peo­ple tell their sto­ries about how the pain is mak­ing a dif­fer­ence to their life, that we give peo­ple every oppor­tu­ni­ty to say the things that mat­ter to them. For some peo­ple, in terms of our ser­vice user group, the old­er peo­ple that we spoke to in our research said ‘Oh, I don’t think it mat­ters at all, I don’t need to talk to my doc­tor about my reli­gion – it’s not pos­i­tive­ly help­ing me, it’s not neg­a­tive­ly get­ting in the way – it does­n’t mat­ter at all.’ As is [the case with] lots of oth­er things that we do around our pain – but when it does mat­ter, it mat­ters a lot. So I think that the impor­tant thing is that our assess­ments and when patients come and talk about pain, if it is an issue, that they are able, and they have per­mis­sion be able to talk about it when it does matter.

Evans: Depend­ing on your lev­el of faith, what­ev­er that faith maybe.

M Brig­gs: Yes, yep.

Evans: Pain is an all embrac­ing thing – it’s your life, it’s biopsy­choso­cial. If that is your life and your faith is your life, then every­thing is linked.

M Brig­gs: Absolute­ly, and it’s part of any health professional’s role to con­sid­er all aspects of some­body’s health and think about these social, cul­tur­al and spir­i­tu­al aspects, where they may pro­vide solace or they may pro­vide an area where there’s work to be done in terms of improv­ing some­body’s pain man­age­ment. So it’s incum­bent on peo­ple to be con­sid­er­ing those. The real dif­fi­cul­ty is how you con­sid­er those and how you sen­si­tive­ly and cul­tur­al­ly ask ques­tions, so that peo­ple feel safe and able to talk about their pain in that way.

Evans: That’s right, if a pain doc­tor says to you, would you like to see a chaplain?

M Brig­gs: [laughs] Absolute­ly!

Evans: …and says it the wrong way and…

M Brig­gs: And cer­tain­ly our ser­vice users group said that that cer­tain­ly should­n’t ever be the first ques­tion and that it should be a sense of ‘What is your reli­gion, if any? Do you have a reli­gion? If you have one, does it influ­ence how you under­stand your pain? Does it influ­ence how you make deci­sions about your pain man­age­ment?’ And if peo­ple are say­ing ‘yes’ to those ques­tions, then there are deep­er ques­tions to ask around ‘Can you tell me par­tic­u­lar aspects of your reli­gion that are help­ing you and is there a way we can help you facil­i­tate that?’

The exam­ple I gave about some­body strug­gling to par­tic­i­pate in their prayers, and there was a way that that could be helped. Anoth­er exam­ple was a Sikh gen­tle­man who found that part of his faith was to par­tic­i­pate in the ser­vice and he was­n’t able to, so there was a way found to allow him to con­tin­ue to par­tic­i­pate. There are ways that unless we have those con­ver­sa­tions, we can’t work out ways of helping.

But you’re absolute­ly right, some­times if you just leap in with ‘Would you like to see a Chap­lain?’ the word ‘Chap­lain’ might not even be under­stand­able to most peo­ple, or the rea­son for see­ing that per­son. Bear­ing in mind the group of peo­ple we are speak­ing to are peo­ple who are con­nect­ed to the faith, they said ‘Oh no, don’t ask that ques­tion first, ask us why this is impor­tant to us and ask us whether this should be part of our pain man­age­ment plan’.

Evans: So, biopsy­choso­cial should be socio­biopsy­cho or maybe sociobiopsychospiritual?

M Brig­gs: Ceci­ly Saun­ders would argue that a total pain mod­el includes con­sid­er­a­tion of the bio­log­i­cal, psy­cho­log­i­cal, social and spir­i­tu­al fac­tors with­in that per­son­’s life. And, of course, for some peo­ple it will be a total­ly phys­i­cal prob­lem, for some peo­ple it will be a phys­i­cal and psy­cho­log­i­cal dif­fi­cul­ty that they’re work­ing with and for oth­er peo­ple the social and the spir­i­tu­al fac­tors will also be a part of that equa­tion to get­ting to good pain relief.

Evans: That was Michelle Brig­gs, Pro­fes­sor of Nurs­ing Care, Leeds Met­ro­pol­i­tan University.

