The influence of contextual variables on judgments about patients and their pain

Practice recommendations for contextualizing explanations of headache pain within a biopsychosocial model

OBJECTIVE

The current study aimed to identify non-dismissive language and synthesize practice recommendations for medical providers to use when discussing potential psychological etiologies of chronic pain.

METHODS

Community-recruited emerging adults (18- to 25-year-olds; N = 138; 68 % female) participated in the current study as part of a larger online survey. Participants were randomly assigned to read either a "dismissive" (i.e., attributed pain to primarily psychological etiologies) or "biopsychosocial" (i.e., provided a more nuanced explanation of the complex interplay between psychological and physiological etiologies of pain) vignette describing hypothetical patient-provider interactions regarding -chronic daily headache complaints.

RESULTS

Participants who read the biopsychosocial vignette and male participants reported significantly more positive reactions (e.g., more satisfaction, higher likelihood of continued care). Qualitative results showed that participants who read the dismissive vignette were more likely to feel their time had been wasted and obligated to explain their pain further.

CONCLUSIONS

Hypothetical provider explanations of psychological etiologies of chronic daily headache pain were received more positively when contextualized within a biopsychosocial framework.

PRACTICE IMPLICATIONS

This article presents practice recommendations for how medical providers should introduce potential psychological etiologies of a patient's headache pain experience in a non-dismissive manner to decrease the likelihood of provider-generated pain dismissal experiences.

Investigating the relationship between pain indicators and observers' judgements of pain

BACKGROUND

Due to the inherent subjectivity of pain, it is difficult to make accurate judgements of pain in others. Research has found discrepancies between the ways in which perceived "objective" (e.g., medical evidence of injury) and "subjective" information (e.g., self-report) influence judgements of pain. This study aims to explore which potential cues (depictions of sensory input, brain activation, self-reported pain and facial expressions) participants are most influenced by when evaluating pain in others.

METHODS

First, 60 participants (23 women, 36 ± 10 years old) judged who was in more pain between two different pain indicators representing two different patients. These trials revealed which congruent indicator (i.e., two high pain indicators) would most influence participant decisions. Second, participants prescribed quantities of analgesia for one patient's pain based on two different pain indicators. These trials revealed which incongruent indicators (i.e., one high and one low indicator) would most influence participant decisions.

RESULTS

As predicted, facial expressions were perceived as subjective and were the least likely, among all pain indicators, to influence observer's judgements of pain. Participants relied upon indicators they perceived as objective. Self-report pain ratings had the greatest influence on participants judgements about how much analgesic cream to prescribe and was perceived as objective by half of the participants.

CONCLUSIONS

We found that in situations where incongruent information was presented about an individual's pain, participants relied on pain indicators that they perceived to be objective. The current study provides important insights about biases that people hold when making judgements of pain in others.

SIGNIFICANCE

Interpretation and assessment of pain remains one of the largest barriers to pain management and involves complex, idiosyncratic processing. This study provides insights into what information participants view as critical in making attributions of pain when presented with multiple, seemingly incongruent sources of information.

Popcorn in the pain clinic: A content analysis of the depiction of patients with chronic pain and their management in motion pictures

The watching of films is popular and accessible to broad segments of the population. The depiction of medical conditions in films has the potential to affect the public's perception of them and contribute to stereotypes and stigma. We investigated how patients with chronic pain and their management are depicted in feature films. Films that contained characters with or references to chronic pain were searched for using databases such as the International Movie Database. Themes that emerged from the content analysis revolved around the films' depictions of characters with pain, their health care providers, and therapies for pain management. Patients with chronic pain were depicted in various ways, including in manners that could elicit empathy from audiences or that might contribute to the development of negative stereotypes about them. The attitudes of health care professionals toward patients with chronic pain ranged from compassionate to dispassionate. Pain management was typically depicted as lacking in breadth or using multidisciplinary approaches with a focus on pharmacological management. The variety of topics related to chronic pain depicted in feature films lends to their use in medical education strategies to better inform health care professions trainees about chronic pain management.

Neural mechanisms of modulations of empathy and altruism by beliefs of others' pain

Perceived cues signaling others' pain induce empathy which in turn motivates altruistic behavior toward those who appear suffering. This perception-emotion-behavior reactivity is the core of human altruism but does not always occur in real-life situations. Here, by integrating behavioral and multimodal neuroimaging measures, we investigate neural mechanisms underlying modulations of empathy and altruistic behavior by beliefs of others' pain (BOP). We show evidence that lack of BOP reduces subjective estimation of others' painful feelings and decreases monetary donations to those who show pain expressions. Moreover, lack of BOP attenuates neural responses to their pain expressions within 200 ms after face onset and modulates neural responses to others' pain in the insular, post-central, and frontal cortices. Our findings suggest that BOP provide a cognitive basis of human empathy and altruism and unravel the intermediate neural mechanisms.

