Agreement among undergraduate and graduate veterinary students and veterinary anesthesiologists on pain assessment in cats and dogs: A preliminary study

Abstract

This study investigated agreement among undergraduate and graduate veterinary students and veterinary anesthesiologists on video pain assessment at the University of Montreal. Pain assessment in dogs and cats appeared to be affected by gender, previous experience, and degree of training despite a small population of observers.

Introduction

Effective pain management can only be achieved and maintained when pain is assessed accurately and reliably. The guidelines for recognition and assessment of pain from the World Small Animal Veterinary Association (WSAVA) Global Pain Council note that there is a disparity between the occurrence and the successful management of pain, despite advances in the area. The inability to accurately diagnose pain, limited availability of analgesics, and limitations in clinical understanding remain the most important causes (1). Pain assessment has been shown to be influenced by several factors including gender, cultural differences, and training experience (2).

The aim of this preliminary study was to investigate the agreement among undergraduate and graduate veterinary students and veterinary anesthesiologists on pain assessment in canine and feline patients. The authors hypothesized that undergraduate third-year veterinary students would score pain in dogs and cats similarly to graduate students and board-certified anesthesiologists.

Materials and methods

This preliminary investigation was conducted immediately after a week-long course (6 h of teaching divided in 3 blocks of 2 h) on pathophysiology, assessment, and treatment of pain presented by one of the anesthesiologists (PS) to third-year veterinary students at the University of Montreal. Lectures were given as part of course DMV3132 — “Veterinary Anesthesia, Analgesia, and Resuscitation.”

Participants and study groups

A total of 93 undergraduate third-year veterinary students (student group, SG) were invited by e-mail to participate. Participation was anonymous and voluntary, and the results had no impact on final grades. Three graduate students [2 individuals enrolled in a 3-year residency training program approved by the American College of Veterinary Anesthesia and Analgesia (ACVAA) and 1 PhD student studying the pharmacology of pain; graduate students group, GG] and 2 diplomates of the ACVAA (anesthesiologists group, AG) were also included.

Study design and performance

The post-training survey model used was designed as a preliminary, exploratory, prospective study. The vice-dean of student affairs at the University of Montreal approved the study. Approval from the animal ethics committee of the University of Montreal was not required since live animals were not included.

Questionnaire

Participants completed an anonymous questionnaire before video analysis. The questionnaire, composed in French, consisted of items to determine the participant’s age, gender, previous work experience (health professional, veterinary technician, veterinarian, and/or previous work in a veterinary clinic) and previous pain experience. The latter was investigated by asking the following questions (Yes/No answer): “Have you ever had surgery while under general anesthesia?” and “Have you ever taken analgesics for a chronic painful condition?”

Videos

Four videos of approximately 5 min each were presented in the same order. The content of the videos included 2 domestic female shorthaired cats (cats 1 and 2) in the postoperative period following ovariohysterectomy (available online at www.animalpain.com.br, test videos numbers 4 and 7), 1 male Doberman dog with suspected prostatic disease (dog 1) and 1 female Dogue de Bordeaux following exploratory celiotomy (dog 2). Before each video, participants were informed about the patient’s signalment (age, gender, and breed), as well as medical condition (dog 1) or type of surgery performed (dog 2, cats 1 and 2). However, they were blinded to any analgesic treatment and were not allowed to discuss the cases.

Pain scales

The pain assessment of the video cases was performed individually using ordinal validated instruments, 2 for each cat, and 1 for each dog. Pain in cats was evaluated using the French version of the UNESP-Botucatu multidimensional composite pain scale (MCPS) (3) and the short-form of the Glasgow composite pain scale (GCMPS-SF) (4). Pain in dogs was evaluated using the French version of the Glasgow composite pain scale short-form (GCMPS-SF) (5). These instruments require both static and dynamic behavioral evaluations. After watching each video and completing the scales, participants were asked if they would administer rescue analgesia to the animal: “Should the animal on the video receive rescue analgesia?” (Dichotomous answer, Yes/No).