I’ll just remind you of my usu­al words of cau­tion, the small print if you like, that whilst we believe the infor­ma­tion and opin­ions on Air­ing Pain are accu­rate and sound, based on the best judge­ments avail­able, you should always con­sult your health pro­fes­sion­al on any mat­ter relat­ing to your health and well­be­ing. He or she is the only per­son who knows you and your cir­cum­stances and there­fore the appro­pri­ate action to take on your behalf.

Now, pick­ing up on the points made by Michelle Brig­gs about the biopsy­ch­so­cial and maybe spir­i­tu­al fac­tors affect­ing a patient’s well­be­ing, is the next gen­er­a­tion of doc­tors and health pro­fes­sion­als receiv­ing the appro­pri­ate train­ing to be able to take all of a patient’s life fac­tors into account?

Emma Brig­gs is a lec­tur­er and Kings teach­ing fel­low at King’s Col­lege Lon­don. She’s also chair of the British Pain Soci­ety Pain Edu­ca­tion Spe­cial Inter­est Group. Back in 2011 the group pub­lished the results of a study look­ing at how much pain edu­ca­tion stu­dents across the health dis­ci­plines were receiv­ing. And it may sur­prise you to know that some vet schools were includ­ed in the study.

E Brig­gs: There was one Uni­ver­si­ty, one Vet­eri­nary School which did do a sig­nif­i­cant amount of pain teach­ing in their cur­ricu­lum, which was high­er than some of the schools that were teach­ing health dis­ci­plines for human health­care. How­ev­er, we only had two schools in the sam­ple. It’s dif­fi­cult to make that con­clu­sion uni­ver­sal. How­ev­er, we do know that it makes up less than one per cent of the cur­ricu­lum, pain edu­ca­tion, when it is an increas­ing health con­cern. We have a third of our adult pop­u­la­tion who are expe­ri­enc­ing long term per­sis­tent pain and just tak­ing back pain alone, it’s cost­ing the econ­o­my 12 bil­lion a year, esti­mat­ed. It has a dev­as­tat­ing effect on the indi­vid­ual lives of that many adults, yet we don’t have it rep­re­sent­ed in the prepa­ra­tion of our health­care pro­fes­sion­als in that way. And it being an increas­ing health­care con­cern, we need to see it in the cur­ricu­lum; we need to see our health­care pro­fes­sion­als bet­ter pre­pared, so that they can man­age pain for indi­vid­u­als, for their fam­i­ly and for pub­lic health.

Evans: So what sort of edu­ca­tion are they getting?

E Brig­gs: What we know is that they’re get­ting on aver­age about twelve hours of edu­ca­tion. We’ve recent­ly con­duct­ed a study with the Euro­pean Pain Fed­er­a­tion (EFIC) and this looked at just med­ical under­grad­u­ates this time, where­as our pre­vi­ous study was a whole range of dis­ci­plines, but it com­pared the edu­ca­tion across Europe and that was fas­ci­nat­ing in itself. So we reck­on they’re get­ting on aver­age twelve hours, which in those fig­ures when the Euro­pean stan­dard is for med­ical stu­dents to have a cur­ricu­lum which is 5,500 hours. So real­ly, we’re only get­ting 0.2 per cent of the curriculum.

But what is inter­est­ing is how they are being edu­cat­ed and it’s large­ly by lec­tures, their knowl­edge is then test­ed through exams. So it’s all about infor­ma­tion and knowl­edge recall, which is great but by itself it’s not going to help me as a clin­i­cian, learn how to com­mu­ni­cate, learn how to have empa­thy with a patient, learn to prob­lem solve, assess their pain and then make some clin­i­cal deci­sions about how am I going to treat this; how’s the best phar­ma­co­log­i­cal treat­ment; how’s the best drug tech­niques that I need and is there any non drug tech­niques, some alter­na­tive ther­a­pies, that might help this indi­vid­ual? None of those tech­niques are going to help those skills and that com­pe­tence that we need.

Evans: Are we on a par with oth­er coun­tries in Europe or the world even?

E Brig­gs: Unfor­tu­nate­ly not, the UK fig­ure is that six­ty-eight per cent of uni­ver­si­ties in the UK have some sort of pain teach­ing, but that’s usu­al­ly spread out in oth­er mod­ules. So it might be in a mod­ule on phar­ma­col­o­gy, it might be on the pain mech­a­nisms and phys­i­ol­o­gy, but they don’t have ded­i­cat­ed pain man­age­ment time.

