Workshop Guide

Open Workshop




Open Instructor

Challenging Patients Curriculum Instructor Guide^

The Patient with Chronic Pain



A PGY-3 resident will be able to evaluate and develop a treatment plan for a patient with a history of addiction or medication misuse 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
  • Discuss a plan to work up and treat back pain in a standardized patient with low back pain at high risk for substance abuse which incorporates regular monitoring and screening
  • 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

Systems-Based Practice / Medical Knowledge

  • Develop a treatment plan which incorporates regular monitoring/screening for substance abuse and diversion
  •  Engage in a group discussion about the epidemiology of substance abuse and diversion

Professionalism / Interpersonal Communication Skills

  • Watch a video, engage in a group discussion and/or role play relating to boundary setting techniques and troubleshooting


Session Guide^


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

Equipment Needed:

  • Computer with projector as well as DVD player
  • Room with several chairs and tables which can support residents as they practice the physical exam
  • DVD by VideoArts: “Straight Talk.”
  • Examination rooms for the standardized patients during the separate standardized patient interaction (generally scheduled the day after this session is taught)

Suggested online modules:, module “Identifying and Meeting Challenges,” as well as any other modules they would like to review.

Instructor Script and Notes

  1. Introduce Pain Management Specialist co-teacher. Describe a challenging case experience trying to treat a patient with chronic pain at high risk for substance abuse.
  2. Ask residents about their struggles and successes managing chronic pain with similar patients. Elicit questions.
  3. Demonstrate the LBP physical exam (PGY1 handout), and have residents practice on one another.
  4. 28 minute DVD, “Straight Talk.” If there is time and interest, role play patient scenarios the residents come up with.
  5. 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)?
  6. Alternate Activity/Conversation Starter: Defense against the Dark Arts. This activity can be useful if students wish to explore the difficult interpersonal interactions that can make treating chronic pain uncomfortable for the provider. It takes approximately 30 minutes to complete.



Open Handout

Low Back Pain Physical Exam^




  • Spine
  • Leg length discrepancy/pelvic tilt
  • Scoliosis
  • Postural dysfunction
  • Muscle asymmetry
  • Skin lesions, incisions


  • Velocity, symmetry
  • Heel and toe walking


  • Romberg

Range of Motion

  • Flexion (cephalad to caudal progression reversed at the L spine? Disc pain?)
  • Extension (facet pain?)
  • Rotation
  • Lateral flexion
  • Facet loading maneuver


  • Spinous processes, interspinous ligaments
  • Lumbar paraspinal
  • Buttock
  • Other areas

Waddell Signs – Pain caused by:

  • Rotating hips WITH spine
  • Light pressure on the head
  • Gentle effleurage of superficial tissues
  • Non-physiologic pain/sensory patterns (e.g. non-dermatomal leg pain, sensory deficits from waist down)


Extremity Strength

  • Flexion of thigh at the hip against resistance (iliopsoas – L1, 2, 3)
  • Extension of leg at the knee against resistance (quadriceps – L2, 3, 4)
  • Heel walking (tibialis anterior – L4)
  • Dorsiflexion of great toes (extensor hallucis longus – L5)
  • Plantar flexion


  • Patellar
  • Achilles
  • Babinski

Sensory Exam

  • Light touch
  • Sharp stimulus (toothpick)
  • Consider temperature (ice) if exam is difficult to evaluate
  • Straight Leg Raise (Waddell’s if different seated vs. supine)


Straight Leg Raise (pain at 30-60 degrees is positive – L5, S1)

  • Ipsilateral
  • Contralateral

FABER Test (sacroiliac dysfunction)

Gaenslen’s (SI dysfunction)

Decubitus Position

  • Palpation of trochanteric bursa, gluteal muscles
  • Passive external rotation of the hip
  • External rotation of hip against resistance, repeat while palpating piriformis


Femoral Stretch (L2, 3, 4)

Watch for fluidity of exam, ease of changing position, which leg used to get up on table, etc.  Look for consistency (inconsistency) between complaints, studies and behaviors.


Defense against the Dark Arts^


Real Life Weekend Phonecall: Catherine vs A.V.
Catherine: This is Dr. Casey from Family Medicine, how can I help you?


AV: Yes, this is A.V.  I’m having terrible, throbbing back pain.


Catherine:  I’m sorry to hear that.  Tell me about it.

AV: Well, I’ve had it for several years, but I go to the emergency department and no one will help me.  They told me I needed to get a regular doctor.  I went to Family Medicine and saw someone, but she didn’t help me either.