Statistical analysis

Statistical analysis was conducted using unequal variances t-tests (P ≤ 0.05) for investigating differences among the undergraduate students group (SG), for gender, previous work experience (e.g., health professional, veterinary technician, veterinarian, previous clinical work), and previous pain experience (e.g., if they were under surgery previously, if they were treated with analgesics anytime). Comparisons among the different groups (SG, GG, AG) were investigated for age and for the pain scores recorded for the various videos assessed. Data were compared with the group (SG, GG, AG) as a between-subject factor. The unequal variances in the different groups were also taken into account using the Tukey-Kramer post-hoc test (P ≤ 0.05). For the analysis of the question, “Should the animal in the video receive rescue analgesia treatment?” responses among groups were compared using an exact Chi-squared test. The GG and AG groups were combined for the Chi-squared analysis due to the limited number of respondents in these groups. A P-value ≤ 0.05 was considered to be statistically significant. Standard software was used to carry out statistical analyses (SAS, version 9.3, SAS Institute, Cary, North Carolina, USA).

Results

Mean ± standard deviation of students’ age was 23.8 ± 8.5 y. Student demographics are presented in Table 1. Fifty-six (60%) students participated and 8 (14%) completed all sections of the questionnaire and pain assessment. With respect to pain evaluations, response rate to the MCPS and canine GCMPS-SF were at least 77% (n ≥ 43), case-specific response rates are shown in Table 2.

Table 1.

Demographic data collected from third-year veterinary students at the University of Montreal who completed video-based pain assessments

Collected information	Number of individuals
Gender
Female	47
Male	9
Previous work experience
Healthcare professional	2
Veterinary technician	3
Worked in a veterinary clinic	12
Veterinarian (foreign-trained)	1
Previous pain experience
Students who have had surgery which required general anesthesia	16
Students who have taken analgesics for a chronic condition	7

Table 2.

Pain scores (mean ± SEM) with respect to previous painful experiences. Undergraduate students did not score pain significantly different with respect to their previous painful experiences

Video case	Cat 1		Cat 2		Dog 1	Dog 2
Pain scale	UNESP-MCPS	GCPS feline	UNESP-MCPS	GCPS feline	GCPS-SF canine	GCPS-SF Canine
QUESTION 1: Have you ever had an operation under general anesthesia?
Number of total answers (N)	45	15	44	13	50	43
No
n	29	10	31	9	34	28
mean (± SEM)	18.8 (± 0.4)	10.3 (± 1.8)	6.6 (± 0.7)	4.7 (± 1.1)	3.3 (± 0.5)	7.2 (± 0.5)
Yes
n	16	5	13	4	16	15
mean (± SEM)	19.7 (± 0.5)	9.6 (± 2.4)	7.3 (± 1.3)	3.0 (± 1.1)	4.6 (± 0.8)	8.1 (± 1.0)
P-value (P < 0.05)	P = 0.14	P = 0.82	P = 0.62	P = 0.31	P = 0.19	P = 0.42
QUESTION 2: Have you ever taken painkillers for chronic disease?
Number of total answers (N)	45	15	44	13	50	43
No
n	50	15	40	13	43	37
mean (± SEM)	19.1 (± 0.3)	10.1 (± 1.4)	7.1 (± 0.6)	4.2 (± 0.9)	3.7 (± 0.4)	7.6 (± 0.5)
Yes
n	5	0	4	0	7	6
mean (± SEM)	18.8 (± 0.8)	—	4.0 (± 1.4)	—	3.6 (± 1.4)	6.8 (± 2.0)
P-value (P < 0.05)	P = 0.72	—	P = 0.11	—	P = 0.96	P = 0.70

UNESP — multidimensional composite pain scale (MCPS); Glasgow composite pain scale (GCPS); SF — Short form; SEM — standard error of the mean.

