Surgical trainee perspectives on the opioid crisis: the influence of explicit and hidden curricula

Abstract

Objective:

In order to effectively create and implement an educational program to improve opioid prescribing practices, it is important to first consider the unique perspectives of residents on the frontlines of the opioid epidemic. We sought to better understand resident perspectives on opioid prescribing, current practices in pain management, and opioid education as a needs assessment for designing future educational interventions.

Design:

This is a qualitative study using focus groups of surgical residents at 4 different institutions.

Setting:

We conducted focus groups using a semi-structured interview guide in person or over video conferencing. The residency programs selected for participation represent a broad geographic range and varying residency sizes.

Participants:

We used purposeful sampling to recruit general surgery residents from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. All general surgery residents at these locations were eligible for inclusion. Participants were assigned to focus groups by residency site and their status as junior (PGY-2, PGY-3) or senior resident (PGY-4, PGY-5).

Results:

We completed 8 focus groups with a total of 35 residents included. We identified 4 main themes. First, residents relied on clinical and non-clinical factors when making decisions about opioid prescribing. However, hidden curricula based on unique institutional cultures and attending preferences heavily influenced residents’ prescribing practices. Second, residents acknowledged that stigma and biases towards certain patient groups influenced opioid prescribing practices. Third, residents encountered barriers within their health systems to evidence-based opioid prescribing. Fourth, residents did not routinely receive formal education on pain management or opioid prescribing. Residents recommended several interventions to improve the current state of opioid prescribing, including standardized prescribing guidelines, improved patient education, and formal training during the first year of residency.

Conclusions:

Our study highlighted several areas of opioid prescribing that can be improved upon through educational interventions. These findings can be used to develop programs aimed at improving residents’ opioid prescribing practices, both during and after training, and ultimately the safe care of surgical patients.

ACGME Competencies:

Patient care; Practice-based learning and improvement; Systems-based practice

INTRODUCTION:

Misuse and abuse of prescription opioids following surgery continue to exacerbate the opioid crisis in the United States. In 2019, 11% of deaths attributable to opioid overdose were related to prescriptions originating from a surgeon.¹ The majority of interventions aimed at addressing this problem have targeted reducing the number of pills prescribed,^2,3 increasing patient education around opioid use and pain management,^4,5 or improving the disposal of leftover opioids.^6,7 Educational efforts aimed at opioid prescribers have also been attempted, with variable success.^8,9 Despite these efforts to minimize the negative impact of surgeon-prescribed opioids, surgeons continue to overprescribe opioids following surgery.¹⁰

At many hospitals, surgical residents are the main providers of postoperative opioid prescriptions; however, current surgical residents report they do not receive sufficient training in medical school or residency to prescribe opioids in compliance with best practices.^11–13 Limited evidence demonstrates that residents who receive education on prescribing best practices are less likely to be high prescribers of opioids; however, educational interventions on this topic remain largely absent from surgical curricula.¹² Educational interventions for residents may have career-long benefits for learners and for patient safety as residents will carry these learned behaviors forward into their future practices. However, educational interventions should be informed by an understanding of how current residents learn about pain management and the factors that influence their opioid prescribing.

We conducted a qualitative focus group study at four general surgery residency training programs as part of a needs assessment before developing new curricula and/or other educational interventions. Our goal was to understand current prescribing practices for residents, the factors that influence how they prescribe, and their perspectives on the current opioid crisis. In addition, we asked residents to identify areas of educational gaps in opioid prescribing. Focusing future educational interventions on these areas may help bring resident prescribing patterns in line with current best practices and evidence-based guidelines.

MATERIALS AND METHODS:

We performed a qualitative study evaluating the perspectives of general surgery residents on how they prescribe opioids and how they learn these practices. We performed 8 focus groups in total with residents from 4 different academic institutions. Institutions were selected from different geographical locations (West, Northeast, South, and Midwest) to generate a diverse cross-section of training experiences across the United States. Focus groups were performed with cohorts of junior residents (PGY-2, PGY-3) and senior residents (PGY-4, PGY-5) to determine if there were differences in opinion across training levels. We used focus groups as our unit of data collection as focus groups allow participants to work together to discover “hot button” topics and generate important narratives.¹⁴ We felt the interaction between participants was equally as important for the topics questioned as individual perspectives.

