Journal of General Internal Medicine

, Volume 27, Issue 7, pp 787–793 | Cite as

How Much Time Do Low-Income Patients and Primary Care Physicians Actually Spend Discussing Pain? A Direct Observation Study

Original Research

ABSTRACT

BACKGROUND

We know little about how much time low-income patients and physicians spend discussing pain during primary care visits.

OBJECTIVE

To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions.

DESIGN

We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables.

PARTICIPANTS

A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents.

MAIN MEASURES

Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain.

KEY RESULTS

Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9 min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously.

CONCLUSIONS

Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.

KEY WORDS

pain patient-physician communication direct observation time primary care patient-physician relationship black patients 

Supplementary material

11606_2011_1960_MOESM1_ESM.doc (78 kb)
ESM 1(DOC 77 kb)

References

  1. 1.
    Gureje O, Von Korff M, Simon GE, Gater R. Persistent pain and well-being—a World Health Organization study in primary care. JAMA. 1998;280:147–51.PubMedCrossRefGoogle Scholar
  2. 2.
    Stewart WF, Ricci JA, Chee E, Morganstein D, Lipton R. Lost productive time and cost due to common pain conditions in the US workforce. JAMA. 2003;290:2443–54.PubMedCrossRefGoogle Scholar
  3. 3.
    Krueger AB, Stone AA. Assessment of pain: a community-based diary survey in the USA. Lancet. 2008;371:1519–25.PubMedCrossRefGoogle Scholar
  4. 4.
    Institute of Medicine. Relieving Pain in America: a Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academies Press; 2011.Google Scholar
  5. 5.
    Kerns R, Otis J, Rosenberg R, Reid MC. Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev. 2003;40:371–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Anderson KO, Green CR, Payne R. Racial and ethnic disparities in pain: causes and consequences of unequal care. J Pain. 2009;10:1187–204.PubMedCrossRefGoogle Scholar
  7. 7.
    Shavers VL, Bakos A, Sheppard VB. Race, ethnicity, and pain among the US adult population. J Health Care Poor Underserved. 2010;21:177–220.PubMedCrossRefGoogle Scholar
  8. 8.
    Mantyselka PT, Turunen JHO, Ahonen RS, Kumpusalo EA. Chronic pain and poor self-rated health. JAMA. 2003;290:2435–42.PubMedCrossRefGoogle Scholar
  9. 9.
    Butchart A, Kerr EA, Heisler M, Piette JD, Krein SL. Experience and management of chronic pain among patients with other complex chronic conditions. Clin J Pain. 2009;25:293–8.PubMedCrossRefGoogle Scholar
  10. 10.
    Matthias MS, Parpart AL, Nyland KA, et al. The patient-provider relationship in chronic pain care: Providers’ perspectives. Pain Med. 2010;11:1688–97.PubMedCrossRefGoogle Scholar
  11. 11.
    Upshur CC, Bacigalupe G, Luckmann R. "They don’t want anything to do with you": patient views of primary care management of chronic pain. Pain Med. 2010;11:1791–8.PubMedCrossRefGoogle Scholar
  12. 12.
    Dosa D, Teno J. Haven’t got time for the pain. J Gen Intern Med. 2010;25:889–90.PubMedCrossRefGoogle Scholar
  13. 13.
    Zubkoff L, Lorenz KA, Lanto AB, et al. Does screening for pain correspond to high quality care for veterans? J Gen Intern Med. 2010;25:900–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Mularski RA, White-Chu F, Overbay D, Miller L, Asch SM, Ganzini L. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med. 2006;21:607–12.PubMedCrossRefGoogle Scholar
  15. 15.
    Zulman DM, Kerr EA, Hofer TP, Heisler M, Zikmund-Fisher BJ. Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients. J Gen Intern Med. 2010;25:408–14.PubMedCrossRefGoogle Scholar
