St Emlyn’s Lesson Plans
Assessing persistent pain in the emergency department
Practise a respectful ED assessment that recognises suffering, checks for new pathology and makes a realistic plan.
Medical Students · 45-minute session
For learners
Before: Allow about 13 minutes in total.
When we meet: We will practise a respectful assessment and treatment conversation, then consider how new bladder symptoms change the plan.
For facilitators
Send: the learner preparation link before teaching.
Bring: A fictional care-plan summary and paper for drafting a patient explanation.
Before the session
If you are attending this session, complete the core preparation below before you come. Allow about 13 minutes in total.
Core preparation
NICE NG193: assessing chronic pain · About 10 minutes
Read 1.1.1–1.1.10 on assessment, possible causes and the effect of pain on everyday life, then “Flare-ups” (1.1.22–1.1.23). Focus on the person’s experience, function and new symptoms. The treatment recommendations for chronic primary pain are additional reading.
https://www.nice.org.uk/guidance/ng193/chapter/recommendations
Prepare (allow 3 minutes): Write two opening questions: one about what has changed today and one about what the pain is preventing the person from doing.
Think about: What would you ask to understand why someone with longstanding pain has attended today?
Picture the scene
A person who has attended several times with persistent back pain is waiting near the end of your shift. The notes suggest a flare, but you have not yet heard what is different today.
By the end of the session
- Ask about the reason for today’s attendance without dismissing persistent pain.
- Distinguish assessment of all persistent pain from treatment recommendations specific to chronic primary pain.
- Explain a realistic ED plan that includes safety, function and continuity.
After the session
- Replace one judgemental shorthand in your next case presentation with a description of the person’s symptoms and needs.
Facilitator guide
Send learners the preparation link several days before teaching. Allow about 13 minutes in total.
Before learners arrive
- Locate the pain service, primary-care communication route and local frequent-attendance support pathway.
- Identify where care plans are stored and who can update them. Review the local urgent spinal pathway for the contrast case.
Equipment: A fictional care-plan summary and paper for drafting a patient explanation.
Setup: Triads: patient, student and observer. The observer listens for acknowledgement, new-symptom assessment and an agreed next step.
If the preparation has not been completed
Use five minutes instead of “Prepare together”. With the case on screen and a board, spend one minute replacing “frequent attender wanting opioids” with a neutral description, two minutes developing questions about change and function, and two checking the NICE flare-up recommendations. Then start case 1; do not add a separate reading period.
Suggested session plan
- 0–5 min — Explore. Invite private reflection on language that changes how we approach a patient.
- 5–10 min — Prepare together. Compare neutral openings and distinguish primary from secondary pain.
- 10–32 min — Discuss & Apply. Spend 14 minutes on the conversation and 8 on the changed presentation.
- 32–40 min — Consolidate. Ask pairs to explain how they would use an existing care plan, respond to new symptoms and agree a useful outcome for today.
- 40–45 min — Reflect & Transfer. Invite learners to replace one judgemental phrase they have heard with a clear description of symptoms and needs.
Start the discussion
Read the opening scenario together. Give everyone a moment to think, then ask what concerns them and what they need to know next.
Cases and discussion
Use these cases, or invite an anonymised case from the group that addresses the same questions.
The familiar presentation
A person with longstanding back pain attends because sleep has become impossible. They request the opioid that helped briefly on a previous visit. An existing care plan is available.
Add this information as the discussion develops:
- They say, ‘Every time I come, people act as though I’m making it up.’
- The history and examination identify no new emergency feature; they report dizziness from several medicines and have missed a pain-clinic appointment because of transport problems.
Ask the group:
- What is your first response to that statement?
- What do you still need to assess before relying on the care plan?
- What could a useful outcome look like today if pain cannot be abolished?
Discussion notes
Points to draw out:
- Acknowledge the experience and ask permission to explore today’s change. Pain is real even when tests do not identify a new cause.
