Physicians’ pain management confidence versus competence


  • Mark A. Douglass, PharmD
  • Gail M. Sanchez, PharmD, BCPS
  • Daniel P. Alford, MD, MPH
  • Gail Wilkes, RNC, MS, AOCN
  • Jeffrey L. Greenwald, MD



pain management, physician knowledge, physician confidence


Objective: To assess awareness of existing pain management guidelines and compare physicians’ confidence versus competence in selected pain management skills.
Design: Prospective survey study.
Setting: A large urban tertiary medical center.
Patients, participants: All Department of Medicine interns, senior residents, and attending physicians were sent a questionnaire; the overall response rate was 30 percent (91/304).
Interventions: The questionnaire assessed physicians’ awareness of the institution’s pain management guidelines, their self-reported comfort level (confidence) with, and a knowledge assessment (competence) of three pain management skills (managing chronic-continuous pain, equianalgesic dose conversion, and managing breakthrough pain) using validated, standardized case vignettes.
Main outcome measures: A comparison of physicians’ confidence with their competence in these pain management skills.
Results: A total of 23 percent (21/91) of the respondents reported an awareness of the institution’s pain management guidelines. Interns were significantly less confident than senior residents in all three pain management skills (p < 0.001, 0.006, 0.02) but nonsignificantly more competent in two of three skills (chronic-continuous pain, dose conversion). Attendings were generally more confident and nonsignificantly more competent than senior residents in all three pain management skills.
Conclusions: The underutilization of the pain management guidelines illustrates that the mere existence of these resources as a means of ensuring optimal pain management is insufficient. Creative pain management educational initiatives are needed to address the disparity between physician confidence and competence.

Author Biographies

Mark A. Douglass, PharmD

Department of Pharmacy Practice, Northeastern University School of Pharmacy, Boston, Massachusetts.

Gail M. Sanchez, PharmD, BCPS

Department of Pharmacy Services, Boston Medical Center, Boston, Massachusetts.

Daniel P. Alford, MD, MPH

Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.

Gail Wilkes, RNC, MS, AOCN

Division of Nursing, Boston Medical Center, Boston, Massachusetts.

Jeffrey L. Greenwald, MD

Section of General Internal Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.


National Institutes of Health: New Directions in Pain Research. September 1998: 98-102.

Chandler S, Payne R: Economics of unrelieved cancer pain. Am J Hosp Palliat Care. 1998; 15(4): 223-225. [homepage on the Internet]. Indiana: Press Ganey Associates, Inc.; c2009. Available at Accessed February 18, 2009.

Potter M, Schafer S, Gonzalez-Mendez E, et al.: Opioids for chronic nonmalignant pain: Attitudes and practices of primary care physicians in the UCSF/Stanford collaborative research network. J Fam Pract. 2001; 50(2): 145-151.

Gallagher R: Opioids in chronic pain management: Navigating the clinical and regulatory challenges. J Fam Pract. 2004; 53 (Suppl 10): S23-S32.

Loder E, Witkower A, McAlary P, et al.: Rehabilitation hospital staff knowledge and attitudes regarding pain. Am J Phys Med Rehabil. 2003; 82(1): 65-68.

Von Roenn J, Cleeland C, Gonin R, et al.: Physician attitudes and practice in cancer pain management: A survey from the Eastern cooperative oncology group. Ann Int Med. 1993; 119(2): 121-126.

Elliott T, Murray D, Elliott B, et al.: Physician knowledge and attitudes about cancer pain management: A survey from the Minnesota Cancer Pain Project. J Pain Symptom Manage. 1995; 10(7): 494-504.

Lebovits A, Florence I, Bathina R, et al.: Pain knowledge and attitudes of healthcare providers: Practice characteristic differences. Clin J Pain. 1997; 13(3): 237-243.

Ponte C, Johnson-Tribino J: Attitudes and knowledge about pain: An assessment of West Virginia family physicians. Fam Med. 2005; 37(7): 477-480.

Levin M, Berry J, Leither J: Management of pain in terminally ill patients: Physician reports of knowledge, attitudes, and behavior. J Pain Symptom Manage. 1998; 15: 27-40.

Wilkes G, Lasch K, Lee J, et al.: Evaluation of a cancer pain education module. Oncol Nurs Forum. 2003; 30(6): 1037-1043.

Lasch K, Wilkes G, Lee J, et al.: Is hands-on experience more effective than didactic workshops in postgraduate cancer pain education? J Cancer Educ. 2000; 15: 218-222.

Friedman CP, Gatti GG, Franz TM, et al.: Do physicians know when their diagnoses are correct? J Gen Intern Med. 2005; 20: 334-339.

Xue Y, Schulman-Green, D, Czaplinski C, et al.: Pain attitudes and knowledge among RN’s, pharmacists, and physicians on an inpatient oncology service. Clin J Onc Nurs. 2007; 11(5): 687-695.

Mortimer JE, Bartlett NL: Assessment of knowledge about cancer pain management by physicians in training. J Pain Symptom Manage. 1997; 14(1): 21-28.

Von Gunten CF, Von Roenn JH, Weitzman S: Housestaff training in cancer pain education. J Cancer Educ. 1995; 9(4): 230-234.

Harasym PH, Tsai TC, Hemmati P: Current trends in developing medical students’ critical thinking abilities. Kaohsiung J Med Sci. 2008; 24: 341-355.

Boulet JR: Summative assessment in medicine: The promise of simulation for high-stakes evaluation. Acad Emerg Med. 2008; 15: 1017-1024.

Srinivasan M, Hwang JC, West D, et al.: Assessment of clinical skills using simulator technologies. Acad Psychiatry. 2006; 30: 505-515.



How to Cite

Douglass, PharmD, M. A., G. M. Sanchez, PharmD, BCPS, D. P. Alford, MD, MPH, G. Wilkes, RNC, MS, AOCN, and J. L. Greenwald, MD. “Physicians’ Pain Management Confidence Versus Competence”. Journal of Opioid Management, vol. 5, no. 3, Jan. 2018, pp. 169-74, doi:10.5055/jom.2009.0017.