Instructor Guide

Open Instructor

The Patient with Chronic Pain



A PGY-2 resident will be able to evaluate and develop a treatment plan for a geriatric patient with several co-morbidities presenting with low back pain.

ACGME Core Competencies:

Patient Care/Interpersonal Communication Skills

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

Patient Care/Medical Knowledge

  • List red flag signs, symptoms, and findings following a standardized patient encounter on a geriatric patient
  • Write out a plan to work up back pain after seeing a standardized patient who is older with co-morbidities
  • Engage in a group discussion about medications and therapies to be used and avoided in geriatric patients with chronic back pain, as well as in patients with such co-morbidities as liver or kidney failure

Medical Knowledge

  • Generate a differential diagnosis specific to an older or medically complicated 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 “Common Pain Diagnoses: Fibromyalgia,” and “Common Pain Diagnoses: Neuropathic Pain.” They are free to review “Overview and Assessment,” “Treatment Goals,” “Legal and Regulatory Aspects,” and “Virginia” if they feel they need it.

Instructor Script and Notes

  1. Introduce Pain Management Specialist co-teacher. Describe a real-life challenging case trying to assess and treat an older patient with co-morbidities and chronic low back pain.
  2. Ask residents about their struggles and successes managing chronic pain in similarly challenging patients. Elicit questions.
  3. PowerPoint lecture, “How to Prescribe Pain Medications without Killing People” (PainMeds.ppt), followed by 10 minute break.
  4. Demonstrate the LBP physical exam (can refer to PGY1 Word document outline), and have residents practice on one another.
  5. Go over how the differential for low back pain changes with older patients (see Word document handout for PGY2). Pass out handout “How to Prescribe Pain Medicines without Killing People” (list of medications indicated/contraindicated with geriatric, liver or kidney disease patients – see handout 2).
  6. Group discussion: what questions were left unanswered? What other questions have come up? What resources are available if questions arise in the future (people, online references such as the Johns Hopkins Opioid Calculator, VCU Online Modules)?