Quite inter­est­ing­ly, in France, I sup­pose our clos­est com­par­i­son, eighty-four per cent of their med­ical schools actu­al­ly had ded­i­cat­ed time, ded­i­cat­ed mod­ules for pain teach­ing. That’s because they have had a nation­al plan around pain man­age­ment since 1997 and in 2004, they made it com­pul­so­ry that all med­ical schools should include pain with­in their teach­ing. All of them have pain teach­ing and eighty-four per cent of them have ded­i­cat­ed mod­ules – so a block of teach­ing actu­al­ly on pain itself. Ger­many are not far behind because they have worked with pal­lia­tive care to get it on the cur­ricu­lum and get it on the stu­dents final exams as well.

Evans: But, I sup­pose pain may not be a sexy sub­ject for young under­grad­u­ate. It may not be an easy mod­ule to sell for the pow­ers that be, in the uni­ver­si­ties and col­leges. How do you make it sexy?

E Brig­gs: I think we’ve got to demon­strate the impact and con­tin­ue to shout from the rooftops, the impact that it’s hav­ing on indi­vid­u­als and their fam­i­lies. The increas­ing pub­lic health con­cern and, very sad­ly, I think, peo­ple respond much more to the eco­nom­ic aspect. And I think we’ve got increas­ing num­bers in Europe. And I think there was a study that was con­duct­ed in Ire­land, that said on aver­age some­body in per­sis­tent pain can cost the econ­o­my 5,000, 6,000 euros, but that fig­ure can actu­al­ly go up to 30,000 euros, depend­ing on the treat­ment some­body is hav­ing. So unfor­tu­nate­ly some­times the pow­ers that be only respond to the eco­nom­ic argu­ments, but increas­ing­ly, there is this argu­ment around social justice.

But actu­al­ly, it’s around say­ing that the health needs of the pop­u­la­tion need to be rep­re­sent­ed in how we are prepar­ing our under­grad­u­ates. I was talk­ing with some lec­tur­ers from South Africa and they were say­ing, actu­al­ly, their local pop­u­la­tion… they increas­ing­ly need to teach around HIV and it’s very dif­fi­cult to get pain in there. Our pop­u­la­tion needs are dif­fer­ent and pain needs to be up there as a priority

Evans: Emma Briggs.

Now Nathan Goss, is not a stu­dent, rather he’s Senior Phys­io­ther­a­pist at the pain man­age­ment pro­gramme at the Wal­ton Cen­tre in Liv­er­pool. But when I spoke to him he was a rel­a­tive new­com­er to the world of pain, with just two years in this spe­cial­ist field.

Nathan Goss: The area I worked in pri­or to pain was the men­tal health field. So I was a men­tal health phys­io­ther­a­pist – not the most usu­al field to be work­ing in. There are plen­ty of phys­io­ther­a­pists work­ing in the men­tal health field but we’re not well known or under­stood real­ly, what our roles were. And I was look­ing for an area in that I could com­bine my knowl­edge of phys­i­cal health and men­tal health and the stan­dard of mood prob­lems and psy­cho­log­i­cal dif­fi­cul­ties real­ly and pain brings those two fields together.

Evans: In what way?

Goss: Pain affects us not just phys­i­cal­ly, but emo­tion­al­ly and men­tal­ly as well. As a phys­io­ther­a­pist, I have always thought we are in one of those great posi­tions, to be able to pre­scribe move­ment and exer­cise, which we recog­nise as being very impor­tant in the pres­ence of any men­tal health prob­lems or pain prob­lems. Not a lot of peo­ple can actu­al­ly do that I sup­pose, pre­scribe the exercise.

Evans: So, you were involved with peo­ple with men­tal health issues, depres­sion, anxiety?

Goss: Absolute­ly, absolute­ly, the inci­dences of depres­sion and anx­i­ety are recog­nised as being much high­er in the chron­ic pain pop­u­la­tion. Like I said, the role of exer­cise, the fear of move­ment that chron­ic pain brings is well recog­nised and it’s a good role to be able to be able to under­stand both par­ties and actu­al­ly help peo­ple get mov­ing; because it’s one thing being rec­om­mend­ed move­ment but, actu­al­ly, you need to have the recog­nised back­ground knowl­edge to be able to do that, the reas­sur­ance… The method of deliv­er­ing that advice, slots in very nice­ly with the area I’m mov­ing into I suppose.