General surgery residents were recruited from the University of Utah, University of Wisconsin, Dartmouth-Hitchcock Medical Center, and the University of Alabama at Birmingham. A general surgery resident at each institution sent a recruitment e-mail to all general surgery residents asking for participation. We recruited participants with the goal of having two focus groups of 4–6 residents each, stratified by training level (junior vs. senior residents), at each institution. Surgical interns (PGY-1) were excluded as some states do not allow interns to prescribe opioids. Protection of resident anonymity was critical to creating a safe space for residents to share their opinions. Therefore, demographic information other than PGY-level of individual residents was intentionally not collected. The University of Utah Institutional Review Board (IRB) approved this study (IRB_00118491). All participants provided signed consent.

Focus groups were performed in person or over video conferencing, lasting approximately 60 minutes. All focus groups were conducted by a single member of the research team with training in qualitative research methodology (JB). The interviewer was also a surgical resident with a good understanding of the jargon used by focus group participants. Questions were based on a 6-question semi-structured interview guide developed to gauge resident perspectives on the opioid epidemic, opioid prescribing, challenges with pain management, and resident education around opioids (Supplement 1). The guide was generated with input from experts in general surgery, pain management, surgical education, and qualitative methodology. The interview guide was pilot-tested with 2 small groups of general surgery residents and refined based on feedback and input from these groups. Data from these pilot-tests was not included in the final analysis.

All focus groups were audio-recorded, then transcribed verbatim (Production Transcripts, CA). All personal names or other information that could contribute to a loss of resident anonymity was removed from the transcript at this time. We analyzed the data using the constant comparative method with the focus group as the unit of analysis.^15,16 Two researchers reviewed 2 randomly selected transcripts to identify common themes across focus groups and generated a codebook based on this inductive thematic analysis. This process was repeated with two additional transcripts to further refine the codebook. At this point, both coders felt the codebook was complete and concise, and there was a high degree of inter-rater reliability, defined as a Cohen’s kappa value of 0.7 or higher for all individual codes, between investigators.¹⁷ The final codebook consisted of 32 codes in 6 key areas (the opioid epidemic, communication, prescribing habits, institutional culture, education, and provider bias). The remaining focus groups were then coded independently. The codes were then analyzed by all members of the research team, including researchers from all 4 study locations, to identify key themes that best described the main themes of the focus groups. Quantitative analysis of responses was not uniformly performed, as semi-structured interview guides do not use standardized question wording and not all focus groups were asked the same questions. The COREQ guidelines for reporting of qualitative research were followed.¹⁸

RESULTS

We performed 8 focus groups with a total of 35 residents between 08/01/2020–10/31/2020. Across institutions, 18 residents were considered senior residents (8 PGY-5 and 10 PGY-4), while the remaining 17 were considered junior residents (5 PGY-2 and 12 PGY-3).

Rationale Behind Resident Prescribing Patterns

The main criteria used by residents to decide how to write opioid prescriptions were clinical factors. Residents mentioned 16 different clinical factors that they regularly considered when writing opioid prescriptions for post-surgical patients (Table 1). The most commonly described factors were the type of incision, chronic pain or prior opioid use, length of stay, and inpatient opioid use. Other factors included trauma, cancer diagnosis, age, patient functional status, a history of substance abuse, anorectal operation, mental illness, surgical complications, patient weight, emergent operations, and comorbidities. These were mentioned to varying degrees by individual residents with a lack of consensus over the importance of certain clinical factors. Individual focus groups and institutions had greater consistency in which factors were deemed important than between groups and institutions. However, the combination of factors used was debated even among residents within each focus group.

