ACUTE PAIN ROTATION
At the University of Kentucky, residents spend an obligatory 2 months on the Pain Service, one month each during the CA-I and CA-II years respectively. During this time, they alternate daily between the Acute Pain Service and regional anesthesia. Residents may opt to spend part of the CA-III rotation on the Pain Service. This may consist of a combination of acute and chronic pain or solely of acute or chronic pain. The duration (1-6 months) is dependant on rotation availability and the resident's interest. The Anesthesia Pain Management teams provide inpatient as well as outpatient services including:
a) Perioperative/trauma pain management
b) Consultative services for patients needing simple pharmacologic management
c) Primary care services for patients requiring complex pain management and interventional pain management services.
The basic goal of the rotation is for the residents to be exposed to the interdisciplinary evaluation and management of acute, chronic, and cancer-related pain, and to procedures related to the treatment of these patients. After the end of the rotation, the resident may elect to request additional time during the CA-3 year. Generally, this time will be used to investigate advanced pain management techniques and to improve techniques already acquired.
Clinical Responsibilities and Schedule of Activities:
The basic goal of the Each morning, it is the resident's responsibility to ensure that the daily list of all surgical patients is updated, with correct patient information and current locations of patients. Residents must identify potential candidates for regional techniques and execute the consults as required. An attending anesthesiologist is allocated to cover the pain service and is readily available for consultation at all times.  
During the rotation, there are didactic sessions given at a prearranged time by the attending physician on the APS that day. Clinical teaching is on a case-by-case basis, depending on clinical assignments. The faculty will use clinical scenarios for educational purposes.  
The attending may not be familiar with each resident's knowledge base. Thus, it is the resident's responsibility to request clarification of concepts, assessments, or patient care plans.  
On a daily basis the clinical activities will begin in the Main Operating Room, assisting with and/or placing neuraxial and/or regional blocks for surgical cases. Daily in-patient acute pain service rounds will follow. The primary responsibility of the service is to consult and manage in-patients' pain needs upon request of the primary service. Call responsibilities are taken from home via pager.  
Pain service patients requiring bedside evaluation and management decisions after regular hours will be referred to the in-house call team. If the call team cannot assist with the service, then it is the responsibility of the acute pain resident to provide the service.

Goals and Objectives
The goals and objectives are accomplished by using our existing curriculum and instructional activities. These are detailed under the section Acute Pain Manual. The specific goals and objectives pertaining to different aspects of training are outlined below including all six general competencies:
1. Patient care
Residents must be able to provide patient care that is compassionate, appropriate, and effective in dealing with patients in pain. Residents are expected to:
• Perform an appropriate history and physical examination to identify co-morbid conditions that may affect pain management.
• Verify that appropriate tests have been ordered or reviewed giving the patients findings on history and physical examination, scientific evidence and clinical judgment.
• Educate patients about all available options for the management of pain, their risks and benefits, and the current evidence-based recommendations.
• Create a management plan for acute, postoperative pain including postoperative epidural analgesia management, as well as other forms of regional infusion therapies.
• Should be able to prescribe standard intravenous PCA orders and a standard continuous epidural regiment.
• Should be able to prescribe and manage intravenous PCA and continuous epidural analgesia for most clinical situations including pediatric and elderly patients.
• Should be aware of the problems of acute pain management in the opiate dependent and addicted patients.
• Evaluate and manage inpatient consultations for parenteral/oral opioid conversion, moderate complexity malignant and non-malignant pain problems.
• Should accompany acute pain rounds and learn about common clinical problems.
• Should be able to manage most clinical problems during rounds on the Acute Pain Service.
• Evaluate patients for pain management procedures (e.g., lumbar, thoracic, and cervical epidural access and injection techniques).
• Should be able to place a lumbar epidural catheter and a brachial plexus block for post-operative pain management.
• May have attempted thoracic epidural placement and continuous brachial plexus blockade for post-operative pain management.
• Evaluate patients for advanced pain management techniques (e.g., neurolytic techniques, including radio frequency ablation techniques; neuroaugmentation techniques, chronic neuraxial drug delivery techniques).
• Identify advanced pain management techniques (e.g., neurolytic techniques, neuroaugmentation techniques, chronic neuraxial drug delivery techniques, etc).
• Monitor the performance of advanced techniques (e.g., neurolytic techniques, neuroaugmentation techniques, chronic neuraxial drug delivery techniques).
2. Medical Knowledge  
• Residents must demonstrate knowledge about the effectiveness of various preoperative evaluation techniques and the scientific support regarding appropriate preoperative interventions.
• Understand the management of acute, postoperative pain including postoperative epidural analgesia management, as well as other forms of regional infusion therapies.
• Should have an understanding of the basic physiology of nociception and understand the major differences between Acute and Chronic pain models and philosophies.
• Should be familiar with the basic pharmacology of opiates, non-steroidal anti-inflammatories (NSAIDs) and local anesthetics with emphasis on the side effects of these agents.
• Understand the basic anatomical and pathophysiological mechanisms involved in common chronic malignant and non-malignant pain problems.
• Understand the procedures and medical data for inpatient consultations involving parenteral/oral opioid conversion, moderate complexity malignant and non-malignant pain problems.
Residents are expected to:
• Apply knowledge of various co-morbid conditions (such as diabetes renal insufficiency, addictions, etc) and the effects of those conditions or medications on the safe conduct of analgesic techniques.
• Discuss the basic anatomical and pathophysiological mechanisms involved in common chronic malignant and non-malignant pain problems.
• Be aware of the Stress Response to surgery and trauma and of the concepts of Peripheral and Central Sensitization and Pre-Emptive Analgesia and of the differences between Acute Pain and nociception.
• Know the anatomy of the epidural space including the difference between the thoracic and lumbar epidural space.
• Should understand the concept and rationale of Patient Controlled Analgesia (PCA).
• Know the pharmacology of agents administered epidurally. Be aware of difference between lipophilic and hydrophilic opiates.
• Understand advanced pain management techniques and observe these techniques where practical (e.g., neurolytic techniques, neuroaugmentation techniques, chronic neuraxial drug delivery techniques).
3. Practice-based Learning Improvement
Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:
• Locate, appraise, and assimilate evidence from scientific studies related to their patient's health problems.
• Use information technology to manage information, access on-line medical information and support their own education.
• Facilitate the learning of students and other health care professionals.
• Read the literature on important analgesic issues including Consensus Statement on Anticoagulation (ASRA), Consensus Statement on Prevention of Infections (ASRA), Acute Pain Guidelines (ASRA).
4. Interpersonal and Communication Skills
Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, and professional associates.
• Practice oral communication with other services and clinics regarding patient assessment and care.
• Perform written documentation of patient assessment and care.
• Engage in communication to ensure other services and clinics are equipped to provide excellent patient assessment and care.
• Complete accurate and concise written documentation of patient assessment and care.
5. Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population.
• Demonstrates responsibility and physical and mental attentiveness in a positive and constructive manner.
• Demonstrates willingness to show consideration and appreciation for patients and co-workers.
• Exhibits compassion, empathy and support in patient care and professional interactions.
• Demonstrates truthful and ethical standards in professional interactions and conduct.
• Engage in communication to ensure collegiality for all members of the Pain Management team and other service providers.
• Express plans, issues and concerns in language and using non verbal cues to demonstrate respect for the diversity of our patient and work communities.
• Produces timely, accurate and appropriate patient care documentation.
• Maintain privacy of records and communication.
• Maintain a professional appearance at all times.
• Perform clinical, administrative and education related duties, including reading, in a timely manner.
• Attend all departmental conferences.
• Acknowledge limits of competence and act accordingly.
6. Systems-based Practice
Gain experience in the principles of multimodal acute pain management, including psychological and physiotherapy evaluations and treatment options for inpatients.
• Gain experience in the principles of interdisciplinary pain management, including psychological and physiotherapy evaluations and treatment options.
• Describe the options multimodal acute pain management, including psychological and physiotherapy evaluations and treatment for inpatients.
• Describe principles of interdisciplinary pain management, including psychological and physiotherapy evaluations and treatment options Instructional Methods.

