Graphic Medicine Reflective Learning Activity on Chronic Pain Beliefs Among Dentistry Students

Pain is complex and may be mismanaged, particularly when patients face intersecting stigma related to substance use, racism, or resource insecurity [1, 2]. Pain is a primary reason for dental visits; however, dental students consistently report low knowledge and confidence in assessing and managing orofacial pain [3]. The need has previously been identified for biopsychosocial pain education for dentists with an emphasis on complex cases requiring interdisciplinary approaches [3]. We describe our approach to encourage student reflection on patient perspectives and diverse biopsychosocial factors contributing to pain. Interactive activities centered around a graphic medicine story [4] (comic-style visual storytelling) were implemented, including self-reflection, small-group discussion, and a lecture. We evaluated student perspectives and change in beliefs and attitudes toward people living with pain with third-year Doctor of Dental Medicine (DMD) students at the University of Saskatchewan (n = 44 invited; n = 39 submitted data; 89% response rate). With ethics review board approval (BEH-4686), chronic pain beliefs were assessed pre-activity using the nine-item subscale-one of the Chronic Pain Myths Scale (CPMS-1; Survey-one; α = 0.86), which focuses on knowledge, beliefs, and attitudes toward people living with chronic pain [5]. Students read a graphic medicine story depicting a person living with chronic pain who presents to the emergency department for pain relief (5 min; see URL: https://saskpain.ca/wp-content/uploads/2025/03/Theresas-Story_Colour-FINAL.pdf). The story portrays universally applicable principles regarding assessment, communication, and patient-centered care. Students discussed the story in small-groups and identified three key group learnings and one challenging question they had after reflection and discussion (30 min). These were shared on a class Google document and discussed with the full class (10 min). Chronic pain beliefs were reassessed post-activity using the CPSM-1 (Survey-two). A 2-h lecture followed, focused on neurophysiological mechanisms of pain, optimizing pain assessment, multimodal pain management, shared decision-making, and reducing stigma in healthcare. Students rated the learning activity with four, five-point Likert scale questions and descriptions of individual key learnings. Likert question response options ranged from “Strongly Disagree” to “Strongly Agree,” with higher ratings indicating greater agreement (Survey-three). Change in pain beliefs was examined with a paired t-test. CPMS-1 scores showed small, statistically significant improvement post-activity (t[38] = 2.91; p = 0.006; Cohen's d = 0.465; see Table 1). Individual change scores revealed interindividual variability in belief changes (see Table 2). Small-group and individual qualitative results were analyzed with structural coding. Three repeating structural codes were drawn from small-group and individual key learnings: (1) awareness of gaps in knowledge about pain management and equity in health services, (2) recognition of the need for patient-centered assessment and approaches to care, and (3) empathy regarding the impacts of pain and limited access to healthcare. Overall, students positively rated the learning activity (see Table 3). Although this activity with a non-dental story was favorably rated, assumptions of broad generalizability of findings are not possible since student demographics were not collected. Further research is needed to determine if stories with dental-specific content elicit different responses. The brief CPMS-1 scale was useful for in-class assessment, but more rigorous measurement of pain-related concepts and experimental study designs could further inform educational approaches. We would like to acknowledge Patient Partner Dayna Fesciuc and Indigenous Knowledge Keepers Judy Pelly and Gilbert Kewistep for their involvement on the team to develop the graphic medicine stories, and Taylor Teckchandani for statistical support. We acknowledge Arcana Creative for illustrations and story development. Thank you to the Saskatchewan Pain Society, Inc. (SaskPain), the University of Saskatchewan, the University of Regina, and the Saskatchewan Health Authority for supporting this research. Funding for this project was provided by the Saskatchewan Health Research Foundation and Saskatchewan Centre for Patient Oriented Research (Innovation Grant #6174). Funding for this project was provided by the Saskatchewan Health Research Foundation and Saskatchewan Centre for Patient Oriented Research (Innovation Grant #6174). The authors declare no conflicts of interest.