John has been Dr. Walker’s patient for years, and has been very happy with his care. But over the past six months, John has developed pain in his back and leg, and has mentioned it several times to Dr. Walker. Now, when John talks about it, he struggles to describe the pain and, as the conversation continues, he becomes uneasy and frustrated. Though Dr. Walker listens to his concerns, John finds the conversation unproductive and leaves the appointment unhappy.
Both patients and primary care physicians often report that conversations about pain, like the one described above, are a frequent source of frustration that can sometimes strain doctor-patient relationships. But few studies have investigated whether conversations about pain actually affect patient-physician interactions or communication during clinic visits. A study led by Stephen Henry, MD, a Robert Wood Johnson Foundation (RWJF)/U.S. Department of Veterans Affairs Clinical Scholar (2009-2012), sought to shed light on the issue and yielded some unexpected results.
The study, published in the July 2013 edition of The Journal of Pain, finds that pain discussions have a significant influence on patients’ displays of emotion, but less influence on physicians’ displays of emotion and on doctor-patient rapport.
Henry, an assistant professor of medicine at the University of California, Davis in Sacramento, and his co-author, Susan Eggly, PhD, studied video recordings of Detroit-area primary care visits involving a predominantly low-income, minority population. The videos had previously been collected by investigators at the Wayne State University Karmanos Cancer Institute, where Eggly is an associate professor.
Henry and Eggly used these videos to investigate whether discussions about pain were associated with changes in emotions or doctor-patient rapport. Trained research assistants, who were unaware of study hypotheses, rated 30-second clips from each visit on variables related to patient-physician rapport and the emotions that patients and providers displayed. “We specifically selected the slices in a way that allowed us to compare discussions about pain and other topics within the same visit and across visits,” Henry says.
The research team found that patients tended to display more intense emotions during pain discussions than during discussions of other topics in the same visits. Patient unease increased during these pain discussions, as did their engagement with the physician.
Physicians, on the other hand, showed no significant change in emotions when patients discussed pain, and the discussions did not affect physician-patient rapport. “We think that, most likely, physicians have more experience in managing their emotions and not displaying them as transparently as patients,” Henry says. “We’re not suggesting physicians don’t feel strong emotions when patients talk about pain, but we think they hide these emotions as part of their professional role or because they have more experience maintaining a composed demeanor.”
Physicians did show unease when patients reported great pain. By analyzing patients’ self-reported pain levels before their visits, the researchers found that greater pain was associated with significant increases in both physician and patient unease. However, despite the unease, there was no change in physician-patient rapport, or positive engagement during discussions of greater or severe pain.
The study is congruent with anecdotal reports that pain is often an emotionally charged and frustrating topic for patients and physicians, Henry says. But the finding that pain discussions are not significantly associated with patient-physician rapport “seems to be at odds with the common assertion that discussions about pain are associated with poor patient-physician relationships and poor patient-physician communication,” the study says.
The authors suggest that discussions of pain may only indirectly affect rapport, or that regardless of the topic being discussed, “strong social and institutional conventions” may keep relational aspects of patient-physician communication from changing as much as individual communication behaviors.
Henry plans to continue his research in California, using a new patient population and investigating misunderstandings that take place in office visits to identify specific areas of disagreement or tension. “We hope to develop interventions or training programs to improve communication about those issues. This is only one building block in a long program of research,” Henry says.
“Patient-clinician interaction and communication were a major focus of my time as a Clinical Scholar. I’m very grateful for the program, which allowed me the training and support to do this type of very detailed, important, basic communication research,” he says.
Henry’s study was funded by the RWJF Clinical Scholars program, supported in part by the U.S. Department of Veterans Affairs (VA), and by grants from the RWJF Health & Society Scholars program at the University of Michigan and the Blue Cross Blue Shield of Michigan Foundation.
Read the study.
Read more about Henry’s research here and here.
Learn more about the RWJF Clinical Scholars program.
For an overview of RWJF Scholar and Fellow opportunities, visit www.RWJFLeaders.org.