Table 1:

Clinical and non-clinical factors used by residents to determine what opioid prescription their patients should receive after surgery

Clinical Factors			Non-Clinical Factors
Factor	Effect on Opioid Prescriptions	Focus Groups Mentioned	Factor	Effect on Opioid Prescriptions	Focus Groups Mentioned
Type of Incision	Variable	1, 3, 5, 6, 7, 8	Travel Distance to Hospital	Larger	1, 3, 4, 5, 7, 8
Chronic Pain or Prior Opioid Use	Larger	2, 3, 4, 5, 6, 8	Perceived Attending Preference	Larger	4, 5, 6, 8
Length of Stay	Variable	1, 2, 4, 5, 7, 8	Rurality	Larger	1, 3, 4
Inpatient Opioid Use	Variable	1, 2, 3, 6, 7, 8	Patient Preference	Variable	1, 3, 4
Trauma	Larger	1, 3, 4, 6	Patient Reliability	Larger	5, 7, 8
Cancer Diagnosis	Larger	1, 7, 8	Out-of-state patient	Larger	2, 5
Older Age	Smaller	4, 5, 6	Proximity to the Weekend	Larger	5, 7
Functional Status	Variable	1, 5, 8	Time to Follow-up Appointment	Variable	6
History of Substance Abuse	Larger	5, 6, 8	Avoidance of Phone Calls	Larger	4
Anorectal Operation	Larger	2, 4, 8
Mental Illness	Larger	3, 7
Complications	Larger	4, 5
Younger Age	Variable	2, 4
Patient size (weight)	Smaller	4
Emergent Operation	Larger	8
Comorbidities	Smaller	5

A number of non-clinical factors were also considered in resident’s rationale for their opioid prescribing practices (Table 1). The most common non-clinical factors were travel distance to the hospital and patient rurality, preferences, and/or reliability. Other factors included whether a patient lived out-of-state, proximity to the weekend, time to follow-up appointment, perceived attending preferences, and a desire to avoid patient phone calls. In all groups, these non-clinical variables were viewed as less important than clinical factors; however, they still influenced resident decision-making on opioid prescribing.

Despite the heterogeneity of prescribing practices, residents seemed anchored within institutional norms. These norms originated from the culture around pain control and opioid prescribing of the institution or individual service. Because of this, residents at the same institution (or on a particular clinical service) fell within a narrow range of prescribing practices, both with regards to the clinical and non-clinical factors they considered important and the type and quantity of opioids prescribed. Residents reported a wide range of different cultures from institution to institution, and resident prescribing habits also differed widely. One institution had a strong culture around minimizing opioid prescribing, and residents took pride in this. Residents at this institution reported prescribing fewer opioids for both inpatient and outpatient procedures and were more able to cite evidence-based guidelines around optimal opioid prescribing.

“I think it’s actually the culture in our hospitals to not give opioids as much as possible, which is really nice.” – Respondent 2, FG2

“We do have a pretty strong culture of thinking about these things, being careful about the opioids we prescribe” – Respondent 3, FG 2

Focus groups of residents from the other three institutions also revealed that prescribing practices were dictated by institutional culture; however, this culture was not always as focused on minimizing opioid prescriptions or prescribing opioids in an evidence-based manner.

“If we do a diagnostic laparoscopy and we inject a bunch of local anesthetic, we’re still going to send them home with pain medications and I don’t know if we even think that we need to, but it’s kind of a cultural thing that the whole system is set up like the patient’s perspective.” – Respondent 2, FG 7

“Yeah, I think training regarding all that stuff [prescribing fewer opioids] is helpful, but again, it’s the tip of the iceberg. It’s more of a cultural thing that can’t be changed.” – Respondent 2, FG 5

“I just feel like in our culture the residents here are getting the calls about the people that run out of pain meds and then like you said, the nurses are going to page you, “Hey, this patient doesn’t have a pain prescription.” So I would rather just send them home with seven pills, even if they’re only taking like one a day rather than get paged.” – Respondent 2, FG 8

Residents described a hidden curriculum, implicitly taught attitudes and values, that led to residents anchoring their prescribing habits within a narrow range. This can be seen in resident responses to the question, “How many opioid pills do you prescribe after a laparoscopic cholecystectomy?” (Table 2). The institution with a stronger culture around minimizing opioid prescribing reported prescribing lower numbers of pills. Moreover, when residents fell outside of the institutional norms, they were teased by their co-residents in an effort to re-anchor them within the institutionally accepted quantities.

