An APPEAL for better pain education: results from a recent study

14 Aug 2015  |  Print

An APPEAL for better pain education: results from a recent study

“When junior doctors are qualifying, they just don’t understand the basics of pain control,” so said a lecturer from a European medical school participating in the recently completed APPEAL study.

He is not alone in this belief.

Indeed, there is a substantial body of evidence to suggest that the pain education provided by many undergraduate courses is inadequate preparation for clinical practice.[1–4] This represents a major concern, given that chronic pain is both common and often poorly managed.[5]

The APPEAL (Advancing the Provision of Pain Education And Learning) study was initiated to better understand the scale of the problem. It focused on 15 countries in Europe, and examined undergraduate pain education across the continent.[6,7]

Simple but effective methodology

Under the stewardship of a European Pain Federation expert taskforce, APPEAL was conducted in two phases.[6,7]

Phase 1 was a web-based survey of pain education, based on the assessment of publicly available curricula from 242 undergraduate medical schools. It assessed: how pain teaching is provided; time or credits spent focusing on pain; the teaching methods employed; and the assessment methods used.[6]

Phase 2 was an interview-based analysis involving both students and educators (deans and lecturers) to understand their perspectives on: prioritization and perceptions regarding pain education; teaching strategies employed; and issues regarding curriculum design and review.[7]

The study was conducted between April and September 2013, and included a diverse range of European countries:Belgium, Bulgaria, Denmark, France, Germany, Ireland, Italy, Netherlands, Poland, Portugal, Romania, Spain, Sweden, Switzerland and the United Kingdom.[6]

Results: current teaching programs are inadequate

Some of the most significant findings from the APPEAL study are as follows:[6]

  • 82% of medical schools have no dedicated and compulsory pain teaching.
  • Even where there is dedicated and compulsory pain teaching, medical students receive on average only 12 hours of undergraduate training on this subject (equivalent to just 0.2% of their entire medical teaching).
  • 69% of medical schools across Europe have no dedicated pain teaching at all.
  • The provision of pain education is variable and inconsistent. Nearly two‐thirds of all undergraduate medical schools (62%) offer pain teaching only within other subjects – and these subjects vary across schools.
  • Less than half (48%) of all medical schools employ practical methods in the teaching of pain, and only a quarter (26%) use placement‐based teaching.

Importantly, both students and educators surveyed in APPEAL felt that pain education had only low-to-medium priority within current undergraduate training programs.[7] Furthermore, there was broad agreement that pain education is not sufficiently thorough – with insufficient time given to the subject, and a focus on theory at the expense of practical training and patient contact.

One student described the current situation as follows:[7]

“Each professor thinks that another one will deal with this topic [pain management], and in the end, nobody does anything about it.”

Students said that they would welcome a dedicated pain module within their training, and those that had attended such a module rated the experience very positively. Students also felt that the teaching of pain should be consistent and systematic across compulsory modules, with greater patient contact and practical experience.[7]

Key recommendations

Based on these results, the expert taskforce overseeing the APPEAL study has called on medical schools, pain specialists and policy makers to ensure that undergraduate pain education is fit for purpose.[6]

Three specific recommendations have been put forward:[6]

  • The establishment of a framework for pain education, drawing on the European Pain Federation ‘Core Curriculum in Pain Management’, to ensure consistency in pain teaching within undergraduate medical curricula and between medical schools.
  • The introduction of compulsory pain teaching for all undergraduate medical students, to enable them to acquire a defined minimum level of competency in pain management.
  • Improved documentation of pain teaching within undergraduate medical curricula, with clearly stated teaching content and defined student competencies in pain.

The Asian context

APPEAL was a European study, but can its conclusions also apply in Asia? Recently published data suggest that they perhaps can apply.

In a study conducted across 10 Asian countries and territories – China, Hong Kong, Indonesia, Republic of Korea, Malaysia, Philippines, Singapore, Taiwan, Thailand and Vietnam – one third of physicians managing cancer pain felt that medical school training on opioid use was inadequate.[8] Furthermore, over half of those surveyed had received ≤10 hours of continuing medical education in the past year.[8]

Hence, just as in Europe, there remains a need for improved pain education in Asia and the recommendations from the APPEAL expert taskforce could provide a valid template. Policymakers, pain specialists and other stakeholders within the region can play a key role in moving this agenda forward.


  1. 1. Briggs EV, Carr EC, Whittaker MS. Survey of undergraduate pain curricula for healthcare professionals in the United Kingdom. Eur J Pain 2011;15:789-795.
  2. 2. Tauben DJ, Loeser JD. Pain education at the University of Washington School of Medicine. J Pain 2013;14:431-437.
  3. 3. Watt-Watson J, McGillion M, Hunter J, et al. A survey of prelicensure pain curricula in health science faculties in Canadian universities. Pain Res Manag 2009;14:439-444.
  4. 4. Mezei L, Murinson BB, Johns Hopkins Pain Curriculum Development Team. Pain education in North American medical schools. J Pain 2011;12:1199-1208.
  5. 5. Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: Prevalence, impact on daily life and treatment. Eur J Pain 2006;10:287-333.
  6. 6. The APPEAL (Advancing the Provision of Pain Education And Learning) study backgrounder. October 2013. Available at: Accessed 14 May 2015.
  7. 7. Kopf A, Battelli D, Briggs E, et al. Qualitative assessment of pain education in undergraduate medical schools across Europe: the Advancing the Provision of Pain Education And Learning (APPEAL) study phase II. Poster presented at: International Association for the Study of Pain 15th World Congress on Pain. 6-11 October 2014. Buenos Aires, Argentina.
  8. 8. ACHEON Working Group. Current practices in cancer pain management in Asia: a survey of patients and physicians across 10 countries. Cancer Med 2015. [Epub ahead of print].