Saturday, January 1, 2011

Why Practitioners Dislike Chronic Pain Patients

While many studies have looked at the treatment of chronic pain from patients’ perspectives, recent research reported in the journal Pain Medicine suggests that treating these patients can be a pain for healthcare practitioners. Accordingly, improving the delivery of effective pain management should consider the needs and concerns of practitioners, especially primary care providers.

Last October 2010, our blogpost titled “Why Do Patients Dislike Pain Care Providers?” [here] reported that patients have low levels of satisfaction with their pain care providers, the care they receive, and the outcomes. In general, patients felt disrespected and distrusted, suspected of drug-seeking, and having their self-reported symptoms dismissed as trivial and/or not warranting medical attention.

To examine perceptions from the “practitioner side of the stethoscope,” researchers gathered healthcare provider perspectives on caring for patients with chronic pain. A qualitative study used open-ended, in-depth interviews to survey 20 primary care providers. Participants had clinical experience ranging from 5 to 20+ years and were employed at the Roudebush VA Medical Center, Indianapolis, Indiana; half were male, and there were 15 physicians, 4 nurse practitioners, and 1 pharmacist (PharmD) representing 5 different clinics at the Center.

Three broad themes emerged from the analysis of survey responses:
  1. Providers emphasized the importance of the patient–provider relationship, acknowledging that productive relationships with patients are essential for good pain care;

  2. however, they detailed many problems encountered when caring for patients with chronic pain, including (a) feeling pressured by patients to treat with opioids, (b) the believability of patients' reports of pain, (c) worries about patients seeking medications for uses other than pain control or to divert for financial gain, and (d) dealing with hostile, abusive, or otherwise difficult patients; and

  3. they described the emotional strain they sometimes experienced in caring for chronic pain, including feeling frustrated, ungratified, and guilty if treatment outcomes were less than expected or desired.
According to study first author Marianne S. Matthias, PhD, in an interview, “The providers often described dread when seeing a [pain] patient's name on their clinic schedule, knowing the interaction was going to be unsuccessful at best, difficult or hostile at worst. They described feeling ineffective and unsuccessful in their ability to treat many of their patients with pain. Interestingly, reports of frustration and negative experiences were present throughout the sample. Even those who were generally positive about their relationships with their patients reported difficulties, distrust and other relational issues at times."

In their comments, providers noted how they want to be liked by patients and respected by their peers; being “fired” by a patient who believes he/she has not received adequate pain care is personally demoralizing and professionally detrimental. Some providers expressed having inadequate training and poor guidelines to follow for treating pain, and they regretted being perceived as cruel when they could not relieve a patient’s pain. As one remarked, “Of course you want to relieve their pain, so I beat myself up. I feel guilty when these people end up yelling at me, and they do!”

The study authors conclude that strategies are needed to ease frustrations and defuse hostility in clinical interactions, and such approaches would improve pain management from the perspectives of both patients and providers. However they note that solutions to difficulties in chronic pain care extend beyond the individual provider. The organizational culture in which healthcare providers practice — for example if there is pressure to prescribe or not to prescribe opioids for chronic pain — can play an important role in shaping their experiences and ultimately make a difference in their relationships with patients.

COMMENTARY: This small study was funded by the U.S. Department of Veterans Affairs and the VA Medical Center from which primary care providers were sampled serves about 30,000 patients per year; 38% are over age 65, 94% male, and 89% Caucasian. Furthermore, this population included a high prevalence of financially disadvantaged patients with coexisting medical and psychiatric disorders. So, the experiences and perspectives expressed in the survey may not completely generalize to other healthcare providers, nor to other settings apart from the VA system in the U.S.

It is interesting and of some importance that many of the challenges expressed by practitioners in this study directly parallel those typically stated by patients. Unresolved issues of trust, frustration, misunderstandings, and failed expectations on both sides lead to negative interactions that take an emotional toll from practitioners and patients alike. In patients this may incur anger and hostility, while practitioners may develop what Matthias and colleagues call “compassion fatigue” brought on by repeatedly disappointing or negative encounters. Yet, healthcare providers are expected to effectively manage patient-practitioner relationships just as they are expected to successfully manage pain via appropriate interventions.