Evans: As a patient, if I were being referred to a phys­io­ther­a­pist, and the plus point of that par­tic­u­lar phys­io­ther­a­pist was ‘he’s worked with men­tal health patients’ – that would ring some alarms bells in me.

Goss: I think that’s inevitable, we’re assess­ing peo­ple with pain prob­lems all the time. The men­tion of men­tal health, mood, depres­sion, psy­cho­log­i­cal dif­fi­cul­ties cre­ates that impres­sion in a lot of peo­ple. And that’s why we have to be good at under­stand­ing the impact of pain. And not just telling peo­ple, we have to learn from the patient, we have to under­stand their expe­ri­ence of pain.

And, actu­al­ly, I think it’s just about tak­ing away the stig­ma real­ly. I always describe men­tal health or psy­cho­log­i­cal prob­lems as some­thing that we all expe­ri­ence. We’re all on a slid­ing scale, it’s not just some­thing that gets to a cer­tain tip­ping point and you’ve got some­thing wrong with you. We’re human beings, so we all have human psy­chol­o­gy. We’re on the slid­ing scale of mood – I wake up some days feel­ing not so great and find it more dif­fi­cult to inter­act with oth­ers and maybe those inter­views made me a lit­tle bit anx­ious as well before­hand. But these are human emo­tions and dif­fi­cul­ties and we try to nor­malise that a lit­tle bit, I sup­pose, that’s what we try to do, when I’m work­ing with peo­ple with pain prob­lems, rather than mak­ing them feel ‘I’ve got a men­tal health prob­lem’. Because I can under­stand that, if that’s not deliv­ered in the right way, it could be a bit of a shock.

Evans: But you’re not a mind ther­a­pist, you’re a body therapist.

Goss: You can’t sep­a­rate the two, real­ly. Men­tal health work and work­ing with the psy­cho­log­i­cal side of things a lit­tle bit was the under­rep­re­sen­ta­tion at uni­ver­si­ty. We’ve just had a talk, sug­gest­ing uni­ver­si­ty stu­dents get thir­ty sev­en and a half hours of pain edu­ca­tion, which I’m not sure was the case when I was at Uni­ver­si­ty. I know we had a three hour lec­ture on men­tal health prob­lems and I remem­ber just think­ing, that’s not rep­re­sen­ta­tive of where I want to be as a ther­a­pist. I need to be able to deal with both the mind and body [laughs] side of things. I think that’s what ther­a­py is about real­ly, treat­ing a phys­i­cal dif­fi­cul­ty or the oth­er side, it’s both togeth­er – they need to be inte­grat­ed really.

Evans: What have you learned in your first two years of pain management?

Goss: I’ve learned that pain is a very com­plex thing. It’s not some­thing that is bril­liant­ly under­stood in the con­text of oth­er med­ical prob­lems and in the field of the med­ical world – there’s still lots and lots to learn and I’ve got a long, long way to go. But there are also some very sim­ple, help­ful mes­sages that you can give to our group mem­bers, to help them move for­ward and lead a bet­ter qual­i­ty of life. That’s what I sup­pose keeps me inter­est­ed and makes me enjoy my job, is the fact that there is scope for peo­ple to improve their qual­i­ty of life. But cer­tain­ly, there’s a lot more to learn and lots of excit­ing future direc­tions as well I think for pain management.

