Regional anesthesia and pain education in Greece

In Greece there are seven medical schools in major cities of the country, namely Athens, Thessaloniki, Larissa, Ioannina, Patra, Heraklion and Alexandroupolis, consisting of three preclinical and three clinical academic years. The Athens Medical School is the largest in the country. Anesthesiology and/or Emergency Medicine and/or Intensive Care Medicine is  part of the compulsory curriculum in all medical schools, aiming at increasing pre-graduate exposure to the relevant specialties.

The aim of Anesthesiology as an academic subject in the pre-graduate level is to provide medical students with the knowledge and ability to formulate a basic anesthetic management plan, understand the risks and benefits associated with general and regional anesthesia and develop an approach to perioperative pain management and acute resuscitation.

«Fortunately, in most medical schools of Greece, an elective undergraduate course about the management of malignant and non-malignant chronic pain has been integrated in the educational program in order to meet the educational needs of future physicians.»

Teaching about pain is not well-integrated into the compulsory Medical School curriculum and both basic science material as well as the complex behavioral and psychosocial implications of pain have not been major components of the Greek medical education for many years. This is a worldwide problem; defects of conventional medical education regarding the basic science of pain  means that this subject is properly addressed by very few medical schools around the world. Pain is one of the most undertreated medical complaints, with barriers to effective pain management lying in poor education of health professionals and misconceptions regarding patients in pain. Fortunately, in most medical schools of Greece, an elective undergraduate course about the management of malignant and non-malignant chronic pain has been integrated in the educational program in order to meet the educational needs of future physicians. The course is in most cases quite popular and is selected by a vast majority of medical students. As an example, we describe the Course of the Athens Medical School, that includes most of the IASP’s recommended content on medical school pain curriculum. It is taught for 25 hours per semester, 20 hours of which being lectures and five hours being participation in pain clinic practice. A few years ago, we performed a study, the results of which were later published [1]. The study aimed to assess whether this elective undergraduate course on chronic pain offered in the Athens Medical School influences knowledge and attitudes of medical undergraduates about chronic pain and helps them clarify pain-related concepts or change their perceptions and beliefs towards chronic pain. According to their responses, medical students had good knowledge about the definition and consequences of pain and those who attended the pain course had greater knowledge regarding the adequacy of treatment of chronic pain and were more familiar with the recent classification of types of pain. Students who did not have exposure to the undergraduate pain course had little information regarding pain clinics and had poor knowledge regarding the use of opioids in cancer and in non-malignant chronic pain. All students responding to the questionnaire expressed concerns regarding addiction to opioids. It appears therefore that although students enter medical school with little knowledge about pain issues, pain awareness can be positively influenced by education. A curriculum about pain should not only teach the basic science of pain but also present treatment strategies available and address the socio-emotional dimensions of pain. Additionally, if misconceptions about opioid use and addiction are properly elucidated early in medical education, the future health practitioners will be one step forward in achieving the goal of alleviating suffering patients’ pain.

«Students also have the opportunity to actively practice in pain clinics in the pharmacological therapies of pain as well as in interventional techniques under specialist guidance.»

As far as postgraduate pain education is concerned, Athens University offers the postgraduate program: “Algology: Pain Management, Diagnosis and Treatment, Pharmacological, Interventional and other Techniques”. This program incorporates among others, teaching on the anatomy, history and genetics of pain, physiology, biochemistry and pharmacology of pain, epidemiology, statistics and research methodology in pain, psychology of pain, ethics and code of conduct in pain, evaluation and diagnosis of pain as well as organization, curriculum and function of pain clinics. Postgraduate students are thoroughly taught about the pharmacological management of pain, adverse effects and interaction of drugs used in the treatment of pain and interventional techniques used in the treatment of pain syndromes. Special clinical subjects are also taught, such as management of pain during end-of-life care, alternative methods in the treatment of pain, rehabilitation medicine, physical therapy and occupational therapy in the management of pain, nursing techniques in the treatment of pain and pain management of special needs patients. Students also have the opportunity to actively practice in pain clinics in the pharmacological therapies of pain as well as in interventional techniques under specialist guidance. A similar postgraduate program is offered by the Larissa University, called Algology and Palliative care.

«The Greek Chapter of the European Society of Regional Anesthesia and Pain Therapy (ESRA-Hellas) has established a structured six-day intensive hands-on regional anesthesia teaching module held annually since 2009.»