Table 2:

Resident responses to the question, “How many pills do you prescribe after a laparoscopic cholecystectomy?” as an example of residents anchoring their prescribing patterns within institutional norms.

Focus Group	Pills Prescribed by Different Residents	Quotations Between Residents Aimed at Re-Anchoring Residents Who Fell Outside the Institutional Norm
1	1: 3–5 2: 5 3: 0–5 4: 10*	In response to respondent 4:   “He is liberal with the juice.” – Respondent 3   “Mr. Just in Case over here.” – Respondent 2   “[He] would have given her 100.” – Respondent 2
2	1: 7 2: 5 3:0–5	On hearing of the response from Respondent 4, FG 1:   “He’s such a pushover, he’s such a pushover.” – Respondent 1.”
3	1: 6 2: 6–8
4	1: 10–15 3: 12 4: 20
5	1: 5–7 3: 5–7
6	1: 5–10 2: 5–10 3: 5–10
7	1: 5 2: 10–12
8	1: 12 2: 12 3: 12 4: 5*	In response to respondent 4:   “Just five?”- Respondent 1   “Only 5 pills?” – Respondent 2

Role of Patient-Provider Relationships and Stigma in Opioid Prescribing

Residents reported that they are more willing to prescribe to patients whom they have an established relationship with or to patients who they trust. This led to many residents being hesitant to prescribe to patients when they did not participate in the primary delivery of their surgical care. Most frequently, this meant patients were unlikely to receive opioids for pain when discussing pain with residents over the phone or with residents who were providing cross-coverage for them.

“I had a patient last week who was-- you know, took care of him for five days and he seemed like a reliable person. Obviously, we all have our biases. But he hadn’t used any in the last 24 hours and before he left I had actually left the hospital and he had called and said that he felt uncomfortable being discharged without something in case he had more pain. And I couldn’t convince him to not want an opioid pain medication, so I ended up writing him a prescription…And I have to recognize that I think probably my bias would have been different if I didn’t trust-- if I hadn’t built a relationship or trusted the patient more.” – Respondent 4, FG 1

“In general…, I just made it my practice to never refill narcotic prescriptions over the phone overnight ever.” – Respondent 3, FG 2

“I think the other thing that goes into my decision is how close we are to a weekend, how far away this person lives, are they going to be able to call someone, are they reliable, that kind of thing goes into-- I don’t know how much that affects how many I actually prescribe, but I do think about that for certain patients.” – Respondent 4, FG 7

Residents from different institutions had broad agreement over the “types” of patients who were challenging to provide appropriate pain management for. There was some agreement across institutions about which patient populations are challenging to manage pain for; however, these biases were interpreted differently across institutions. Resident bias towards certain patients affected how they perceived their pain and, in some cases, how they prescribed to these patients. Certain patient characteristics were seen as “red flags” that indicated patients were “drug-seeking” or would be challenging to manage from a pain management stand point (Table 3). These include chronic opioid users, patients with multiple allergies, and patients with certain diagnoses, such as fibromyalgia.

“Yeah, I mean, undoubtedly. You know? We over-prescribe, we under-prescribe. I think we all have some biases, and when we have the opioid epidemic kind of in our mind, it’s hard not to apply those biases to things we think about in terms of socioeconomic, education, whatever status that we then apply that to and under prescribe, right?” – Respondent 3, FG 6

“It’s like a constant joke, but if you have more than five allergies or something like that, it’s just like everyone rolls their eyes in clinic or everyone just assumes that they’re lying, it’s just like an unspoken thing that we all say when we’re like, “Oh their allergy list is like ten,” but we’re saying is that they’re lying and then they’re trying to manage their own pain which we hate.” – Respondent 2, FG 2

“When…somebody says, I have a really high pain tolerance, then I’m just like-- rather than trying to have an honest conversation about, you know, what are reasonable expectations and that I’m going to try to adequately treat your pain and we’re going to have to try some stuff…, I think I immediately feel extorted or manipulated. And whether or not my instincts are real, it puts me on the defensive.” – Respondent 1, FG 5

“I think my reaction is not so much like, “Oh, I’m going to not give them pain meds,” or whatever, it’s more like a gut reaction, where I’m like, “Oh, they’re going to be difficult to manage.” I think that’s more what it is for me.” – Respondent 3, FG 1

Table 3:

Resident reported patient characteristics that triggered residents to think pain management and opioid prescribing would be challenging.