Evans: Nathan Goss, Senior Phys­io­ther­a­pist at the Pain Man­age­ment Pro­gramme at the Wal­ton Cen­tre in Liv­er­pool. Now when I got my first job in a com­plete­ly unre­lat­ed field, I received three months of inten­sive lec­tures and cram­ming, before being let loose on the real thing. But I felt I’d learned more in the first week fol­low­ing that train­ing peri­od, than in the pre­vi­ous three months with my head buried in a text­book. Learn­ing the the­o­ry is, of course, essen­tial but expe­ri­ence of real life sit­u­a­tions can­not be learnt in a book. So, going back to our under­grad­u­ates, how could the gap between lec­ture room and deal­ing with real patients be bridged? Emma Brig­gs again:

E Brig­gs: How we teach our under­grad­u­ates at Kings Col­lege Lon­don, is to make sure they get some lec­tures and they get a chance to rehearse those skills they need to work with patients. We have an under­grad­u­ate pro­gramme, some­thing called an Inter­pro­fes­sion­al Pain Man­age­ment Learn­ing Unit and thir­teen hun­dred stu­dents come togeth­er to learn about pain. And they’re from all dif­fer­ent dis­ci­plines, so they’re from den­tistry, med­i­cine, nurs­ing, mid­wifery, phar­ma­cy and phys­io­ther­a­py, and we give them some back­ground infor­ma­tion, some online learn­ing to do and they meet a vir­tu­al patient with dif­fer­ent painful conditions.

And they work through some of their com­mu­ni­ca­tion issues, their empa­thy and then they need to demon­strate that to us in the class­room as well. So we then meet them in the class­room, they work in an inter­pro­fes­sion­al group, it’s called, they work as a team because they need to col­lab­o­rate as a team, as that’s how they would work in prac­tice when they qual­i­fy. So they col­lab­o­rate to actu­al­ly demon­strate the com­mu­ni­ca­tion, the empa­thy, their under­stand­ing of the biopsy­choso­cial, so they real­ly under­stand the impact of that pain on the individual.

Then they come up with a plan which includes drug tech­niques and non drug tech­niques and we make sure that they under­stand the impor­tance of work­ing as a team. And in fact they do – the feed­back that we have from that learn­ing unit is… some of the direct quotes from the stu­dents is ‘I now under­stand the need to work togeth­er as a team and how the out­comes for the patient can be bet­ter as a direct result from that’.

Evans: These are vir­tu­al patients, do they meet real patients?

E Brig­gs: They do indeed, but at dif­fer­ent stages of their career. They will have place­ments through­out – it’s a core require­ment of the course, that they have a cer­tain num­ber of hours. So in nurs­ing for instance, half the course, fifty per cent has to be clin­i­cal time. Whether they have expe­ri­ence with some of the pain ser­vices varies accord­ing to the indi­vid­ual. We take in four hun­dred stu­dents, unfor­tu­nate­ly, we could­n’t get four hun­dred stu­dents time with clin­i­cal nurse spe­cial­ists or spe­cial­ist phys­ios, but some of them do rotate in, if they have an inter­est in pain man­age­ment. And they often do projects around pain man­age­ment and spe­cial study units, which will focus on pain, so they do have opportunities.

Evans: Do they meet expert patients, peo­ple who come in and talk about how pain affects their life?

E Brig­gs: The expert patient in the class­room is a real­ly pow­er­ful tool and yes they do. My expe­ri­ence with expert patients is, to give you one exam­ple, was of a patient who had to come and talk to a group and some­body says ‘well we don’t some­times have time to do that assess­ment on pain man­age­ment’. And they’d said this to me in the morn­ing and I said ‘let’s have a think about that and what are the alter­na­tives’ and we worked round it. In the end I said ‘What would the Nurs­ing and Mid­wifery Coun­cil say about that? If you said “I haven’t had time to do a pain assessment?”’

When the expert patient came in the after­noon and the stu­dent repeat­ed the ques­tion – ‘some­times I don’t have time to do a pain assess­ment’ – the patient said to me ‘You don’t need a lot of time, but I need to know you are with me and that you’re under­stand­ing me and that you’re lis­ten­ing to me and that is enough for me. I realise that some­times you don’t have half an hour to do an exten­sive pain assess­ment but just be on my side and that means a lot to me.’

Evans: That’s very pow­er­ful isn’t it?

E Brig­gs: Very, very pow­er­ful, very pow­er­ful and they clear­ly weren’t lis­ten­ing to me in the morn­ing but when the patient came along, it was incred­i­bly powerful.

Evans: You men­tion stu­dents who’ve been through this process of learn­ing, do you have any feed­back from peo­ple who haven’t, who would have liked to have gone through it?

E Brig­gs: That’s very inter­est­ing, with the study we’ve been doing, the Euro­pean study, look­ing at med­ical stu­dents, we inter­viewed stu­dents in their final year or who’re just qual­i­fied and we inter­viewed deans and lec­tur­ers and around man­ag­ing pain itself.

