The goal is to train a consultant in all aspects of acute pain management, including the opportunity to participate in research activities. Knowledge to be gained will be principles of acute postoperative pain management using various modalities.

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.
Acute Pain Service
Largely responsible for acute postoperative/post trauma pain management. The resident should be involved in preoperative consultation, patient education and recommendation for postoperative analgesic regimen for complicated patients or complex surgical procedures, as well as implementing such regimen or interventions. It is very important for the resident to be involved in planning and performing postoperative analgesic techniques as well as in the daily rounds on postoperative patients, to evaluate their interventions and deal with the side effects/complications of their planned therapy.
Goals and Objectives of the CA-3 Rotation
In addition to the goals and objectives established for the CA-1 & 2 rotation, on completion of a CA-3 rotation, residents should:  
• Cognitive Objectives
• Discuss in detail the pathophysiology of acute pain.
• Discuss pharmacology of opioids, local anesthetics and non-steroidal anti-inflammatory drugs.
• List and describe the advantages and disadvantages of various modalities of management of acute pain (neuraxial drug administration, IV-PCA, regional anesthesia techniques, peripheral nerve blocks, etc).
• List and discuss the criteria of patient selection for each modality of acute pain management, especially regarding high risk, pediatric and geriatric patients.
• Have a detailed knowledge of the physiology of acute pain including such concepts as preemptive analgesia, multimodal analgesia, benefits of suppression of the stress response, and non-analgesic benefits of epidural analgesia.
• Have a detailed knowledge of the anatomy of the epidural space and the brachial plexus.
• Know the advanced pharmacology of commonly used opiates, non-steroidal anti-inflammatory drugs and local anesthetics.
• Know the pharmacology and clinical uses of the adjuvant agents in acute pain management.
• Be able to outline a postoperative pain management plan for most patients and surgeries.
• Have some experience as a consultant on acute pain management in the non-operative setting.
• Skill Objectives:
By the end of the rotation the resident should be able to:
• Place neuraxial catheters, perform regional techniques and nerve blocks for postoperative continuous pain control.
• Recognize and manage side effects and complications of neuraxial or IV administration of narcotics or local anesthetics.
• Operate and program drug infusion pumps for various routes of administration.
• Provide appropriate documentation of patient care.
• Conduct acute pain management service rounds.
• Effectively communicate and coordinate care with the referring physicians/other providers.
• Participate in the placement of an epidural or caudal catheter in a patient less than 2 years for post-operative pain management.
• Perform continuous brachial plexus blockade by at least 2 routes.
• Perform femoral nerve, sciatic nerve, or continuous lumbar plexus block for postoperative pain management.
• Lead “Acute Pain Rounds” and deal with most clinical problems.
• Manage acute pain in the cancer patient and in the opiate addicted patient.
• Recognize the major controversies in acute pain management and be able to organize the subspecialty conference.
• Provide training in all aspects of acute pain management, including acute post-operative pain, as well as acute cancer, AIDS and trauma related pain
• Provide training in both chronic malignant and non-malignant pain. Emphasis will be on a multidisciplinary approach toward the management of pain, and incorporates both outpatient and inpatient populations settings. The primary area of knowledge will include chronic pain syndromes, diagnostic and therapeutic interventions, and interactions with other disciplines, such as physical therapy, psychology, rehabilitation, orthopedics, neurosurgery, oncologists, and nursing.
• Identify and understand different administrative models that may be used to operate an acute pain service.
• Understand the different roles that may be delegated to nurses, and to understand the process of nursing policy development, including how to obtain approval of nursing policy and procedures.
• Understand the basics of third party reimbursement for pain management, including billing procedures and required documentation.

The goals and objectives are accomplished by using our curriculum, instructional and learning activities including direct collaborative patient care and other scholarly activities. Six general competencies are indicated and applicable to the individual goals and objectives:
1. Patient care
2. Medical Knowledge
3. Practice-based Learning Improvement
4. Interpersonal and Communication Skills
5. Professionalism
6. Systems-based Practice

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 at least one month in the acute pain service as CA-1 or CA-2.