  16. 16.
    Krein SL, Hofer TP, Holleman R, Piette JD, Klamerus ML, Kerr EA. More than a pain in the neck: how discussing chronic pain affects hypertension medication intensification. J Gen Intern Med. 2009;24:911–6.PubMedCrossRefGoogle Scholar
  17. 17.
    Sullivan M, Ferrell B. Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt. J Pain. 2005;6:2–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Matthias MS, Bair MJ. The patient-provider relationship in chronic pain management: where do we go from here? Pain Med. 2010;11:1747–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Stange KC, Zyzanski SJ, Smith TF, et al. How valid are medical records and patient questionnaires for physician profiling and health services research? A comparison with direct observation of patient visits. Med Care. 1998;36:851–67.PubMedCrossRefGoogle Scholar
  20. 20.
    Krebs EE, Bair MJ, Carey TS, Weinberger M. Documentation of pain care processes does not accurately reflect pain management delivered in primary care. J Gen Intern Med. 2010;25:194–9.PubMedCrossRefGoogle Scholar
  21. 21.
    Smith DM, Brown SL, Ubel PA. Mispredictions and misrecollections: challenges for subjective outcome measurement. Disabil Rehabil. 2008;30:418–24.PubMedCrossRefGoogle Scholar
  22. 22.
    Hertwig R, Fanselow C, Hoffrage U. Hindsight bias: how knowledge and heuristics affect our reconstruction of the past. Memory. 2003;11:357–77.PubMedCrossRefGoogle Scholar
  23. 23.
    Ory MG, Yuma PJ, Hurwicz ML, et al. Prevalence and correlates of doctor-geriatric patient lifestyle discussions: analysis of ADEPT videotapes. Prev Med. 2006;43:494–7.PubMedCrossRefGoogle Scholar
  24. 24.
    Bensing JM, Roter DL, Hulsman RL. Communication patterns of primary care physicians in the United States and The Netherlands. J Gen Intern Med. 2003;18:335–42.PubMedCrossRefGoogle Scholar
  25. 25.
    Penner LA, Dovidio JF, Edmondson D, et al. The experience of discrimination and black-white health disparities in medical care. J Black Psychol. 2009;35:180–203.CrossRefGoogle Scholar
  26. 26.
    Penner LA, Dovidio JF, West TV, et al. Aversive racism and medical interactions with black patients: a field study. J Exp Soc Psychol. 2010;46:436–40.PubMedCrossRefGoogle Scholar
  27. 27.
    Stewart AL, Hays RD, Ware JE. The MOS short-form general health survey: reliability and validity in a patient population. Med Care. 1988;26:724–32.PubMedCrossRefGoogle Scholar
  28. 28.
    Albrecht TL, Ruckdeschel JC, Ray FL, et al. A portable, unobtrusive device for videorecording clinical interactions. Behave Res Methods. 2005;37:165–9.CrossRefGoogle Scholar
  29. 29.
    Noldus LPJJ, Trienes RJH, Hendriksen AHM, Jansen H, Jansen RG. The observer video-pro: new software for the collection, management, and presentation of time-structured data from videotapes and digital media files. Behav Res Methods Instrum Comput. 2000;32:197–206.PubMedCrossRefGoogle Scholar
  30. 30.
    Harris J, Pryor J, Adams S. The challenge of intercoder agreement in qualitative inquiry. Electronic Emissary; 1997; Available from: http://emissary.wm.edu/templates/content/publications/intercoder-agreement.pdf. Accessed 1 December 2011.
  31. 31.
    Hsaio C, Cherry DK, Beatty PC, Rechtsteiner EA. National ambulatory medical care survey: 2007 summary. Hyattsville, Maryland: National Center for Health Statistics. Available from: http://www.cdc.gov/nchs/data/nhsr/nhsr027.pdf. Accessed 1 December 2011.
  32. 32.
    Kerr EA, Heisler M, Krein SL, et al. Beyond comorbidity counts: how do comorbidity type and severity influence diabetes patients’ treatment priorities and self-management? J Gen Intern Med. 2007;22:1635–40.PubMedCrossRefGoogle Scholar
  33. 33.