Resident Assessment
Residents will receive daily informal evaluation, as well as an evaluation at the end of their rotation from each attending that worked with them.
• Case logs: maintained by the residents.
• Chart /record review: as performed by the attending pain physician when assessing the documentation of E&M services including consultations, consents and procedure notes.
• Standardized Oral Examination: as performed biannually with the Department.
• Didactic tutorials: include problem-based learning on common pain syndromes including pathophysiology, diagnostic approaches and management strategies.
• Direct Observation of Invasive Pain Procedures: one-on-one supervision by faculty for each procedure. Review and verbal feedback on the resident's technical skills, approach to the patient, and interpersonal skills in regards to his/her interaction with the patient and other members of the Pain Team.
• Evaluation and Management Services: discussion of patient's pain and medical history; physical exam; differential diagnosis and treatment plan. Immediate review of the residents approach is detailed; areas of positive accomplishment and needing improvement are identified.
• 360-degree evaluations: Evaluations are sought from the support staff, nursing staff, and faculty members that the resident interacts with during their rotation.
• Follow up: areas of weakness discovered and defined through any of the assessment methods above, will be communicated back to the resident through various channels including:
• Routine departmental monthly resident evaluation
• Daily feedback
• Specific intermittent feedback from the director of the Pain Service
Appropriate interventions and steps shall be recommended to the resident and faculty to address deficiencies.
• Evaluation and feedback: is an ongoing process during the rotation. There is ongoing evaluation and feedback in the areas of pain history taking, physical examination, diagnostic skills, clinical application of pain management principles, and administrative responsibilities.

Formal Resident Evaluation
Every resident rotating through is formally evaluated by the faculty. The departmental standardized evaluation forms are used. The essential elements to be assessed are:
• Knowledge
• Clinical skills
• Clinical judgment
• Character (professionalism, compassion and ethical nature) and demeanor, and,
• Progress made during the rotation
• Areas of strength and weakness
This evaluation is submitted to the Clinical Competence Committee.

Faculty Evaluation by the Resident
Independent of departmental evaluations, residents will be encouraged to provide assessments of Pain Faculty. These evaluations are to be used in a positive and proactive manner to provide guidance where improvement can or should be made and to recognize where merit is due. Categories to be evaluated include:
• Teaching
• Clinical care
• Professionalism, supervision and fairness
• Didactic teaching

In addition the residents will be encouraged to provide an overall assessment of the rotation commenting on:
• Orientation to the service
• Availability of clinical supervision
• Workload
• Educational value
• Supervision
• Assistance of the support staff
• Areas of strength and needing improvement

Prerequisites
Satisfactory completion of a PGY-1 year including at least 6 months of general anesthesia.