Pain Medicine

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Physical exam observed

1. ●no
2. ●yes

Presentation

1. ●abdominal pain
2. ●CRPS
3. ●fibromyalgia
4. ●headache
5. ●low back pain
6. ●neck pain
7. ●other

Medical Expert

• □ME 2.2 Gather a relevant clinical history
• □ME 2.2 Gather information about the patient’s social circumstances and supports
• □ME 2.2 Perform a physical exam relevant to the presentation
• □ME 2.2 Organize clinical information for clear and succinct presentation to a supervisor

Communicator

• □COM 1.2 Optimize the physical environment for patient comfort, dignity, and privacy
• □COM 1.1 Establish rapport with the patient and family
• □COM 2.1 Use patient-centred interviewing skills and inclusive, person-first language
• □COM 2.3 Seek and synthesize relevant information from other sources (e.g., family, medical record)

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Presentation

1. ●abdominal pain
2. ●CRPS
3. ●fibromyalgia
4. ●headache
5. ●low back pain
6. ●neck pain
7. ●other

Chronic pain

1. ●no
2. ●yes

Medical Expert

• □ME 2.2 Synthesize and interpret information from the clinical assessment
• □ME 2.2 Develop a differential diagnosis relevant to the patient’s presentation
• □ME 2.2 Select and/or interpret investigations
• □ME 4.1 Determine the need and timing of referral to another health care professional
• □ME 2.4 Propose a management plan, which may include non-pharmacologic, pharmacologic and/or interventional strategies

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case mix

1. ●acute cardiovascular event
2. ●anaphylaxis
3. ●cardiorespiratory arrest
4. ●local anesthetic toxicity
5. ●low back pain red flags
6. ●motor block after procedure
7. ●opioid overdose
8. ●opioid withdrawal
9. ●psychiatric emergency
10. ●vasovagal episode

Settings

1. ●pain clinic
2. ●simulation
3. ●other

Medical Expert

• □ME 2.1 Determine the acuity of the issue and the priorities for patient care
• □ME 2.2 Focus the clinical assessment, performing it in a time-effective manner without excluding key elements
• □ME 2.2 Develop a differential diagnosis relevant to the patient’s presentation
• □ME 2.2 Select and/or interpret investigations
• □ME 2.4 Develop and implement a plan for initial management
• □ME 1.4 Recognize urgent problems that may need the involvement of more experienced colleagues and seek their assistance

Collaborator

• □COL 3.1 Identify patients requiring handover to other physicians or health care professionals
• □COL 1.3 Communicate effectively with other health care professionals involved in the patient’s care

Leader

• □L 2.1 Apply knowledge of local resources

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case mix

1. ●new consultation
2. ●follow-up

Medical Expert

• □ME 2.2 Synthesize and interpret information from the clinical assessment

Communicator

• □COM 5.1 Document all relevant findings and investigations
• □COM 5.1 Provide a clear plan for ongoing management
• □COM 5.1 Convey clinical reasoning and the rationale for decisions
• □COM 5.1 Organize information in appropriate sections
• □COM 5.1 Complete clinical documentation in a timely manner

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observation

1. ●direct
2. ●case review

Presentation

1. ●abdominal pain
2. ●CRPS
3. ●fibromyalgia
4. ●headache
5. ●low back pain
6. ●neck pain

Complexity

1. ●simple
2. ●moderate
3. ●high

Medical Expert

• □ME 1.4 Apply a biopsychosocial approach to the clinical assessment
• □ME 2.2 Elicit a history and perform a physical exam
• □ME 2.2 Select, administer, and interpret validated assessment tools
• □ME 2.2 Select and/or interpret investigations
• □ME 2.2 Develop a differential diagnosis and identify the most likely diagnosis
• □ME 2.4 Propose a plan which may include further investigation and/or non- pharmacologic, pharmacologic and/or interventional strategies
• □ME 4.1 Determine the need and timing of referral to another health care professional

Communicator

• □COM 2.3 Seek and synthesize relevant information from other sources (e.g., family, medical record)
• □COM 4.3 Engage the patient in goal setting and shared decision-making regarding management