Patient Characteristics	Focus Groups
Chronic opioid user	1, 2, 3, 4, 5, 6, 7, 8
Certain diagnoses: Fibromyalgia, chronic back pain, IBD	2, 3, 4, 5, 6, 7, 8
Multiple listed allergies (particularly to specific opioids)	2, 3, 5, 6, 7, 8
Substance abuse disorder	1, 2, 4, 6, 8
Mention of a “high pain tolerance”	1, 5, 6, 7, 8
Middle-aged women	1, 3, 5
Young males	1, 6, 7
Hx of mental health disorder	4, 7

Effect of Attendings and Health Systems on Residents’ Prescribing Practices

Attending oversight of prescribing practices was also frequently taken into account by residents when writing opioid prescriptions, although residents reported that attending expectations on this topic were rarely stated explicitly. The amount of oversight was dependent on the institution and junior residents reported more oversight than senior residents. Residents also sometimes mentioned using defensive prescribing practices, such as writing larger opioid prescriptions to avoid patient phone calls or prescribing opioids “just-in-case” a patient needed them after a minor procedure. When residents reported defensive prescribing habits, it was often in response to perceived attending preferences.

“I’m just saying that based on my experiences with my attendings and how they typically behave, and how that push-pull goes is that I’m usually the one trying to pull down the number, and they’re usually pushing it up.” – Respondent 1, FG 6

“I’m always guessing my attending’s choices.” – Respondent 2, FG 6

“I think sometimes residents certainly are driving the boat on opioid prescribing, but sometimes we are told by our attendings to prescribe X number of pills, and sometimes it’s too much, and you kind of then sit there questioning, should I just disagree with my attending and write something different than what they told me to do? Or should I just go along with what they told me to do so that I don’t get called out for not following their direction?” – Respondent 3, FG 5

“And when they get-- two hours away, and they’re in a lot of pain, they blow up our attendings, nurses in the clinics, and harass them, and take away from the responsibilities that they really need to be doing, and then we get yelled at by our attending. Why is my nurse getting harassed, how much pain meds did you write her, so forth.” – Respondent 1, FG 4

Residents also reported a number of barriers within their different health systems that impeded their ability to manage patients’ pain optimally. First, residents frequently noted that the lack of continuity in clinical training limited their ability to develop relationships with patients in which they could set expectations with patients around pain preoperatively and provide education to patients on pain management and opioid use postoperatively. Residents felt that they often did not have the opportunity to see the same patients in clinic who they ultimately operated on, so the task of setting expectations around pain for patients fell to their attendings. Second, residents felt they did not receive feedback on their opioid prescribing practices and therefore, did not know whether the prescriptions they were writing were adequate. If a patient requires a refill, that call is often fielded by a colleague or clinic nurse without feedback provided to the resident who wrote the initial prescription. Conversely, if a patient returns to clinic and reports they did not use their opioid prescription, the resident who wrote this prescription has often already moved on to a different clinical service. Finally, residents noted that the many tasks they are asked to accomplish leads to significant time constraints. This ultimately led to residents failing to perform what they felt was adequate education with patients around opioids and pain management.

