Instructor Guide

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The Patient with Chronic Pain


A PGY-1 resident will be able to evaluate and develop a treatment plan for a patient with no major co-morbidities presenting with low back pain.

ACGME Core Competencies:

Patient Care/Interpersonal Communication Skills

  • Demonstrate a comprehensive history and physical examination on an uncomplicated standardized patient with low back pain

Patient Care / Medical Knowledge

  • List red flag signs, symptoms, and findings following a standardized patient encounter
  • Write out a plan to work up back pain in a standardized patient
  • Engage in a group discussion about medications and therapies to be used and avoided in patients with chronic back pain, as well as the principles of the WHO Analgesic Ladder

Medical Knowledge

  • Generate a differential diagnosis specific to a patient presenting with low back pain


Session Guide


Time Needed: 3-4 hours total. One to one-and-one-half hours for didactic lecture on low back pain, one half-hour to review and practice the physical exam, and one hour for discussion.

Equipment Needed:

  • Computer with projector if PowerPoint is to be used in the didactic lecture
  • Room with several chairs and tables which can support residents as they practice the physical exam
  • Examination rooms for the standardized patients during the separate standardized patient interaction (generally scheduled the day after this session is taught)

Suggested online modules:, modules “Overview and Assessment,” “Treatment Goals,” “Legal and Regulatory Aspects,” and “Virginia.”

Instructor Script and Notes

Part 1 – 90 minutes

  1. Introduction to Pain Management
    1. Introduce Specialist co-teacher
    2. Struggles with treating chronic pain
      1. Describe a personally difficult experience trying to treat a patient with chronic pain.
      2. Ask residents about their struggles and successes managing chronic pain. Elicit questions.
    3. PowerPoint presentation and lecture, “Issues in Pain Management: The Patient with Chronic Low Back Pain” by Robin Hamill-Ruth (LBPorthoGR.ppt)


Part 2 – 30 minutes

  1. Physical Exam
    1. Demonstrate the LBP physical exam (Word document outline); and
    2. Residents practice on one another.

Part 3 – 60 minutes

  1. Group Discussion
    1. What questions were left unanswered?
    2. What other questions have come up? What resources are available if questions arise in the future (specific faculty, online references such as the Johns Hopkins Opioid Calculator, VCU Online Modules)?
    3. Alternate Activity/Conversation Starter: Pain Management Jeopardy. This activity can be used in several situations: either as a conversation starter if the students are shy or for diagnostic purposes to gauge the knowledge base of the students. The activity consists of one round of Jeopardy with one Final Jeopardy question. It takes approximately 30 minutes to complete, longer if you use the questions as jumping-off points for discussion.