The key to understanding patients’ needs for pain management is context. The tool to help achieve that understanding is communication. It is becoming more widely accepted that the Medical Home is an important foundation of effective and concerted medical care. Further, an effective relationship between health care providers in Primary Care (PCPs) and their patients is recognized as a critical piece of the complex health care puzzle1. The significance of this important component is even further magnified in the management of patients with chronic pain when one considers that pain is the most commonly reported symptom in the primary care setting; approximately 57% of American adults suffer from chronic or recurrent pain2.
A number of obstacles can impede the development of an effective patient-provider relationship for chronic pain management. From the provider perspective, when questioned about treatment of chronic pain, PCPs often voice specific concerns about major challenges they face in providing effective pain treatment. These include a lack of adequate training, time constraints in the primary care setting, lack of consensus on the benefits of long-term treatment of chronic pain with opioids, fear of regulatory scrutiny, and aberrant drug-related behavior (e.g., addiction), to name a few.
In addition to these clinician-based barriers of managing chronic pain is the challenge of developing and maintaining an effective relationship with the chronic pain patient. Specific challenges exist in the primary care setting and can have a negative impact on treatment outcomes. It is generally considered essential that the interaction between health care providers and their patients demonstrate understanding and empathy, the knowledge to promote self-management, empowerment, and shared decision making, as well as a feeling of partnership.
Most clinicians recognize the value of a strong relationship with their patients. Matthias et al. recently conducted interviews with PCPs in the VA system in Indianapolis2. Many of those surveyed confirmed the thinking that the provider-patient relationship is a key ingredient in primary care. Participants stated clear advantages to a strong relationship, such as:
- – Development of trust
- – Enhanced ability to assess pain and function
- – Facilitation of treatment adjustments
- – Overall improved communication
Providers surveyed by these investigators also expressed concerns about specific patient-related “threats” to a quality relationship. These included patient pressure and expectations that opioids would be prescribed in a “fast-food” fashion; the subjectivity of patient complaints (further complicated by a disconnect between diagnostic findings and patient accounts of pain); perceived deficiencies of credibility of complaints; and guilt about not treating a patient compassionately, even in the absence of a clear rationale for using an opioid as a component of therapy. Other concerns included the “difficult” patient. These included patients who were angry and/or abusive as a result of their chronic pain or prior treatment, patients who did not adhere to treatment plans, or patients who were considered to be “doctor shopping”. Other patient variables can be barriers as well, such as age, gender, health literacy, and cultural background.
A common pitfall in the clinical practice of pain management is the tendency to focus on the medical or technical aspects of a patient’s pain, and not on how it affects the patient in their personal life. Effective communication between a health care provider and a patient is a very important bridge to empathy. If it is a given that patient-centered care requires a provider to consider the patient’s perspective, then by definition, a degree of empathy is required. At an empiric level, empathetic medical care in general is associated with better health outcomes4, “possibly because empathic physicians elicit more information from patients, as well as higher levels of patient participation in treatment”3. As published literature on the positive effects of communication skills in medical care increases, it is becoming increasingly evident that effective communication is a core competency in medical training.
Beck at al6 and other experts7 mention specific tactics that health care providers can employ to improve information exchange.
- – Listen to the patient
- – Acknowledge and validate the patient’s pain symptoms
- – Address patient problems in the context of daily living, social relations and emotions
- – Establish eye contact
- – Be aware of body language, mannerisms and vocal inflections
- – Have available trusted health education to give to the patient to review at a later time
- – Summarize patient statements to provide clarification
- – Clarify one’s own statements to assure understanding by the patient
- – Speak at the patient’s level of understanding and health literacy
- – Share medical data and findings throughout the diagnostic workup
- – Discuss treatment effects
- – Avoid directive behavior
Evidence supports the fact that when patients are informed and involved in decision making they adhere more to medical recommendations and carry out more health-related behavior change5. Improved information exchange has the potential to result in higher levels of informed consent, and improved clinician and patient satisfaction. From the perspective of the patient-provider relationship in chronic pain management, this should include:
- – A detailed history and physical to assess the pain condition and identify the specific context of how the patient’s pain interferes with their activities of daily living
- – Mutual establishment and understanding of realistic treatment goals and expectations
- – Formulation of a meaningful treatment plan that is tailored to the patient’s specific needs and the clinician’s comfort level
- – Participatory decision making with the patient
- – Modification of the treatment plan based on re-assessment and communication with the patient
The National Board of Medical Examiners, Federation of State Medical Boards and the Educational Commission for Foreign Medical Graduates have proposed an examination between the third and fourth year of medical school that “requires students to demonstrate they can gather information from patients, perform a physical examination, and communicate their findings to patients and colleagues” using standardized patients7. Many training institutions already include this. The paternalistic approach to medical decision making is changing as patients have more access to information, and increasingly pose questions requiring answers about therapeutic choices. Patients now often advise each other as a way to become educated and “informed consumers”.
Patient satisfaction with their care is an important metric in health care today, and it may rest heavily on how successfully the transition from paternalism to partnership in the patient-health care provider relationship is accomplished. Access to trusted and quality information and effective, empathetic patient-provider interaction, is at the center of this change. The responsibility lies with the health care provider to nurture the relationship. Teutsch7 accurately states “The practice of medicine is much more than a black bag of clever tests and diagnoses—it encompasses the art of human interaction.”
- 1. Brown JB, Stewart M, Ryan BL. Outcomes of patient-provider interaction. In: Thompson TL, Dorsey AM, Miller KI, Parrott R, eds. Handbook of Health Communication. Mahwah, NJ: Erlbaum; 2003:141–61.
- 2. Matthias MS, Krebs EE, Collins LA, Bergman AA, Coffing J, Bair MJ. Communicating about Opioids for Chronic Pain: A Qualitative Study of Patient Attributions and the Influence of the Patient-Physician Relationship. European Journal of Pain 2014;18(6):835-843. PMID: 24921073
- 3. Hojat M. Empathy in Patient Care: Antecedents, Development, Measurement, and Outcomes. New York: Springer; 2007.
- 4. DiBlasi Z, Harkness EE, Georgiou A, Kleijnen J. Influence of context effect on health outcomes: a systematic review. Lancet. 2001, 357:762.
- 5. DiMatteo R. Health behaviors and care decisions: an overview of professional-patient communication. In: Gochman DS, ed. Handbook of Health Behavior Research II: Provider Determinants. New York: Plenum Press;1997:5–22.
- 6. Beck RS, Daughtridge R, Sloane PD. Physician-patient communication in the primary care office: a systematic review. J Am Board Fam Pract. 2002 Jan-Feb; 15(1):25-38.
- 7. Teutsch C. Patient-doctor communication. Medical Clinics of North America. 2003 Sep; 87(5):1115-45.