“We are also powerless, in many ways, to the anticipatory guidance part I was talking about. The attending surgeons have their own practices with respect to how they consent people before surgery, what they talk to them about, and we are, you know, variably involved in that process. So we can’t really affect stuff on the front end as much as on the back end. And I think that, ultimately, that’s less powerful.” – Respondent 1, FG 5

“I feel like we just prescribe post op and then we switch our patients and we never interact with them again. And so the continuity of like I don’t know if the person takes his opioids, I have no idea.” Respondent 2, FG 8

“We all know it’s important, but it just becomes another box you have to check off…There’s a bit of a fatigue I think that we kind of know all these things, but sometimes it’s just like you want to move onto the next thing.” – Respondent 3, FG 2

Current State of Resident Education on Opioid Prescribing

Residents rarely received formal education on opioid prescribing. Only 2 participants (R1, FG3 and R2, FG5) reported formal, classroom or lecture-based learning on this topic. For one of these residents, the teaching occurred in medical school. Some residents did report receiving formal education through online educational modules associated with their medical or DEA licensing; however, these residents reported that the modules did not adequately answer their questions on how to appropriately prescribe opioids post-operatively. When formal education on opioid prescribing did occur, it was in the form of grand rounds, conferences, or other research presentations.

“I mean officially there are e-learnings we’ve had to do, but I would say I have learned almost nothing from those.” – Respondent 1, FG 2

In response to a question about online educational modules: “You play it in the background while you watch TV.” – Respondent 2, FG 4

“I feel like it’s more like grand rounds and word of mouth.” – Respondent 2, FG 1

“Yeah, research related stuff, and…research presentations, I think. We like pay a lot of attention to those, because it’s very relevant. I don’t know that we’ve had other formal education, though.” – Respondent 2, FG 3

Despite this, residents felt they were expected to know how to prescribe opioids when they became physicians. Most education on opioid prescribing was received in the form of informal, on-the-job training. While most reported seeking out this knowledge from senior residents, some reported a trial and error approach to learning how to appropriately prescribe opioids. Knowledge on how to prescribe opioids was largely passed down from one resident to another. Most frequently, this knowledge is passed from chief residents to interns in an informal way; however, some residents reported learning from advance practice providers as well. Most residents acknowledged there was variation in how they prescribe opioids compared to other residents, and blamed this variation on this model of training.

“We just assume that junior residents, and residents across the board, know how to appropriately prescribe opioids, even though, at least for me, I certainly didn’t learn about that in medical school. I don’t know how-- I didn’t know how to choose the right number. And so it kind of becomes a little bit of just your personal gestalt on what the appropriate amount is.” – Respondent 3, FG 5

“We learned like on the ground, on the streets, just like you had to do this for a discharge so you better learn how to do it or else you’re going to get chewed out.” – Respondent 2, FG 2

“The most useful training I got in my first two years of residency was just on-the-job training, frankly, working with my senior residents or attendings, and what they taught. And there was certainly variations in practice and gaps and stuff.” – Respondent 2, FG 5

When asked to provide solutions on how to improve education around opioid prescribing, several residents voiced a desire for formal education in the first year of training. Many residents expressed appreciation for having guidelines, whether national or institutional, that dictate how many opioids to prescribe in different situations. Opioid prescribing guidelines were popular with the residents who worked at institutions or on services where guidelines were routinely used. Other proposed solutions included increasing access to acute and/or transitional pain services, creating shortcuts in the electronic medical record to make prescribing multi-modal pain therapy and standardized opioid prescribing faster and easier, and developing standardized education for patients to ensure all patients had adequate expectation-setting preoperatively and education on pain management and opioid use postoperatively. Nearly all residents were opposed to online educational modules on this topic, feeling that they were unhelpful and unnecessarily burdensome.

“Like those little charts we have where it’s like lap chole gets this many pills, lap appy you get this many pills and then be like this is all data driven, just these very simple charts we have that’d just give you a formula for this procedure gets this, this procedure gets this. And some way to access that by pressing a [button], some way to just make it populate in your face…that would make it the most easy to do.” – Respondent 3, FG 2

“It’s so easy just to click buttons on order sets. If you make an order set with 20 of oxy, I’m going to click that versus if you make an order set with eight of Norco or eight of Ultram, that’s made a big difference for me just clicking what’s sort of recommended on my order set.” – Respondent 3, FG 7

