The Effect of Discussing Pain on Patient-Physician Communication in a Low-Income, Black, Primary Care Patient Population

An Interview with Stephen G. Henry, MD

Stephen Henry is assistant professor of medicine (Division of General Medicine, Geriatrics, and Bioethics) at University of California, Davis. His research focuses on understanding and improving patient-clinician communication, with a particular focus on improving face-to-face communication about pain and opioids in primary care. Dr. Henry works clinically as a primary care physician at UC Davis in Sacramento, California.

Elsbeth McSorley:

Could you summarize your study?

Stephen G. Henry, MD: Patients and physicians report that discussions about pain are frequently frustrating and unproductive. However, the relationship between discussions about pain and patient-physician communication is poorly understood. This study used video-recorded primary care visits to explore whether primary care discussions about pain were associated with changes in ratings of patient or physician emotions or patient-physician rapport. Our study found that the discussions about pain were associated with heightened displays of both positive and negative patient emotions. Discussions about pain were not significantly associated with physician emotions or with patient-physician rapport. Additionally, patients’ pain severity was significantly associated with greater physician and patient unease, but not with other variables.


EM: What do these findings suggest?

SGH: The study’s findings suggest that primary care patients, unlike their physicians, tend to display significantly greater emotional intensity during discussions about their pain compared to discussions about other health-related topics.


EM: In your opinion, why is the topic of pain and patient-physician communication important?

SGH: This topic is important because pain is one of the most common reasons that patients seek medical care. Two percent of all outpatient visits are related to back pain alone. Pain is a very common ailment that people want treatment for and therefore it’s an important topic for primary care providers because it takes up a lot of mental space and is very time consuming. We don’t have a simple, highly effective treatment for chronic pain which leaves providers struggling to find effective options. Also the issues surrounding use of opioids to treat chronic pain is always looming in the background and may make primary care providers apprehensive.


EM: How did you gather data for this study?

SGH: We analyzed 133 video-recorded visits and patient self-report data at a clinic providing primary care to a low-income, black patient population. We used “thin slice” methods to rate two or three 30-second video segments from each visit on variables related to patient and physician affect (i.e., displayed emotion) and patient-physician rapport. Discussions about pain were associated with a .32 increase in patient unease (P < .001) and a .21 increase in patient positive engagement (P = .004; standardized coefficients) compared to discussions about other topics during the same visit.


EM: Why did you choose a low-income, black patient population for this study?

SGH: We have good data that vulnerable populations – like the low-income, black patient population we selected for this study – generally have a higher incidence of pain than the general patient population, often at higher levels. The result is a patient population that spends a lot of time talking with their doctors about pain. Out of all the primary care visits we recorded, 70% included discussions about pain.


EM: How could poor patient-physician communication impact chronic pain treatment?

SGH: Effective communication and building trust over time is a very important aspect of the patient-physician relationship. It is much easier for healthcare providers to treat pain when there is a positive, trusting relationship between them and their patients. A poor patient-physician relationship is thus likely to negatively impact chronic pain treatment. Effective chronic pain treatment requires a lot of open, honest communication from both the patient and the physician. Patients need to be honest and forthcoming with their physicians, and in return, healthcare providers should approach pain patients with an open mind and not assume that all patients with pain are looking for opioids.


EM: What would be a good follow-up study?

SGH: A good follow-up study might record pain discussions in primary care like this one did but then have patients and physicians watch the video recordings of their discussion and explain what they were thinking and feeling during those discussions. Getting patients’ and physicians’ perspectives on these discussions can help identify strategies to improve communication about pain in primary care.