Scope and Nature of Pain- and Analgesia-Related Content of the United States Medical Licensing Examination (USMLE)

Abstract

Background: "The ongoing opioid crisis lies at the intersection of two substantial public health challenges-reducing the burden of suffering from pain and containing the rising toll of the harms that can result from the use of opioid medications" [1]. Improved pain education for health care providers is an essential component of the multidimensional response to both still-unmet challenges [2,3]. Despite the importance of licensing examinations in assuring competency in health care providers, there has been no prior appraisal of pain and related content within the United States Medical Licensing Examination (USMLE).

Methods: An expert panel developed a novel methodology for characterizing USMLE questions based on pain core competencies and topical and public health relevance.

Results: Under secure conditions, raters used this methodology to score 1,506 questions, with 28.7% (432) identified as including the word "pain." Of these, 232 questions (15.4% of the 1,506 USMLE questions reviewed) were assessed as being fully or partially related to pain, rather than just mentioning pain but not testing knowledge of its mechanisms and their implications for treatment. The large majority of questions related to pain (88%) focused on assessment rather than safe and effective pain management, or the context of pain.

Conclusions: This emphasis on assessment misses other important aspects of safe and effective pain management, including those specific to opioid safety. Our findings inform ways to improve the long-term education of our medical and other graduates, thereby improving the health care of the populations they serve.

Figure 1

Flow diagram of USMLE question review process. Depicts the reviewed questions from all provided, initially reviewed, and those that were further reviewed for full or partial pain content.

Figure 2

Pain competency domains within the USMLE. Findings represented in questions fully or partially related to pain (x/232) by pain competency domains (Table 1) [19].

Figure 3

Pain competencies within the USMLE. Findings represented in questions fully or partially related to pain (x/232) by individual pain core competencies (also see Table 1) [19].

Figure 4

Major topics. Major topics identified by the Education Committee of the American Academy of Pain Medicine, represented in questions fully or partially related to pain (Supplementary Data) [21].

Figure 5

Key public health issues. Key public health issues identified by expert reviewers participating in the present study, and their representation in questions fully or partially related to pain (x/232).