Matthias et al. believe that the clinical implications of their findings are two-fold. First, practitioners needs cannot be ignored when considering pain care; they require appropriate training along with emotional and institutional support as they care for sometimes difficult patients with chronic pain. Second, improving practitioners' patient-centered communication skills — including demonstrating empathy and encouraging shared decision-making — holds promise for alleviating some of the strain and burden reported by providers, ultimately leading to improved patient care. Actions steps for achieving these important goals, however, still need to be determined.

REFERENCE: Matthias MS, Parpart AL, Nyland KA, et al. The Patient–Provider Relationship in Chronic Pain Care: Providers' Perspectives. Pain Medicine. 2010(Nov);11(11):1688–1697 [abstract here].


Anonymous said...

Could it be that many pain patients are angry and hostile because their pain is being undertreated to begin with? Why don’t medical professionals understand this?

SB. Leavitt, MA, PhD said...

The above point seems important. We noted research evidence in a blogpost last October 2010 [available here] proposing that untreated or undertreated pain (eg, inadequate opioid therapy) may result in a patient who is anxious, dysphoric, irritable, and restless. Anger and hostility might be natural extensions of this during the clinical interaction, and healthcare providers need to be aware of this. -- SBL

healthskills said...

Does the research showing that patients with high distress & chronic pain receive less psychosocial information and more biomedical information play a part in this situation too? Could it reflect the mismatch between biomedical (cure, reduce, abolish pain) model and the reality of chronic pain which is that most meds achieve around a 30% reduction in pain? And conversely the mismatch between patients expectations (of cure, pain reduction, abolish pain) while at the same time wanting to feel heard, listened to, acknowledged?

Reta Russell Houghton said...

I agree with Healthskills about the communication problems aspect. I have a chronic pain disorder (RSD/CRPS) and have received very little information about my disorder from my doctors. I felt that no one was listening to my complaints, while comments of RSD-like symptoms were being recorded in my records. I had a surgeon tell me to look it up and only when I backed my ortho into a corner by asking him directly, did I feel I got an honest answer. Then he dumped me by shipping me off to pain management without any explanation of my problem.

I do not believe our medical school properly prepare doctors for patients with chronic illnesses. It is not a matter of curing the illness but of managing the symptoms and improving the patients quality of life. I can see how not being able to heal a patient can make a doctor feel like a failure.

Back to communication, doctors are reluctant to admit they have no answers or solutions. Patients become increasingly frustrated they place trust in the doctors to fix them, when they can't be fixed. But,no one is talking about this. Doctors don't say these words and patients don't ask these questions.

And there is the double sided sword of the internet. It has given me the knowledge of my disorder that has helped me learn how to manage my disorder and live a somewhat normal life. It has connected me with others like me and saved my sanity. But it has also lead some patients to openly question their doctors or to play doctor and self-diagnose their illnesses. And some patients will pick erroneous information, instead of comparing all the data. I can see the doctor's frustration.

And,the third player in this production is the DEA, standing over good doctors that are trying to help patients. Chronic pain is not like acute pain, but that message has been lost or scrambled. One size does not fit all but the DEA doesn't see it that way. Lurking in the background,questioning doctors and accusing them of illegal activity. Are there bad doctors and patients? Yes, and they make life difficult for the rest of us doing everything according to the rules. So the end result is frustration and anger misdirected between the patient and doctor, when it should be directed at the government.

This is an extremely complex problem that will require several solutions. We can start with communicating about the reality of chronic pain. We need to better educate our CP patients with programs like those we have for diabetics and redesign the way we educate our doctors about chronic pain.

Anonymous said...

I have had chronic upper back pain for seven years,it got worse after a cervical spinal fusion. My primary care doc handled my CP very well for 3 years,then sent me to a pain clinic simply to see if they could do better. The pain doc was horrible, treated me like a criminal, was rude and abusive. I told my primary care doc about the pain doc and my PC took me back as the pain doc was making things worse,anxiety,depression set in under his "care". I am a retired police officer,the some officers look down on folks taking narcotic pain meds, so naturally I felt horrible,it went against my learned instincts to use "narcotics",one officer was friends with me for 25 years, and dropped me as a friend when he learned I was taking pain killers, refused to answer emails,phone calls,etc. I've moved to a new city,my primary doc is continuing to treat me with narcotic pain meds, but isn't very friendly. What am I supposed to do? I tried physical therapy, Botox, steroid injections. My current primary may have poor bedside manners,but he's honest and say's pain clinics are "practically useless" (and he's correct). I cannot tolerate the pain w/o some meds,period. When I was a cop I worked in a poor,minority and drug infested area...often on foot or bike patrol. I treated all citizens with respect, and injected some humor in my interactions with the people I served. Why can't most doctors do the same as I did, treat their pain patients with some respect, as opposed to looking at us as potential abusers/diverters,etc? Surly doctors make chronic pain worse, patients feel as if they've done something wrong, yet they're just sick. Docs need to grow up , get off their high horse
and learn to respect patients. We are not all drug addicts and/or weak people. Anywayas the Bible say's, "let he who has not sinned cast the first stone." I've seen a few doctors hooked on their own drugs, and get away with it; thankfully more and more get arrested when they abuse or divert drugs for money,

