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].