    Rigler SK, Studenski S, Wallace D, Reker DM, Duncan PW. Co-morbidity adjustment for functional outcomes in community-dwelling older adults. Clin Rehabil. 2002;16:420–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Hanley JA, Negassa A, Edwardes MDd, Forrester JE. Statistical analysis of correlated data using generalized estimating equations: an orientation. Am J Epidemiol. 2003;157:364–75.PubMedCrossRefGoogle Scholar
  35. 35.
    Diggle P, Heagerty P, Liang K-L, Zeger SL. Analysis of Longitudinal Data. 2nd ed. Oxford, New York: Oxford University Press; 2002.Google Scholar
  36. 36.
    Royston P. Multiple imputation of missing values: update. Stata J. 2005;5:188–201.Google Scholar
  37. 37.
    Royston P. Multiple imputation of missing values: further update of ice, with an emphasis on categorical variables. Stata J. 2009;9:466–77.Google Scholar
  38. 38.
    Tai-Seale M, Bolin J, Bao X, Street R. Management of chronic pain among older patients: inside primary care in the US. Eur J Pain. 2011;[in press].Google Scholar
  39. 39.
    Rios RR, Zautra AJ. Socioeconomic disparities in pain: the role of economic hardship and daily financial worry. Health Psychol. 2011;30:58–66.PubMedCrossRefGoogle Scholar
  40. 40.
    Bruckenthal P, Reid MC, Reisner L. Special issues in the management of chronic pain in older adults. Pain Med. 2009;10:S67–78.PubMedCrossRefGoogle Scholar
  41. 41.
    Krebs EE, Bair MJ, Damush TM, Tu W, Wu J, Kroenke K. Comparative responsiveness of pain outcome measures among primary care patients with musculoskeletal pain. Med Care. 2010;48:1007–14.PubMedCrossRefGoogle Scholar
  42. 42.
    Howard DL, Bunch CD, Mundia WO, et al. Comparing United States versus international medical school graduate physicians who serve African-American and white elderly. Health Serv Res. 2006;41:2155–81.PubMedCrossRefGoogle Scholar
  43. 43.
    Varkey AB, Manwell LB, Williams ES, et al. Separate and unequal: clinics where minority and nonminority patients receive primary care. Arch Intern Med. 2009;169:243–50.PubMedCrossRefGoogle Scholar
  44. 44.
    Cooper LA, Roter DL, Johnson RL, Ford DE, Steinwachs DM, Powe NR. Patient-centered communication, ratings of care, and concordance of patient and physician race. Ann Intern Med. 2003;139:907–15.PubMedGoogle Scholar
  45. 45.
    Saultz JW. Defining and measuring interpersonal continuity of care. Ann Fam Med. 2003;1:134–43.PubMedCrossRefGoogle Scholar
  46. 46.
    Rogers J, Curtis P. The concept and measurement of continuity in primary care. Am J Public Health. 1980;70:122–7.PubMedCrossRefGoogle Scholar
  47. 47.
    Burgess DJ, van Ryn M, Crowley-Matoka M, Malat J. Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping. Pain Med. 2006;7:119–34.PubMedCrossRefGoogle Scholar
  48. 48.
    Klonoff EA. Disparities in the provision of medical care: an outcome in search of an explanation. J Behav Med. 2009;32:48–63.PubMedCrossRefGoogle Scholar
  49. 49.
    Eggly S, Tzelepis A. Relational control in difficult physician-patient encounters: negotiating treatment for pain. J Heal Commun. 2001;6:323–33.CrossRefGoogle Scholar
  50. 50.
    Donabedian A. The quality of care: how can it be assessed? JAMA. 1988;260:1743–8.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2012

Authors and Affiliations

  1. 1.VA Ann Arbor Healthcare SystemAnn ArborUSA
  2. 2.Department of Internal MedicineUniversity of MichiganAnn ArborUSA
  3. 3.Population Studies and Disparities Research Program, Department of OncologyWayne State UniversityDetroitUSA
  4. 4.Karmanos Cancer InstituteDetroitUSA
  5. 5.Robert Wood Johnson Foundation Clinical Scholars programUniversity of MichiganAnn ArborUSA

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