Catherine: What did she do for you?


AV: She asked some questions and examined my body.


Catherine: And that’s it?


AV: Yes.


Catherine: Did she send you to any specialists?  A pain management doctor?  A spine doctor?


AV: Yes, and they were supposed to give me a shot, but I’m allergic to iodine, so it didn’t work out.


Catherine: And do they know where your pain is coming from?


AV: Yes, I have several discs that are bulging.


Catherine: And has anything helped with your pain?


AV: They gave me Vicodin in the ER once, but that didn’t help much.  Percocet helped.


Catherine: Hmmm.  The weekend doctors on call aren’t allowed to give potentially addictive medicines out.  Has anything else helped?  What are you taking?


AV: I’m taking Tylenol.


Catherine: How much?


AV: 1 gram every 4 hours.


Catherine: Hmmm, that’s max dose.  What about ibuprofen or naprosyn?


AV: No, I have stomach problems, I can’t take those.


Catherine: (sympathetically) That’s tough.


AV: (frustrated now) So you’re saying you can’t help me either?


Catherine: What I would suggest would be to call your doctor first thing Monday and leave a message that you’re still in pain.  She’s examined you and knows your history.  She can make a decision about what the next step should be or what to prescribe.  Is there anything else I can do for you – any other meds that have helped with your pain?


AV: So you’re not helping me at all.  Let me take down your name.  I’m keeping track of all this.  I’m very upset that no one can help me.


Catherine: My name is Dr. Catherine Casey.  And I’m sorry that I wasn’t able to help you today.


AV: OK.  Bye.


Notes on case: Tried pulling up PMP from home.  No matches with that patient’s name or birthdate.


  • What tactics did the patient use to try to obtain narcotics in this case?
    • Guilt
    • I’m the exception because…(stomach problems, contrast allergy)
    • Threats (“what’s your name?  I’m keeping track…”)
    • You are not a good doctor because…(“you’re not helping me…”)
    • You are the one person who can help me…(seen by all these other unhelpful doctors…)
    • False name, date of birth
  • What tactics did Catherine use in talking to the patient?
  • How do they know how to turn our screws?
    • Robin Hamill-Ruth: “Family Medicine doctors tend to be really nice people.”
    • Big parts of our identity
      • Helping others
      • Not disappointing people
      • Being an A+ doctor
      • Following rules and not getting in trouble
      • Doing what we’re told and AVOIDING CONFLICT
    • Often, we’re also rushed for time.  Patients know this.  Patients trying to manipulate you may:
      • Schedule the LAST appointment of the day with the LEAST experienced provider
      • Try to monopolize your time to the extent that writing a script will be the easiest way out of the interaction.

Who are “narcotics seekers?”

  • People with real pain and/or
  • The real disease of addiction and/or
  • People who are diverting medications for money, either for themselves or for others.

How do you tell the difference between them?  Your best tools are:

  • A thorough history and physical
  • A reasonable diagnostic workup (imaging, lab tests)
  • Universal screening (urine drug screens and the Prescription Monitoring Program).

For those times when you feel totally overwhelmed, remember the Harry Potter Analogy:

  • Dementors: Dementors hunt their prey by sensing emotions. They feed on the positive emotions, happiness and good memories of human beings, forcing them to relive their worst memories.
  • Boggarts: A boggart is a shape-shifter that takes on the form of its intended victim’s worst fear (Confrontation?  Being called a “bad doctor”?  Disappointing someone?  Inadequately treating a patient because of your inexperience?).
  • Narcotic seekers aren’t Dementors.  They’re only Boggarts – scary but harmless.  They’re poorly armed compared to you!  Helpful things to remember when you’re feeling uncomfortable during a patient encounter:
    • They’re on YOUR turf.  YOU are wearing the white coat, YOU make the rules, and what YOU say goes.  How much easier does it get than that?
    • You can believe their report of pain, and be sympathetic to it.  But 10/10 pain does not always equal narcotics.  Your job is to find the best possible treatment for them to help them be as FUNCTIONAL as possible while minimizing harm.  They may not agree with your approach.  But YOU have the DEA number because YOU have the training to use it safely.
    • Blame clinic policy if you need to.  You’d like to help, but you CAN’T prescribe narcotics during the first visit.  You CAN’T prescribe pain meds over the phone on weekends.  Then talk about what you CAN do.  “I’m sorry, but I can’t (repeat as necessary).  Is there anything else I can do for you?”
    • Use your backup – your attendings and consultants.