The Greek Chapter of the European Society of Regional Anesthesia and Pain Therapy (ESRA-Hellas) has established a structured six-day intensive hands-on regional anesthesia teaching module held annually since 2009. This Course consists of theoretical didactic lectures on the principles of regional anesthesia, the basics of ultrasound (US) machine operation, image optimization, recognition of sonoanatomy, scanning techniques and practice on manufactured or non-human tissue phantoms (blue phantom gel models and porcine meat) as well as identification of needle insertion points and US scanning on volunteer live models. The Course has been attended by a significant number of Greek Anesthesiologists from all parts of Greece so far, is popular and consistently highly ranked among participants. Very recently, a survey leading to a publication was performed whose aim was two-fold: first to provide an overview about the current practice of regional anesthesia in Greece and secondly to evaluate the effect the aforementioned training Course has on participants’ knowledge and attitude towards regional anesthesia [2]. The main findings of this survey were that anesthesiologists who have attended the regional anesthesia Course are more knowledgeable regarding the performance of peripheral blocks with neurostimulation and/or US guidance as compared to those who have not attended the Course. Attendees are also less likely to practice exclusively general anesthesia in their hospitals, more likely to attempt regional anesthesia techniques and the insertion of peripheral nerve catheters and more likely to consider taking the EDRA exam as opposed to non-attendees. This study also highlighted some interesting findings regarding regional anesthesia pattern of practice in the Greek region. The majority of respondents declared that their technique of choice for lower extremity surgery is a neuraxial block as opposed to a peripheral block. The popularity of central nerve blocks was confirmed in the survey since the majority of anesthesiologists who responded ascertained their very good level of knowledge in central blocks, which did not seem to be affected by the attendance of the Course. Greek anesthesiologists also often use epidural catheters for the provision of postoperative analgesia, whereas this practice is not affected by the attendance or not of the Course either. Also, attendees of the regional anesthesia Workshop ascertained that the Workshop contributed significantly to the acquisition of the theoretical knowledge in all aspects of regional anesthesia, including the basics of US guidance for nerve localization. However, the majority of participants in the Course, by stating that the Course has changed their practice only a little, seem to be reluctant to universally incorporate US use in their everyday routine, admitting that even after the Course, they lack the confidence in broad US application and implementation in their daily practice. It appears therefore that despite the intensive structure of the Greek regional anesthesia Workshop, participants feel that more is needed in terms of quantity of learning so that key competencies taught can safely be extrapolated to the clinical realm and true day-to-day incorporation of regional anesthesia in routine practice can be achieved. Still, it appears that the Course, despite its weaknesses, creates the foundation for the consolidation of basic knowledge in the performance of central and peripheral blocks via US guidance. Moreover, the Course fulfils the target of familiarizing participants with regional anesthesia practice, by creating interest and motivation in the use of regional anesthesia procedures and perhaps enabling long-term retention of skills taught. Similar smaller scale regional anesthesia courses are performed annually nationwide, many of them endorsed by ESRA Hellas.

«It seems that at a national level, future advances in regional anesthesia and pain will be highly dependent on the quality of education both in the pre-graduate and postgraduate level.»

It seems that at a national level, future advances in regional anesthesia and pain will be highly dependent on the quality of education both in the pre-graduate and postgraduate level. Some years ago, the lack of a formal stepwise program incorporated in the curriculum of residency had been emphasized as a significant shortcoming to systematic training in regional anesthesia techniques. In the last couple of years, the situation has changed as relevant administrative authorities have realized the importance of standardized training and formalized teaching programs in many medical specialties including anesthesiology. Training programs have started moving away from apprenticeship models which prevailed in the last several decades and provided inconsistent learning experiences towards competency-based methods of education. Thus, the curriculum of the specialty has been redesigned, amendments have been suggested, deficiencies have been identified and a structured program of specific rotations offering more targeted education in regional anesthesia by incorporating formal regional anesthesia rotations has now been officially integrated into the residency curriculum of Greek anesthesiologists.

Regarding regional anesthesia and pain related subjects, the 60-months spanning, Anesthesiology Specialty curriculum in Greece includes among others: 2 months rotation in anesthesia for gynecological surgery, 4 months rotation in anesthesia and analgesia for obstetrics, 3 months rotation in anesthesia for orthopedic surgery, 1month rotation in anesthesia in ophthalmology and 3 months rotation in pain clinics. During the training period, the residents’ logbook must include at least 100 epidurals, 100 combined spinal-epidurals, 150 spinals and 50 peripheral nerve blockades. Additionally, it must include 100 techniques of acute pain main management (regional analgesia, intravenous analgesia, multimodal, PCA, PCEA etc), 50 cases of monitored anesthesia care and 40 chronic pain cases.

As for pain teaching, the importance of undergraduate pain education cannot be overemphasized since inadequate pain management training is still the norm in European medical schools including those in the Greek region. Attempts are now being rigorously made to introduce a comprehensive curriculum of pain education in the context of various mandatory undergraduate courses in Greek medical schools. Through this process, medical students’ anxiety about encountering patients suffering from chronic pain will be alleviated and they will acquire the clinical skills required to assess and manage pain effectively. Equipped with both knowledge and confidence, they will realize that working with pain patients, although challenging, can be both worthwhile and rewarding.

References

1.                Argyra E, Siafaka I, Moutzouri A, Papadopoulos V, Rekatsina M, Vadalouca A, Theodoraki K. How does an undergraduate pain course influence future physicians’ awareness of chronic pain concepts? A comparative study. Pain Med. 2015 Feb;16(2):301-11. doi: 10.1111/pme.12568.

2.                Theodoraki K, Moka E, Makris A, Stavropoulou E, On Behalf Of Esra Hellas Working Group.  A Survey of Regional Anesthesia Use in Greece and the Impact of a Structured Regional Anesthesia Course on Regional Techniques Knowledge and Practice. J Clin Med. 2021 Oct 20;10(21):4814. doi: 10.3390/jcm10214814.