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observation

1. ●direct
2. ●case review

Presentation

1. ●abdominal pain
2. ●CRPS
3. ●fibromyalgia
4. ●headache
5. ●low back pain
6. ●neck pain

Complexity

1. ●simple
2. ●moderate
3. ●high

Medical Expert

• □ME 2.2 Elicit an interval history and perform a focused physical exam
• □ME 2.2 Interpret the results of investigations performed to investigate and/or monitor the condition and/or treatment
• □ME 2.2 Adjust the differential diagnosis as new information is obtained
• □ME 2.2 Select, administer, and interpret validated assessment tools
• □ME 2.2 Assess response to treatment as well as adverse effects, changes in condition, and/or goals of care
• □ME 2.4 Adjust the existing management plan, which may include further investigation and/or non-pharmacologic, pharmacologic, and/or interventional strategies
• □ME 4.1 Determine the frequency and timing of future investigations and visits

Communicator

• □COM 4.2 Facilitate self-care and chronic disease management

Collaborator

• □COL 1.3 Communicate effectively with other health care professionals involved in the patient’s care

Health Advocate

• □HA 1.2 Work with the patient to increase their understanding of their condition and health care needs

Scholar

• □S 3.4 Integrate best evidence and clinical expertise

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Presentation

1. ●acute post-surgical
2. ●cancer pain
3. ●headache
4. ●neuropathic
5. ●nociceptive (somatic or visceral)
6. ●nociplastic (fibro)
7. ●simple MSK

Medical Expert

• □ME 1.3 Apply knowledge of guidelines for pharmacologic management of pain
• □ME 2.2 Perform a risk assessment if opioids or cannabinoids are being considered
• □ME 2.2 Identify significant drug interactions
• □ME 2.4 Develop a pharmacologic management plan
• □ME 2.4 Select and prescribe the appropriate dose and regimen
• □ME 2.4 Select and prescribe appropriate monitoring strategies

Communicator

• □COM 5.1 Document the encounter to convey clinical reasoning and the rationale for decisions

Professional

• □P 3.1 Adhere to regulations governing the prescribing of controlled substances

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Patient demographic

1. ●child
2. ●adolescent
3. ●adult

Communicator

• □COM 1.1 Establish rapport with the patient and family
• □COM 3.1 Provide accurate information about medical condition and management plan
• □COM 3.1 Use plain language and avoid medical jargon
• □COM 1.5 Recognize when strong emotions (such as anger, fear, anxiety, or sadness) are affecting an interaction and respond appropriately
• □COM 4.3 Answer questions from the patient and/or family
• □COM 3.1 Verify and validate the patient and/or family’s understanding
• □COM 4.3 Use communication skills and strategies that help the patient and/or family make an informed decision
• □COM 4.1 Communicate in a manner that is respectful, non-judgmental, and culturally aware

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 3.2 Explain the risks, including common and rare but catastrophic risks, benefits, rationale, and alternatives for a proposed procedure

Communicator

• □COM 4.3 Answer questions from the patient and/or family
• □COM 3.1 Verify and validate the patient's and/or family's understanding
• □COM 4.3 Use communication skills and strategies that help the patient and/or family make an informed decision
• □COM 5.1 Complete required documentation of the consent discussion

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Procedure

1. ●MSK (peripheral joint, trigger point)
2. ●peripheral nerve
3. ●SI joint
4. ●lumbar facet/medial branch block

Medical Expert

• □ME 2.2 Assess the patient’s suitability to proceed with the procedure, reviewing relevant investigations and medical history
• □ME 3.4 Demonstrate aseptic technique and maintain universal precautions
• □ME 3.4 Demonstrate effective procedure preparation, including gathering required equipment and positioning the patient
• □ME 3.4 Apply knowledge of anatomy, key landmarks, and the procedure
• □ME 3.4 Perform the procedure in a skilful and safe manner
• □ME 3.4 Select and provide sedation and local analgesia, as relevant
• □ME 3.4 Monitor patient comfort and safety, and adjust the procedure as needed
• □ME 3.4 Recognize and manage complications
• □ME 3.4 Establish and implement a plan for post-procedure care

