CME Course

Historical Alternans in the Emergency Department (H.A.t.E.D.) for Pain: An Analysis of Patient Pain Descriptors to Attending and Trainee Clinicians

The concept of “historical alternans” (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. This novel prospective observational study evaluated this concept using identical five-point pain descriptor surveys in an academic emergency department setting administered by trainee and attending clinicians.

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Target Audience

Southern Medical Journal (SMJ) is an interdisciplinary, multi-specialty Journal, and articles span the spectrum of medical topics, providing timely, up-to-date information for primary care physicians and specialists alike. The SMJ enables physicians to provide the best possible care to patients in this age of rapidly changing modern medicine.  Therefore, the readers of the SMJ are an appropriate target for this article.

Goals and Objectives

The concept of “historical alternans” (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain.

This novel prospective observational study evaluated this concept using identical five-point pain descriptor surveys in an academic emergency department setting administered by trainee and attending clinicians. The majority of patient encounters demonstrated at least one difference in categorical pain description between trainee and attending clinicians, most often that of the VNRS score. Our findings show that HA does occur in the ED setting, although the magnitude of difference in description may be minimal. Future studies should aim to increase the size and scope of the population, as well as examine descriptions reported to nursing compared with providers after the patient is in a room. At the conclusion of the session, learners should be better prepared to:

  • Recognize that inter-examiner and inter-examination variability may occur during patient encounters.
  • Recognize potential limitations of using numerical pain scale scores.
  • Recognize that these variability and limitation issues may confound clinical decision-making regarding patient care interventions during patient encounters.

Course Information

CME Release Date: January 8, 2021
Valid for credit through: January 7, 2022
Course type: CME Journal Article 
Estimated time of completion: 1 hour

Credits Available

Southern Medical Association is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Southern Medical Association designates this Journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

 AAPA: AAPA accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society.

AANPCP: The American Academy of Nurse Practitioners Certification Program (AANPCP) accepts AMA PRA Category 1 Credit™ from organizations accredited by the ACCME.

Healthcare Professionals
For information on applicability and acceptance of continuing education credit for this activity, please consult your professional licensing board.  All healthcare professionals who are not MDs or DOs will receive a certificate of participation.

Instructions for Participation and Credit

This activity is designed to be completed within the time designated; learners should claim only those credits that reflect the time actually spent in the activity. To successfully earn credit, participants must complete the activity online during the valid credit period noted, following these steps:

  • Read the course description, accreditation information, and disclosure information.
  • Login to access the course content and resources for further study.
  • Complete the activity evaluation and attestation.

Upon successful completion of the test, evaluation and attestation, your certificate will be processed and emailed from customerservice@sma.org within approximately 1 hour. Credits will be archived for 6 years; at any point within this time period you may login to your account to print a duplicate copy of your certificate.

Disclosure of Relevant Financial Relationships

As an organization accredited by the ACCME, Southern Medical Association requires everyone who is in a position to control the content of an education activity to disclose all relevant financial relationships with any commercial interest. The ACCME defines "relevant financial relationships" as financial relationships in any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest.

Southern Medical Association encourages Speakers/Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

The following individuals, unless otherwise notedhave no relevant financial relationships to disclose.

Manuscript Author(s):
Brandon M. Carius, DSc, MPAS, PA-C
Michael D. April, MD, PhD
Craig S. Pedersen, MD
Steve G. Schauer, DO, MS

 SMJ Editor-in-Chief:
Steven T. Baldwin, MD

Southern Medical Association/Southern Medical Journal Editorial Staff:
Jennifer S. Price, MA, Managing Editor
Anita McCabe, Copyeditor

Course Materials

This content is limited to qualifying members.

Existing members, please login first.

If you have an existing account please login now to access this course or view your purchase options.

Purchase this course now ($10)

Create a free account, then purchase purchase access to this course.

Purchase a membership plan (fees vary)

Premium members can access all courses plus recieve many more benefits. View all membership plans and benefit packages.