Rural Pain Care Challenges

An Interview with Michael Schatman, PhD, CPE

Michael Schatman, PhD, CPE, is the Executive Director of the Foundation for Ethics in Pain Care. He has been involved in multidisciplinary chronic pain care for 26 years and still maintains a private practice in pain psychology. He is the editor of Ethical Issues in Chronic Pain Management and Chronic Pain Management: Guidelines for Multidisciplinary Program Development, and has written more than 40 articles and chapters on pain management. He is chair of the American Pain Society’s Ethics Special Interest Group and also serves on its Ethics Committee. Dr. Schatman serves on the editorial boards of Pain Medicine, The Journal of Pain, Pain Practice, Pain and Therapy, Journal of Pain Research, and Psychological Injury and Law.

Wendy L. Williams, BSN, MEd:

What are some of the challenges that primary care providers (PCPs) in rural areas face when it comes to chronic pain management?

Michael Schatman, PhD, CPE: One major challenge is the access to quality pain care specialists. Nationally, there is a lack of access to quality pain care. The shortage of care is worse in rural areas, which is due in part to the lack of physicians, nurses, and other allied health professionals working in those areas. There are not enough medical social workers or physical therapists, and there is a serious shortage of mental health professionals. Approximately 19% of the U.S. population resides in a rural area – but only 11% of physicians practice in rural settings, and just 3% of medical students choose to practice in rural areas upon graduation.


WW: How does the general healthcare provider shortage impact pain care overall?

MS: There is an inadequate number of practicing pain specialists in the U.S. to meet the needs of Americans with chronic pain. If you take the view that interdisciplinary pain care is an optimal model for persons with chronic non-cancer pain, those comprehensive services are not at the level that they should be across the country. Even in urban settings, or in large cities with academic medical centers, persons with pain cannot access high-quality, interdisciplinary care. The Commission on Accreditation of Rehabilitation Facilities (CARF), the accrediting body for multidisciplinary pain programs (for chronic, non-cancer pain), now lists only 59 accredited pain programs in the U.S., with the total number of multidisciplinary programs now estimated at under 150 (down from over 1000 just a decade ago). The overall shortage of pain specialists affects persons with pain on a national level, and brings even more significant challenges to those living with chronic pain in rural areas.


WW: What other factors affect rural PCPs when caring for persons with chronic pain?

MS: Because rural occupations tend to be physically demanding and hard on the body over time, the likelihood of PCPs assessing and treating pain is high. In addition, the incidence of chronic pain is higher in rural areas because the population is often older, obese, and impoverished. Social factors also play a role: transportation issues, inadequate access to health insurance, and stigma among rural populations in regards to seeking out mental health services that would help to manage the effects of living with chronic pain.


WW: Are there aspects of a rural lifestyle that may actually help people living with chronic pain?

MS: Because of a greater social solidarity and overall community commitment in rural areas, there may actually be less social isolation. Pain is viewed as a part of rural life, since jobs are often physically demanding. There is a willingness to work through pain and not let it derail one’s life, which can be a positive way of coping. The rural culture values independence and self-reliance despite the presence of pain.


WW: What are some concrete strategies that rural PCPs can apply to their practice to enhance their assessment and care for persons with chronic pain?

MS: I would advocate that the rural PCP adopt a biopsychosocial model for pain assessment and care. Moving from the more common biomedical model to the biopsychosocial model is critically important. As far as concrete strategies, I would offer the following for consideration:

  • Adopt the use of telehealth and telerehabilitation. Clinical care at a distance is progressing as a model and is being used more frequently to treat disease in rural areas, and it would be beneficial to integrate distance care into chronic pain care.
  • Screen for anxiety and depression, as they inevitably accompany chronic or persistent pain. My work as both a clinician and researcher has led me to define chronic pain as any type of pain that affects the whole person –vocationally, socially, financially, recreationally, sexually, etc. When the patient’s experience of pain negatively impacts his or her life in any way, it is more than likely that anxiety and/or depression are present. The PCP will be much more effective in caring for patients by screening them for and pharmacologically treating co-occurring conditions. There are many validated tools available for screening in primary care settings that are quick to administer.
  • Approach patients as a health coach. The rural patient is independently-minded. Approaching a patient as a coach is found to be more effective than merely giving out medical advice. One technique I especially recommend is Motivational Interviewing (MI). MI is patient-centered and enables the healthcare provider to “steer” the patient in a healthier direction. So much about pain management involves the patient taking on self-management. MI is an approach that has the patient explore and resolve their ambivalence about behavior change and providers are finding it a useful tool to employ.

It’s hard to provide high-quality pain care in the U.S., and providers in rural areas face challenges in particular. However, rural providers can find ways to improve their skills in chronic pain assessment and care as they strive to treat and serve their patients well.