Female participants (n = 47) recorded lower pain scores for cat 1 (P = 0.01) and higher scores for dog 2 (P = 0.04) compared with male participants in SG using the GCMPS-SF. Previous work experience in veterinary practice or healthcare was associated with significantly decreased pain scoring for dog 2 (P = 0.02). Undergraduate students did not score pain of significant difference with respect to their previous painful experiences (Table 2). Additionally, no significant differences for age were found when the SG was compared with GG and AG. Pain scores were only different between groups for dog 2, in which SG scored significantly higher compared with GG (P = 0.01) and AG (P = 0.01).

Undergraduate students were significantly more likely to administer rescue analgesia for dog 2 (P = 0.01) compared with the combined GG and AG. No significant differences were detected for the other video assessments.

Discussion

This study compared the agreement among undergraduate students and graduate veterinary students and veterinary anesthesiologists on pain assessment in cats and dogs. Results showed that following an introductory course, differences on pain assessment in cats and dogs by veterinary students might be affected by gender and previous experience. Despite using validated instruments, veterinary students scored pain differently for dog 2 compared with graduate students and anesthesiologists.

A better appreciation of pain management has been attributed to previous experience in a survey with Canadian pet owners (6). The pain assessments for “dog 2” showed the most inconsistencies not only within SG but also in the comparisons with GG/AG. The dog was filmed in the early postoperative period and was showing signs of sedation and residual anesthesia. These findings suggest previous experience with anesthetic recovery, pain assessment, and postoperative care may help in differentiating sedation and pain. The absence of practical, “hands-on” training early in the veterinary curriculum could be an explanation, as observed in another veterinary academic institution (7). Clinical practice-based training improved perceptions and the ability of veterinary students to assess and control pain (8). It would be of interest to explore whether this disparity in pain assessments persists with further training.

Proxy pain assessment is influenced by the observers’ personal societal and professional experience. Female participants appeared to be more empathetic and likely to score pain higher, particularly for female-specific (e.g., metritis/pyometra) conditions (9). Historically, female veterinary practitioners have been more likely to assess pain and administer analgesics in the acute setting (10,11). In addition, at least in Canada, there was a trend favoring increased pain recognition and analgesic administration with younger veterinarians (more recent graduates). This was substantiated in a follow-up study in 2001 (12). Gender differences were seen on a case-specific basis in the present study; for example, male participants provided higher pain scores for “cat 1” than did their female counterparts, and vice versa for “dog 2.” Interestingly, no difference was seen using the MCPS for cat 1, possibly because most individuals completed the MCPS and often left the GCMPS-SF blank. Regardless, the feline MCPS scale was simply more robust in this comparison among the students. Further investigation into gender differences and pain instrument validity for veterinary students is warranted.

The current literature on pain education in veterinary medical curricula has generally shown improved appreciation, understanding, and treatment of pain following both didactic and “hands-on” approaches to teaching (7,8,13). As this is an initial investigation and internal audit on the subject in our institution, follow-up investigation should focus on specific teaching methods and determine strengths and weaknesses, both student-perceived and clinical outcome-driven.

There are several limitations in the current study that should be addressed. Small group sizes may have led to type II error within the study, potentially excluding any differences attributable to age or personal pain experiences, or even between groups (SG versus GG and AG) that may exist. Beyond this, the study was entirely based on video assessment. The instruments provided (MCPS and GCMPS-SF) both require patient interaction. The absence of tactile and dynamic interaction with the animal may influence students’ perceptions about pain. It would be of interest to investigate how the students’ first anesthesia course itself may have affected the scores, if at all. Participation was optional; possibly creating an artificial selection bias in which students with greater interest in pain were more likely to participate. Finally, the study involved only one academic veterinary institution in which courses are taught in French. It is not clear how language, veterinary curricula, and cultural differences would have changed these results.

In conclusion, the evaluation of pain in cats and dogs seemed to be affected by gender, previous work experience, and degree of training in this preliminary study. Further investigation into the impact of teaching methods and demographics is required to confirm and better understand these results. CVJ