Communicator

• □COM 5.1 Document the procedure and outcome

Collaborator

• □COL 1.2 Communicate effectively with patient and/or assistant(s) during the procedure

Professional

• □P 1.1 Work within personal limits, asking for assistance as needed

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Settings

1. ●pain clinic
2. ●other

Medical Expert

• □ME 4.1 Determine the need for consultation with another member of the pain management team for patient assessment and/or management

Communicator

• □COM 3.1 Provide the patient with information about the role of other members of the interprofessional team in their care

Collaborator

• □COL 1.2 Demonstrate an understanding of the scope and expertise of other health care professionals within the pain management team
• □COL 1.2 Incorporate the perspective of other members of the pain management team in the development and/or implementation of a management plan

Professional

• □P 1.1 Behave in a professional manner

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observation

1. ●direct
2. ●case review

Demographic

1. ●child
2. ●adolescent/young adult
3. ●adult
4. ●older adult

Diagnosis

1. ●CRPS
2. ●cancer pain
3. ●persistent post-operative pain
4. ●primary headache disorder
5. ●pregnancy-related pain or pain during pregnancy
6. ●pain caused by other medical condition

Medical Expert

• □ME 2.2 Perform a clinical assessment that addresses all relevant issues
• □ME 2.2 Select, administer, and interpret validated assessment tools
• □ME 2.2 Adapt the assessment to the patient’s age, developmental stage, and cognition, as relevant
• □ME 2.2 Select investigations based on a differential diagnosis
• □ME 2.2 Interpret investigations to correlate the findings with the patient’s symptoms
• □ME 2.4 Develop a treatment plan informed by biopsychosocial factors
• □ME 4.1 Determine the need and timing of referral to another health care professional

Communicator

• □COM 4.3 Engage the patient in goal setting and shared decision-making regarding management

Collaborator

• □COL 1.2 Incorporate the perspective of other members of the pain management team in the development and/or implementation of a management plan
• □COL 1.2 Work effectively with other health care professionals, including other physicians

Scholar

• □S 3.4 Integrate best evidence and clinical expertise

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observation

1. ●direct
2. ●case review

Substance

1. ●alcohol
2. ●benzodiazepines
3. ●illicit/street drugs
4. ●opioids
5. ●other

Medical Expert

• □ME 2.2 Gather information about previous substance use or misuse
• □ME 2.2 Perform a risk assessment using validated screening questionnaires and investigations
• □ME 2.2 Recognize when a patient may need addiction consultation prior to or during opioid therapy
• □ME 4.1 Determine the need and timing of referral to another health care professional
• □ME 4.1 Develop plans for monitoring and follow-up

Communicator

• □COM 1.1 Demonstrate empathy, respect, and compassion
• □COM 2.3 Gather information from collateral sources (e.g., family, pharmacy)
• □COM 4.3 Engage the patient in goal setting and shared decision-making regarding management
• □COM 5.1 Document clinical information, including noncompliance and aberrant behaviours

Scholar

• □S 3.4 Integrate best evidence and clinical expertise

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Observation

1. ●direct
2. ●case review

Presentations

1. ●anxiety disorder
2. ●catastrophizing/fear avoidance
3. ●mood disorder (depression)
4. ●personality disorder
5. ●somatic symptom disorder
6. ●suicidal ideation

Settings

1. ●clinical
2. ●simulation

Medical Expert

• □ME 1.4 Perform a clinical assessment that identifies all relevant psychosocial issues
• □ME 2.2 Identify the bidirectional relationship of pain and psychological well- being and its impact on quality of life
• □ME 2.2 Select and administer validated screening questionnaires for pain- related psychological comorbidities
• □ME 2.2 Assess risk of harm to self or others
• □ME 4.1 Determine the need and timing of referral to a mental health professional

Communicator

• □COM 2.2 Gather information about what the patient is experiencing
• □COM 2.2 Explore and respond to requests for Medical Assistance in Dying (MAID)
• □COM 4.1 Communicate in a manner that is respectful, non-judgmental, and culturally aware