SB. Leavitt, MA, PhD said...

Mr/Ms “Anonymous” immediately above raises some important points. First of all, is it really fair to imply that ALL pain clinics and ALL doctors who practice there are “practically useless”? Medicine is an imperfect science practiced by imperfect people (who are just like the rest of us in their imperfections).

Second, “narcotics” is more of a legal than a medical term, and it includes illicit drugs like cocaine, methamphetamine, and heroin. Using “narcotics” in reference to legitimately-prescribed opioid analgesics is largely inaccurate, stigmatizing, and, in some cases, mean-spirited.

Anonymous said...

I have had exactly the same experiences. I just wonder if the gov't know they are the ones that opened Pandora's box on all this pain management crap 15 years ago......State by state in the last part of the 90s, each state revised their medical policy to say it was OK to give opiates to non cancer patients in "necessary" doses, as long as that person was an appropriate candidate...Not much --but some things -- were said about who to judge for abuse , diversion and Dr. shopping. Well,I don't have to tell cp people that probably 1/2 the anesthesiologists in this country fled the hospital operating rooms and opened a pain clinic -- after all, they are experts in drugs -- not pain! -- why should they not be experts who deal with dispensing the hard stuff?

So welcome the pain clinic to the vernacular of the final years of the 20th and certainly the first 10years of the 21st. At first, I was on one, in the early 2000s,doctors were writing opiates to didn't even need radiology tests.....It was clear from my visits to pain clinic waiting rooms that there were a lot of junkies there...How would I know....Well, one can always spot another....But that was 30 years ago. Now I've had 3 back surgeries, disabled, medicare, no drug use -- 30 years after I put my partying ways down I was getting 200 mg Methadone rxed to me for Chronic Back pain and lots of surgery problems and very real documented pain stuff -- but I noticed how SO MANY of my fellow patients, didn't have records! They just showed up.Most didn't have insurance...they paid in cash -- The docs at first wrote three months of rxes of hard drugs to clients -- and so there went any supervision for three moths -- this crap went on for five years before it was announced that the pain pills were now the main street drug -- and methadone was especially bad -- you can get that at a clinic for being an addict -- but it's an excellent painkiller and it's the CHEAPEST PAINKILLER ON THE MARKET -- but not the black market. A month's worth of method to Chronic Pain patients costs $50 a month worth of Oxycontin or Fentanyl patches costs nearly 1,000 with no insurance... So YOU try to take methadone off the market for pain -- so millions of people can go without pain medics cause some addicts and drug seekers have infiltrated the pain clinics, which have gotten SO strict over the last year that one clinic has STOPPED rxing pain pills -- it's back to the REALLY expensive and money making scams like back injections, and tens units, and expensive surgery that only makes you worse.

I saw this open season on opiate therapy for CP as such a great thing: Finally this country is getting in step with other places that treat pain like it should be treated....Doctor: You should NEVER turn down a patients request for pain medication if there is even the smallest chance that this patient actually NEEDS it... I'd rather ONE patient or some patients actually fool you and walk way with their 30 pills than for ONE REAL HONEST TO GOODNESS PAIN PATIENT GET TURNED DOWN BECAUSE THE DOCTORS JUST DOE-SN"T BELIEVE YOU -- This is just another account of how are health care so messed up.

Im moving to Europe...

Anonymous said...

Yes, I was just explaining to my pschycologist last week about all of the predjudice and shit I come across every time I have to tell a Dr that I'm on pain meds and a chronic pain patient. If stress causes physical pain, then they are the ones responsible for my pain when I have an appt.

Anonymous said...

Thank you for posting this newsletter and thanks to everyone who reads it and posts responses...

Those of us in 100 million chronic pain sufferers noted in another study are not alone.....

M. Simon said...

Ah. The Drug War strikes again.