“The integration of like pre-op [opioid] education…, including it as just like your standard education, standard preparation for surgery, that a lot of our clinics have…, and our role is more on the in-patient side, on the prescribing side, where we reassure and reinforce the messages that they’ve-- the expectations that they’ve got, pre-op.” – Respondent 2, FG 5

CONCLUSIONS

In this study, we identified four main themes about resident perspectives on opioid prescribing and resident education about pain management. First, residents use a combination of clinical and non-clinical factors when determining how to manage an individual patient’s pain, including prescribing opioids. There is a high degree of variability amongst residents in determining which factors are important, although residents at the same institution had more similar views than those from different institutions. Second, there are many explicit and implicit biases residents acknowledged that influence how they manage pain and prescribe opioids for different patients. Third, although not unanimous, residents largely viewed attending preferences and their health systems as barriers to prescribing pain medication in a way they felt aligned with current best practices. Finally, there is very little formal education on pain management and opioid prescribing in general surgery residency, and residents felt this was an area of need in their programs.

In our study, very few residents reported receiving any formal training on pain management or opioid prescribing. This is consistent with prior studies demonstrating wide variation in opioid-related education to medical students and residents.^11,13 Residents in this study commented on the common assumption that new residents were just expected to know how to prescribe when they became doctors, with much of the training happening while on the job. This on the job training is often taught by senior residents, but also by attendings and advance practice providers. The training is rarely evidence-based and this training is often through a hidden curriculum. A hidden curriculum is defined as the teaching, most often implicitly, of the attitudes and values of an institution.¹⁹ This hidden curriculum is present throughout medicine and medical training, with both positive and negative attributes, and it can have direct impacts on patient care.²⁰ For new trainees, learning the nuances of their institutional biases around pain control and opioid prescribing was at the core of most residents’ hidden curriculum education on pain management.

Another danger of hidden curricula is that it may contribute to residents’ conscious and unconscious biases towards certain patient populations about how they experience pain and should be prescribed opioid pain medication. Physicians have a long history of minimizing patients’ pain and stigmatizing those who have a higher need for pain medications.²¹ There are many studies documenting how patients are poorly affected by this stigmatization, particularly in patients with cancer or with chronic pain.^22,23 In our study, residents were able to recognize some of their own biases (e.g., rolling their eyes when seeing a long allergy list, challenging patients making residents feel defensive). Future interventions that not only teach residents to recognize their biases but counter them could improve pain management and patient care for these “red flag” patients. Another method for countering unconscious bias on prescribing patterns is through the implementation of opioid prescribing guidelines. Many groups have created opioid prescribing guidelines based solely on the type of surgery a patient receives, eliminating the need to consider the non-clinical factors that contribute to prescriber biases.²⁴ Others have proposed patient-centered guidelines for outpatient opioid prescribing based on patients’ individual inpatient opioid use.^25,26

We found that unique institutional cultures exist around pain management and opioid prescribing at each residency involved in this study. The different cultures had direct impacts on patient care. Culture influenced resident biases on which clinical and non-clinical factors should affect decisions on pain management and opioid prescribing. While residents from the same institutions differed some in their approaches to opioid prescribing, they were anchored within a narrow range of practices set by their unique institutional culture. Residents from the most opioid-conscious institution in this study reported a strong culture around their approach to opioids and pain management. These residents reported greater support from attendings and their health system in managing patients’ pain, greater efforts to eliminate or manage stigma when prescribing opioids, and ultimately, prescribing fewer opioids for common operations than residents from less opioid-conscious institutions. Residents from other institutions noted a culture where they were yelled at by attendings for under-prescribing, taught to view certain patients as “difficult” or “drug-seeking,” and ultimately prescribed more opioids to the average patient to eliminate potential problems.