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Comorbidity

1. ●acute-on-chronic pain
2. ●cognitive or neurological impairment
3. ●hepatic impairment
4. ●perioperative
5. ●polypharmacy
6. ●pregnancy
7. ●psychiatric disorder
8. ●renal impairment
9. ●sleep disorder
10. ●other (write in)

Medical Expert

• □ME 1.3 Apply knowledge of guidelines for pharmacologic management of pain
• □ME 2.2 Synthesize information from the clinical assessment, including concurrent conditions and treatments
• □ME 2.2 Perform a risk assessment if opioids or cannabinoids are being considered
• □ME 2.2 Identify significant drug interactions
• □ME 2.4 Propose a management plan, which may include non-pharmacologic, pharmacologic and/or interventional strategies
• □ME 3.2 Provide information to the patient about probable benefits, risks and adverse effects
• □ME 2.4 Select and/or adjust dosage based on factors such as response, tolerability, age, and pharmacokinetic considerations
• □ME 2.4 Select and implement a monitoring strategy, including laboratory monitoring as relevant

Communicator

• □COM 5.1 Document the encounter to convey clinical reasoning and the rationale for decisions

Scholar

• □S 3.4 Integrate best evidence and clinical expertise

Professional

• □P 3.1 Adhere to regulations governing the prescribing of controlled substances

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Procedure type

1. ●ablation/destructive
2. ●epidural
3. ●sympathetic chain

Patient complexity

1. ●low
2. ●moderate
3. ●high

Medical Expert

• □ME 2.2 Assess the patient’s suitability to proceed with the procedure, reviewing relevant investigations and medical history
• □ME 3.4 Demonstrate aseptic technique and maintain universal precautions
• □ME 3.4 Demonstrate effective procedure preparation, including gathering required equipment, and positioning the patient
• □ME 3.4 Apply knowledge of anatomy, key landmarks, and the procedure
• □ME 3.4 Select and provide sedation and local analgesia, as relevant
• □ME 3.4 Use imaging guidance effectively and safely
• □ME 3.4 Perform the procedure in a skilful and safe manner
• □ME 3.4 Monitor patient comfort and safety, and adjust the procedure as needed
• □ME 3.4 Recognize and manage complications
• □ME 3.4 Establish and implement a plan for post-procedure care

Communicator

• □COM 5.1 Document the procedure and outcome

Collaborator

• □COL 1.2 Communicate effectively with patient and/or assistant(s) during the procedure

Professional

• □P 1.1 Work within personal limits, asking for assistance as needed

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Indication for referral

1. ●intrathecal drug delivery device
2. ●neurolytic procedure
3. ●neuromodulation
4. ●peripheral nerve stimulation
5. ●spinal cord stimulator
6. ●vertebroplasty
7. ●other

Medical Expert

• □ME 2.2 Integrate information from the clinical assessment and investigations to determine the patient's candidacy for advanced interventional treatment
• □ME 3.2 Describe a proposed therapy to the patient, including the rationale, possible adverse events, expected outcomes and alternative treatments
• □ME 4.1 Formulate a clear and complete request for consultation
• □ME 4.1 Establish a plan for follow-up care

Communicator

• □COM 3.1 Convey information about the treatment options clearly and accurately
• □COM 4.3 Use communication skills and strategies that help the patient and/or family make an informed decision

Collaborator

• □COL 3.2 Summarize and document patient issues for the accepting physician, providing rationale for key decisions and recommendations for management

Leader

• □L 2.1 Apply knowledge of local resources

Health Advocate

• □HA 1.1 Facilitate timely patient access to services and resources

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Includes input from

1. ●nurse
2. ●occupational therapist
3. ●pharmacist
4. ●other physician(s)
5. ●psychologist
6. ●physiotherapist
7. ●other

Medical Expert

• □ME 4.1 Coordinate treatment and follow-up across care settings

Collaborator

• □COL 1.2 Demonstrate an understanding of the scope and expertise of other health care professionals within the pain management team
• □COL 1.3 Communicate effectively with other health care professionals involved in the patient’s care
• □COL 1.1 Respond appropriately to input from other health care professionals