- Review new symptoms, function, sleep, mental wellbeing, medication use and access to support. A plan supports continuity but does not replace reassessment.
- Discuss realistic goals with the patient and supervisor: manageable movement, safer medicine use, a clear contact and follow-up.
- Avoid reflex escalation of opioids for chronic primary pain; the treatment decision depends on the pain condition and the existing plan.
Common misconceptions:
- Using repeated attendance as evidence against serious illness.
- Promising that a test or stronger drug will solve the long-term problem.
- Assuming trauma or substance dependence from an attendance pattern.
For a more experienced group: Rehearse how to acknowledge a request while explaining why one proposed medicine may cause more harm than benefit.
A change hidden by the label
The same person now describes new altered bladder sensation, difficulty initiating urine and spreading numbness in the saddle region.
Add this information as the discussion develops:
- A colleague points to yesterday’s normal assessment and the existing pain plan.
- The patient is embarrassed and did not mention bladder symptoms at triage.
Ask the group:
- What changes your priority?
- What needs to be escalated and documented now?
- How could the previous label have delayed recognition?
Discussion notes
Points to draw out:
- Treat new neurological or bladder symptoms as a fresh clinical problem; seek urgent senior assessment using the local suspected cauda-equina pathway.
- Use direct, respectful questions and record the patient’s own description rather than a vague ‘no red flags’.
- Base imaging decisions on the current symptoms and assessment; persistent pain alone does not require imaging at every attendance.
Common misconceptions:
- Copying the previous examination into a new encounter.
- Using a normal old scan as a permanent rule-out.
For a more experienced group: Ask how the care plan can be revised to help future clinicians recognise important change.
Important clinical points
- New symptoms need fresh assessment even when a care plan exists.
- Do not abruptly stop established dependence-forming medicines without an appropriate clinical plan.
- NG193’s ‘do not initiate’ drug advice concerns chronic primary pain; condition-specific guidance may differ.
Closing the session
Use these questions to check what the group will take away. Go back over any clinical points that remain unclear.
- Give one example of a useful question about function.
- Explain why a care plan does not rule out a new emergency.
- Offer a respectful sentence explaining a limit to today’s treatment.
Key teaching points:
- Assess what has changed, even when pain and attendance are familiar.
- Acknowledge the person’s experience and agree realistic goals.
- Coordinate medication decisions and follow-up with the existing care plan.
Before leaving, ask each person to choose one action from After the session and say when they will try it. They complete that follow-up in practice, with supervision where needed.
Adapting the discussion
Uncertainty and local practice
Primary and secondary pain can coexist. No brief ED encounter can fully characterise every pain mechanism or resolve a complex long-term prescription.
If the discussion drifts
What has changed today, and what useful, safe step can we agree with this person?
For a more experienced group
Discuss dependence, withdrawal and compassionate boundaries without reducing the patient to a prescribing problem.
A 30-minute version
30 minutes: opening 3, assessment framework 5, first case 12, contrast 5, consolidation 3, reflection 2.
Evidence and guidance
- NICE NG193 — Assessment, flare-ups and distinction between primary and secondary pain.https://www.nice.org.uk/guidance/ng193/chapter/recommendations
- RCEM adult pain guidance 2024 — Acute assessment and reassessment.https://rcem.ac.uk/wp-content/uploads/2024/10/Management_of_Acute_Pain_in_Adults_2024_v1.pdf
- Iain Beardsell: Pain and Suffering in the ED, SMACC 2014 — Optional historical perspective on persistent pain; use current guidance for prescribing.https://vimeo.com/97811644
Suggested curriculum links
GMC Outcomes for graduates / MLA 2026: Pain management; person-centred communication
Students practise assessment and a collaborative explanation.
Check these links against the learner’s stage and programme. Attendance at a teaching session does not establish competence.
First published 2020-09-22 · Iain Beardsell.