Doctors and patients often disagree on pain treatment goals
Disagreements between doctors and patients over the priorities of pain treatment are common during primary care office visits, new research from UC Davis Health shows. Patients hope to reduce pain intensity and identify the cause, while physicians aim to improve physical function and reduce medication side effects, including dependency.
"We wanted to understand why discussions about pain between patients and doctors are often contentious and unproductive," said lead author Stephen Henry, assistant professor of internal medicine at UC Davis. "Primary care physicians treat the majority of patients with chronic pain, but they aren't always equipped to establish clear, shared treatment goals with their patients."
The proposed training is especially important now, given recent state and federal guidelines recommending that doctors work collaboratively with patients on observable goals for pain treatment, Henry said. In light of the epidemic of opioid abuse and overdose, the guidelines also minimize reducing pain intensity as a primary treatment goal, creating new challenges for physicians when discussing pain treatment with patients.
"It is critical for doctors and patients to be on the same page and not working at cross purposes," Henry said.
The research included 87 patients receiving opioid prescriptions for chronic musculoskeletal pain and 49 internal or family medicine physicians from two UC Davis Medical Center clinics in Sacramento, Calif. In most cases, patients were seeing their regular physicians. Patients receiving pain treatment as part of cancer or palliative care were excluded from the study.
Immediately following clinic visits between November 2014 and January 2016, the patients completed questionnaires to rate their experiences and rank their goals for pain management. The physicians independently completed questionnaires about the level of visit difficulty, along with their own rankings of goals for the patient's pain management.
Nearly half (48 percent) of patients ranked reducing pain intensity as their top priority, followed by 22 percent who ranked diagnosing the reasons for their pain as most important. In contrast, physicians ranked improving function as the top priority for 41 percent of patients and reducing medication side effects as most important for 26 percent.
In addition, patients' and physicians' top priorities for pain management usually did not match. In 62 percent of visits, the physician's first- and second-ranked treatment priorities did not include the patient's top-ranked treatment priority.
Physicians also rated 41 percent of the patient visits as "difficult," meaning the interactions were challenging or emotionally taxing. Primary care physicians typically rate 15 to 18 percent of patient visits as difficult.
One surprising outcome was that patients rated their doctors' office experiences as fairly positive, even when clinicians did not. There also was no evidence that goal disagreements influenced patients' experience ratings. This may reflect the fact that patients tend to have positive relationships with their regular physicians, even though they don't always agree with them, according to Henry.
The researchers next want to identify best practices for patient-doctor communications that can be incorporated into training aimed at helping physicians better communicate with patients suffering from chronic pain.
"We need to make sure physicians have the medical skills it takes to effectively and safely treat pain, as well as the communications skills needed to discuss treatment goals and navigate instances when they don't see eye-to-eye with patients," Henry said.