Evans: So they had been released into the field and sud­den­ly they feel cut adrift.

E Brig­gs: They do, absolutely.

Evans: I glibly said at the start ‘How do you make pain a sex­i­er sub­ject?’ Real­ly, I would think that most peo­ple go into med­i­cine because the patient is the focus of every­thing. Well that’s how you make it sexy – it’s work­ing to help the patients, and an awful lot of us are in pain.

E Brig­gs: Absolute­ly, I agree with you total­ly Paul because in our Inter­pro­fes­sion­al Pain Unit, that exact­ly what we do and that’s always keep­ing the patient at the cen­tre. Mak­ing sure that the stu­dents work togeth­er and focus and col­lab­o­rate and those are the skills that they need for the practice.

We were talk­ing about the expert patient in the class­room, it’s a real­ly pow­er­ful learn­ing tool is bring­ing peo­ple togeth­er, learn­ing about people’s sto­ries and jour­neys and impact, because many of our stu­dents are going to be eigh­teen, nine­teen – they may not have seen any­body with long term pain. They’ll have their own pain expe­ri­ences, but they may be short term and it’s real­ly impor­tant that we help them under­stand. And that’s one of the oth­er feed­backs that we’ve had from our learn­ing unit – ‘we nev­er appre­ci­at­ed the range of painful con­di­tions that peo­ple have had’. So it’s impor­tant that peo­ple under­stand that there are dif­fer­ent treat­ment plans for dif­fer­ent painful conditions.

That’s Emma Brig­gs, Chair of the British Pain Soci­ety Pain Edu­ca­tion Spe­cial Inter­est Group.

Don’t for­get that you can down­load all the pre­vi­ous edi­tions of Air­ing Pain or obtain CD copies direct from Pain Con­cern. If you’d like to put a ques­tion to Pain Concern’s pan­el of experts or just make a com­ment about these pro­grammes, then please do so via our blog, mes­sage board, email, Face­book, Twit­ter or pen and paper. All the con­tact details are at our web­site which is

Last words on under­grad­u­ate train­ing to Emma Briggs:

E Brig­gs: We need to more ade­quate­ly pre­pare them, we need to get their skills – it’s not just about their knowl­edge. We need to devel­op their com­mu­ni­ca­tion, empa­thy, prob­lem solv­ing, those pre­scrib­ing skills, those patient edu­ca­tion skills – help­ing patients with self-man­age­ment – it’s a huge area miss­ing in the cur­ricu­lum at the moment. So we need to edu­cate them better.

In my role as Chair of the Pain Edu­ca­tion SIG [Spe­cial Inter­est Group] we’re work­ing on that and we are hope­ful­ly going to launch a doc­u­ment which will help uni­ver­si­ties with com­pe­ten­cies and val­ues that we feel are impor­tant to bed into the cur­ricu­lum. And we will also work with the indi­vid­ual dis­ci­plines that have a reg­u­la­to­ry body like the Gen­er­al Med­ical Coun­cil, like the Nurs­ing and Mid­wifery Council.

And we need to work with them because they set some of the stan­dards around pain, and pain is in those stan­dards but in very min­i­mal form. So, just to give you an exam­ple, the ‘Tomorrow’s Doc­tors’ doc­u­ment, it refers to being able to pre­scribe for com­mon indi­ca­tions, such as pain and then it says, doc­tors should learn how to use local anaes­thet­ics, and that’s it – that’s the whole of their rec­om­men­da­tions around pain man­age­ment and how we should be prepar­ing our med­ical stu­dents. We need to work with them, in order to get some more stan­dards around pain man­age­ment, make sure it gets into the uni­ver­si­ty cur­ricu­lum, so that our health­care pro­fes­sion­als are bet­ter pre­pared to man­age pain when they are qualified.


  • Michelle Brig­gs, Pro­fes­sor of Nurs­ing, Leeds Met­ro­pol­i­tan University
  • Emma Brig­gs, Lec­tur­er, Kings Col­lege London
  • Nathan Goss, Senior Phys­io­ther­a­pist, Pain man­age­ment pro­gramme at the Wal­ton Cen­tre in Liverpool.


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