Health Advocate

• □HA 1.1 Advocate for the patient’s needs and concerns
• □HA 1.1 Facilitate timely patient access to services and resources

Professional

• □P 1.1 Respond punctually to requests from other health care professionals
• □P 1.1 Behave in a professional manner

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.4 Contribute clinical expertise to the discussion, as required

Communicator

• □COM 1.4 Manage one’s own non-verbal communication

Collaborator

• □COL 1.3 Demonstrate respect for the opinions of other meeting participants

Leader

• □L 3.1 Facilitate the meeting, attending to flow, organization, and time management
• □L 3.1 Ensure engagement and participation of attendees
• □L 3.1 Summarize and clarify key points of the meeting

Health Advocate

• □HA 1.1 Advocate for the patient’s needs and concerns

Professional

• □P 1.1 Intervene when behaviours towards other attendees undermine a respectful environment

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Scholar

• □S 2.4 Identify the learning needs and desired learning outcomes of others
• □S 2.4 Develop learning objectives for a teaching activity, adapting to the audience and setting
• □S 3.3 Critically evaluate the integrity, reliability, and applicability of health- related research and literature
• □S 3.4 Integrate best evidence and clinical expertise
• □S 2.4 Present the information in an organized manner
• □S 2.4 Use audiovisual aids and/or virtual platforms effectively
• □S 2.4 Provide adequate time for questions and discussion
• □S 1.2 Seek out feedback to improve future scholarly teaching

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Medical Expert

• □ME 1.1 Demonstrate responsibility and accountability for decisions regarding patient care, acting in the role of most responsible physician
• □ME 1.4 Triage consultation requests based on clinical acuity
• □ME 2.4 Establish management plans that consider all relevant aspects of the patient’s care

Communicator

• □COM 5.1 Document clinical encounters in an accurate, complete, and timely manner

Collaborator

• □COL 1.2 Work effectively with outpatient clinic staff

Leader

• □L 4.2 Manage bookings to optimize clinic scheduling
• □L 4.1 Manage time effectively to maintain clinic flow
• □L 4.1 Review and act on results of investigations in a timely manner

Scholar

• □S 3.4 Integrate best evidence and clinical expertise

Professional

• □P 1.1 Respond punctually to requests from patients or other health care professionals
• □P 1.1 Make arrangements for coverage by another physician when absent or unavailable

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Case mix

1. ●return to primary care provider
2. ●return to referring physician
3. ●transfer to another physician

Medical Expert

• □ME 2.4 Determine the setting of care appropriate for the patient’s health needs

Communicator

• □COM 3.1 Provide information to the patient regarding the plan for transfer

Collaborator

• □COL 3.2 Incorporate information and the perspectives of other members of the health care team when developing a plan for transfer of care
• □COL 3.2 Organize the handover of care to the most appropriate physician or health care professional
• □COL 3.2 Summarize all relevant issues of the clinical case in a transfer summary
• □COL 3.2 Provide guidance for management of ongoing issues, anticipated changes in the clinical course, and/or indications for referral back to the pain management team

Case description

Feedback provided

Next steps

Entrustment (how much supervision did this activity need?)

1. ●I had to do
2. ●I had to talk them through
3. ●I needed to prompt
4. ●I needed to be there just in case
5. ●I didn’t need to be there

Trainee

1. ●medical student
2. ●junior resident

Setting

1. ●clinical care
2. ●procedure/intervention
3. ●other

Scholar

• □S 2.2 Create a positive learning environment
• □S 2.4 Be available and accessible to junior learners, including responding to questions
• □S 2.3 Balance clinical supervision and responsibility based on junior learner level of training and background, ensuring the safety of patients and learners
• □S 2.4 Provide clinical teaching and/or other informal learning activities
• □S 2.5 Provide specific suggestions for improvement of performance

Professional

• □P 1.1 Complete learner assessments in a timely fashion
• □P 1.1 Respond appropriately when behaviours toward colleagues and/or learners undermine a respectful environment

Case description

Feedback provided

Next steps