Advanced training in pain medicine, through the Faculty of Pain Medicine, and in palliative medicine, through the Royal Australasian College of Physicians, is entered by appointment to accredited units, interviewed by the service: the director, a second specialist, and often a senior nurse or allied health lead. Candidate reports are few, so this guide is built from the two curricula, unit position descriptions and the generic registrar pattern, and it says where it is inferring. The questions overlap heavily between the two fields and the differences are noted.
The format
A unit panel, criterion mapped, about thirty minutes, warm and reflective in tone. Panels assess motivation, understanding of the biopsychosocial model, multidisciplinary practice, communication in difficult conversations, and personal resilience. Pain medicine candidates are usually fellows of a primary college; palliative medicine candidates are usually physician trainees or GPs.
Motivation
- Why pain medicine, or why palliative medicine, and what experiences brought you here?
- What do you understand the biopsychosocial model to mean in practice, and how have you used it?
- What do you know about the training programme, its requirements and its assessments?
- This work carries emotional load and slow progress. How will you sustain yourself, and how will you know when you need support?
- Tell us about your experience working in a multidisciplinary team with psychologists, physiotherapists and nurses.
- Where do you see yourself practising at the end of training?
Panels want the experiences in terms of patients: the one whose pain you could not fix and what you learned, the death you were present for. The biopsychosocial question is answered with a patient in whom the biology, the psychology and the circumstances all mattered and what you did about each. For wellbeing, a strategy and an escalation, because this is the specialty where burnout is quietest.
The conversations
- A patient with chronic back pain is angry that you will not increase their opioids.
- A family want their dying mother to have fluids and antibiotics that will not help.
- A patient asks you directly how long they have to live.
- A patient asks about voluntary assisted dying. How do you respond, and what are your obligations in this state?
- How do you talk to a patient about reducing opioids they have taken for years?
The angry patient: acknowledge the pain and the anger, explain the evidence and the risks plainly, offer what you can (the multidisciplinary plan, the alternatives), hold the line with respect, and keep the relationship. The family: the goals of care, what the treatments would and would not do, the patient's wishes, and the comfort that will be given. The prognosis question: honesty with ranges, the acknowledgement of uncertainty, and the question of what they need to know for. Voluntary assisted dying: know your state's law, the clinician's obligations including those of the conscientious objector, and respond with respect and information rather than deflection.
The clinical scenarios
- A patient with metastatic cancer has uncontrolled pain despite escalating opioids and is now drowsy and confused.
- A 45 year old with three years of back pain, on high dose opioids, not working and depressed.
- A patient at the end of life becomes acutely agitated.
- Opioid induced hyperalgesia.
- A ketamine infusion with hallucinations.
- Complex regional pain syndrome referred to you.
Structure: assess the whole person, treat what can be treated with the specifics (the opioid rotation, the adjuvants, the non drug treatments, the terminal agitation protocol), involve the team, explain to the patient and family, and review.
Ethics
- A patient in a nursing home is receiving inadequate analgesia because staff fear opioids.
- A patient asks you to document a pain condition to support a compensation claim you do not think is justified.
- A colleague is prescribing high dose opioids outside guidelines.
- How do you provide culturally safe end of life care to an Aboriginal patient and their family?
System questions
The gaps in pain and palliative services, especially rural; how community palliative care, hospital teams and hospices fit together in your state; the national opioid prescribing strategy and its effect on practice.
What the panels score
Motivation rooted in patients, the biopsychosocial model understood in practice, communication that can hold anger and grief, the law on assisted dying known, multidisciplinary practice valued, honesty about sustainability, and a public view of the specialty's gaps.
Preparing
Write the patient stories. Learn your state's assisted dying law. Practise the opioid conversation with someone playing the angry patient. Prepare a two minute answer to each question. The bank on this site is marked lower evidence for these programmes; if you are interviewed, tell us what you were asked.