When a patient is experiencing pain, good communication with the doctor is important for proper diagnosis and management. Pain is one of the most common reasons patients seek primary care, Robert Wood Johnson Foundation (RWJF) Clinical Scholar Stephen Henry, MD, says, but pain is also subjective and can be difficult to articulate and describe. This can cause lost time and frustration for both the provider and patient.
A new study by Henry and Susan Eggly, PhD, associate professor at Wayne State University Karmanos Cancer Institute, finds that, for those who are part of underserved populations, discussions about pain take up a substantial amount of time during primary care visits. Pain-related discussions came up in nearly seven of 10 visits, they found, taking up 23 percent of time across all visits. The study was published online in January by the Journal of General Internal Medicine.
“We know from epidemiologic data that racial minorities and those with low socioeconomic status tend to have, on average, more frequent and more severe pain than the general population,” says Henry, a Clinical Scholar (2009-2012) at the University of Michigan and the VA Ann Arbor Healthcare System. “We thought focusing on that population, which suffers under a greater burden of pain, could generate insights with the potential not only to improve pain management generally, but also for reducing disparities in pain management.”
Previous studies on this topic have relied on patient recall and medical records, which may not accurately reflect the frequency and duration of pain-related discussions. So here, the researchers chose instead to use video recordings of Detroit-area primary care visits, which had been previously collected by investigators at the Wayne State University Karmanos Cancer Institute, to directly observe the interactions between patients and physicians.
They created a coding system to identify discussions of the description, history, diagnosis and treatment of physical pain, and to calculate the percent of total visit time spent discussing pain. Questionnaires and the Medical Outcomes Study 20-item health survey (SF-20) completed by patients before the visits provided demographic information, the reasons patients sought care, and measures of general health, physical function, and mental health.
Among the predominantly low-income, minority population sample, the researchers found that 69 percent of visits included pain-related discussions. These discussions proved common even when patients had reported on the SF-20 that they had not experienced pain in the previous four weeks. When patients and physician discussed pain, these discussions lasted on average 5.9 minutes, or 34 percent of the total visit time.
“The more severe and more frequent reports of pain among this population translate into very frequent and very long discussions about pain that take up a lot of time in primary care,” Henry says.
Patients who reported good baseline physical function on the SF-20 were less likely to discuss pain with their physicians, but if the topic did come up, these patients spent a larger percentage of the visit time discussing pain than patients who had reported poor physical function. “Pain is one of the most common causes of physical limitations, but we hypothesize that patients who have worse physical function tend to talk more about their physical limitations rather than talking about pain explicitly,” Henry explains. Their coding system only counted explicit mentions of physical pain. “For example, there was one video in which an older woman talked extensively about having trouble walking because of her knees, but she never actually said her knees hurt or that she was in pain.”
The large percentage of time spent on pain-related discussions suggests that being able to communicate effectively about pain and pain management is important, especially for a physician caring for underserved patients, Henry says. “Better communication may help reduce or eliminate the pain-related disparities we see in this population.”
Improving Doctor-Patient Communication
Effective communication between physicians and patients is an area of focus for Henry in his work in the RWJF Clinical Scholars program. Beyond providing appropriate care for patients, communication helps maintain good rapport between a doctor and patient.
“Many physicians report they don’t feel adequately trained to discuss pain, and physicians and patients commonly report that these conversations are difficult,” Henry says. “One of my long-term goals is to give them both the communication skills to talk about pain in ways that are not frustrating and that can preserve a good doctor-patient relationship.”
Henry plans to continue his research on pain communication by studying whether the length of pain-related discussions affects the quality of pain diagnosis and management.
While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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