The importance of institutional culture in opioid prescribing has been identified in other studies. Nooromid et al found that after an educational intervention on opioid prescribing and abuse, opioid prescriptions actually increased, despite the intent of residents to prescribe fewer opioids.⁸ The reason for this failure was the existence of an already entrenched, opioid prescribing culture. This is something that interventions around opioid prescribing can target. Another study was able to narrow the gap between self-reported prescribing and actual prescribing by implementing a multifaceted intervention aimed at not only education, but also changing residents’ mindsets towards opioid prescribing.²⁷

Our findings suggest that formal, multi-level educational interventions in the first year of surgical training that identify and address the hidden curriculum, conscious and unconscious biases, and institutional culture may be more effective than opioid prescribing education alone. Other studies have demonstrated that formal educational interventions can impact opioid prescribing in a positive way.^28–30 Nguyen et al demonstrated a >20% reduction in the size of opioid prescriptions with only a 20 minute lecture to residents.²⁹ Another study surveyed residents from 4 different training programs and found that formal training on opioid prescribing decreases the average number of opioids prescribed.³¹ The sustainability of these changes is unknown however, and may represent only short term gains as opposed to broad cultural change effecting long-term prescribing practices.

While many effective educational interventions have been used, nearly all of our participants were opposed to online educational modules. Instead, participants reported that department-wide education, through research or grand rounds presentations, had a major impact on their opioid prescribing practices. This is likely because these presentations also impact institutional culture around pain management. In this study and others, residents note the importance of senior resident and attending preferences in their own prescribing patterns.^12,32,33 In another study, 62% of attendings reported that they often or always specify their preferences on opioid prescribing to residents, confirming the impact of attending preferences on resident practices.³⁴ Active engagement and buy-in of attendings at department-wide educational events can help build a supportive institutional culture.

Resident educational efforts would ideally be integrated with other health system interventions to improve peri-operative opioid stewardship. Integrated and consistent delivery of preoperative expectation setting and perioperative education on pain management by nurses, pharmacists, and other staff can limit the burden on residents of these tasks and make residents feel greater institutional support. Our participants recognized the importance of expectation setting and patient education but were constrained by their short clinical rotations and time limitations. Ensuring these tasks were completed by non-resident healthcare workers could have a significant impact on ensuring patients receive best care, altering institutional culture, and improving the efficiency of resident’s time. Acute and transitional pain services can reduce the complexity and stress associated with managing patients with chronic pain or opioid use while also improving the quality of patient care. The involvement of pain services also provides an opportunity for busy surgery residents to learn from their anesthesia colleagues. Finally, implementation of evidence-based and patient-centered opioid prescribing guidelines will help residents counter biases, reduce the complexity of decision-making, and further reinforce an institutional culture of opioid stewardship.

Our study has several limitations. First, focus groups were made up of a diverse group of residents; however, all residents were recruited from academic centers. Institutional culture and resident responses may have differed if residents were recruited from community-based surgical residencies. Second, residents within institutions were recruited on a volunteer basis. Residents are likely aware of how their views on this topic compare to their peers, and residents with strongly discordant views may have chosen not to volunteer. Third, demographic characteristics of the residents in this study are incomplete. We felt that maintaining resident anonymity was critical and the benefits of providing additional, potentially identifying information about residents was not outweighed by this need. Additional information about residents would help interpret the information in this study however.

Our study highlights the impact that hidden curricula, conscious and unconscious biases, and institutional culture have over resident perspectives on pain management and opioid prescribing. Institutional culture impacts how residents learn about pain management, define patients with regards to pain, communicate with patients about pain, and prescribe opioid medications. This demonstrates that educational interventions aimed at improving resident reliance on evidence-based pain management strategies must not only provide education to residents, but also improve institutional culture around these topics. Institutions that already have a positive culture around pain management should lead the way in helping other institutions improve through education of residents and faculty and sharing ideas about successful educational and quality-improvement interventions. The benefits of improving resident education on pain management and opioid prescribing would affect not only current patients, but also residents’ future prescribing habits and the future cultures of institutions where these residents will someday work.

HIGHLIGHTS:

• Unique institutional cultures drive resident attitudes on opioid prescribing

• Provider stigma towards certain patient groups effects pain management decisions

• Residents need support to institute evidence-based pain management strategies

• Opioid prescribing guidelines are broadly supported by residents

• Formal pain management education early in surgical training is needed