Pain is among the most common chronic health problems in the United States (1). The pervasiveness, refractoriness, and costs associated with chronic pain have rendered management of chronic pain a public-health priority, spurring multiple efforts toward fostering improved clinical recognition and assessment of pain. The Joint Commission on Accreditation and Health Care Organizations issued requirements that pain be considered a “fifth vital sign,” and, therefore, an essential component of every patient's assessment (2).

A number of healthcare reform measures have been implemented to improve treatment of chronic pain, including an Institute of Medicine conference on pain, a training program for healthcare professionals, and an increased emphasis on pain research within the National Institutes of Health (3). Concurrently, efforts have been directed at promoting and refining treatment strategies, with the intent of optimizing long-term recovery, functional adaptation, and rehabilitation. Traditional medical models, focusing solely on the physiological bases for acute pain management, have been inadequate in managing the complexities associated with chronic pain. For instance, research has revealed that significant comorbidities exist between psychiatric disorders and chronic pain, which can impede recovery and rehabilitative efforts (4). Consequently, during the past two decades, considerable advances have been made in understanding the role of psychiatric factors in the transition from acute injury to chronic pain.

Although it is expected that only a small subset of psychiatrists specialize in pain management, the skills of the general psychiatrist are important components of the collaborative care of the patient with chronic pain (4–6). Consequently, there is a need for pain-medicine training to be incorporated into general psychiatric residency training. To our knowledge, no attempts have been made to characterize the extent of pain-management training in psychiatry residency training. To address this knowledge gap, we contacted all training directors of psychiatry residency programs in the United States during the 2010–2011 academic year and asked them to complete a survey assessing 1) the number of hours devoted to pain-management didactics; 2) whether topics addressing pain-management constitute a specific focus in consultation–liaison, substance abuse, or outpatient rotations; 3) the availability of clinical rotations in pain-management and the extent to which psychiatry faculty participate in these rotations; 4) the attitudes of training directors' about incorporating pain-management education into existing residency training; and 5) the perceived barriers to such training.

Survey results are summarized in Table 1. Forty-seven training-program directors (26%) from the 183 surveyed programs completed our survey. Although didactics in pain-management were offered in 66% of psychiatry residencies, the average time allotted to this training across all 4 years of residency was only 2.7 hours.

Less-formalized instruction and clinical exposure to pain management occurred in other rotations: substance abuse/addictions (60%), consultation–liaison (57%), and the clinical outpatient year (15%). However, the amount of time devoted to pain-management in these settings was not quantified and, therefore, could not be included in the number of didactic hours above. With regard to clinical rotations, only 7% of programs offered required clinical rotations in pain-management. Elective rotations in pain-management were available in 48% of programs, usually offered through an affiliated program outside of the psychiatry department. However, participation in these rotations was low (i.e., 80% of program directors indicated that 0–1 residents participated in these electives annually). Although most program directors (87%) indicated an interest in expanding pain-management education within residency training, the respondents identified two main barriers to this expansion: 1) lack of faculty with fellowship training or certification in pain-management (79%); and 2) limited available training time for residents (50%). Of note, only 27% of program directors identified lack of interest in pain-management among residents as a barrier.

With regard to increasing pain-management training within residency programs, most program directors (87%) identified the development of a structured pain-management curriculum as a factor that would enhance education and training. Because of the relatively small response rate to our survey, we used statistical simulation to estimate the 95% confidence interval of the true response had every residency director completed the survey. These analyses suggest that despite some potential variation in the absolute values of the data, the overall pattern of results would have remained consistent, had all residency directors responded. Overall, our results suggest that psychiatry trainees appear to have limited exposure to pain medicine during residency. Relatively little time is devoted to formal instruction/didactics in pain-assessment and treatment among surveyed psychiatry training programs.

Clinical exposure to patients with pain is required in few programs. Among programs in which elective rotations are available, residents seldom undertook such clinical experiences. Informal instruction and some clinical exposure to pain-management was provided inconsistently, depending on the nature of cases presenting within consultation–liaison and substance abuse/addiction rotations. Nonetheless, training in pain medicine is deemed to be an important arena for inclusion in residency training. However, efforts to incorporate such training are limited by a lack of trained psychiatry faculty to provide didactics/supervision. Other limiting factors include lack of time to allot to clinical rotations and didactics dedicated to pain medicine and psychiatry. As previously suggested (4–6), residency directors perceive that the development of a pain-management training module may address current inadequacies within their programs.

It is noteworthy that the limited exposure to pain medicine among residents may not be limited to psychiatry. In 2010, an American Medical Association task force examining the barriers underlying effective pain-management concluded that there is a lack of training in pain medicine across most residencies (7). They proposed that core competencies in pain medicine be established by the Accreditation Council for Graduate Medical Education (ACGME) across all residency specialties, to make pain-treatment accessible and cohesive. For psychiatry trainees, specifically, should current trends continue, it is feared that future psychiatrists will be ill-equipped to meet the increasing demands for collaborative and comprehensive pain-management/care. This will undoubtedly limit the interest among psychiatrists in pursuing pain-medicine as a subspecialty and may stifle efforts to inform and collaborate with nonpsychiatric pain practitioners regarding the biopsychosocial components of pain medicine.