Parents Reliably Identify Pain Dismissal by Pediatric Providers

OBJECTIVES

Approximately 40% of children and adolescents with chronic pain report at least 1 dismissal experience, citing medical providers and parents as the primary and most distressing dismissers. Previous research indicates sex differences in pain dismissal experience and observer pain perception. This study examined parental reactions to dismissive provider-child scenarios and the influence of provider and patient sex on perceptions.

METHODS

Community parents (N=326) completed an online survey. Parents were randomized to listen to 1 of 8 vignettes of a provider-child chronic pain scenario. Vignettes varied by type of scenario (appropriate vs. dismissive)×provider sex×patient sex.

RESULTS

Overall, parents rated the dismissive scenario more negatively. There was a significant interaction between provider sex and scenario regarding likelihood to bring their own child to this provider and a significant 3-way interaction regarding provider belief of the pain complaint. When asked how they would feel if this was their own child, parents who heard the dismissive scenario reported more negative reactions. When asked what they would say to the provider, parents in the dismissive condition were more likely to defend their child and request a second opinion.

DISCUSSION

Parents consistently identified the dismissive language in a child and provider scenario. Female providers and sex-matched dyads seem to be more polarizing in terms of likelihood to bring their child to the provider and belief of pain, respectively. Providers within these groups may need to be especially cautious with their language when responding to pediatric chronic pain complaints.

Medical and Nonmedical Information during Multidisciplinary Team Meetings in Cancer Care

Background: Multidisciplinary team (MDT) meetings provide treatment recommendations based on available information and collective decision-making in teams with complementary professions, disciplines and skills. We aimed to map ancillary medical and nonmedical patient information during case presentations and case discussions in MDT meetings in cancer care. Methods: Through a nonparticipant, observational approach, we mapped verbal information on medical, nonmedical and patient-related characteristics and classified these based on content. Data were collected from 336 case discussions in three MDTs for neuro-oncology, sarcoma and hepato-biliary cancer. Results: Information on physical status was presented in 48.2% of the case discussions, psychological status in 8.9% and comorbidity in 48.5% of the cases. Nonmedical factors, such as family relations, occupation, country of origin and abode were referred to in 3.6–7.7% of the cases, and patient preferences were reported in 4.2%. Conclusions: Provision of information on comorbidities in half of the cases and on patient characteristics and treatment preferences in <10% of case discussions suggest a need to define data elements and develop reporting standards to support robust MDT decision-making.

Classism in Pain Care: The Role of Patient Socioeconomic Status on Nurses’ Pain Assessment and Management Practices

Objective

Research on social disparities in pain care has been mainly focused on the role of race/racism and sex/sexism. Classism in pain assessment and management practices has been much less investigated. We aimed to test the effect of patient socioeconomic status (SES; a proxy of social class) on nurses’ pain assessment and management practices and whether patient SES modulated the effects of patient distress and evidence of pathology on such practices.

Design

Two experimental studies with a two (patient SES: low/high) by two (patient distress or evidence of pathology: absent/present) between-subject design.

Subjects

Female nurses participated in two experimental studies (N = 150/N = 158).

Methods

Nurses were presented with a vignette/picture depicting the clinical case of a female with chronic low back pain, followed by a video of the patient performing a pain-inducing movement. Afterwards, nurses reported their pain assessment and management practices.

Results

The low-SES patient’s pain was assessed as less intense, more attributed to psychological factors, and considered less credible (in the presence of distress cues) than the higher-SES patient’s pain. Higher SES buffered the detrimental impact of the presence of distress cues on pain assessment. No effects were found on management practices.

Conclusions

Our findings point to the potential buffering role of SES against the detrimental effect of certain clinical cues on pain assessments. This study contributes to highlighting the need for further investigation of the role of SES/social class on pain care and its underlying meanings and processes.

Exploring assessment of medical students' competencies in pain medicine-A review

Supplemental Digital Content is Available in the Text.

Introduction:

Considering the continuing high prevalence and public health burden of pain, it is critical that medical students are equipped with competencies in the field of pain medicine. Robust assessment of student expertise is integral for effective implementation of competency-based medical education.

Objective:

The aim of this review was to describe the literature regarding methods for assessing pain medicine competencies in medical students.

Method:

PubMed, Medline, EMBASE, ERIC, and Google Scholar, and BEME data bases were searched for empirical studies primarily focusing on assessment of any domain of pain medicine competencies in medical students published between January 1997 and December 2016.

Results:

A total of 41 studies met the inclusion criteria. Most assessments were performed for low-stakes summative purposes and did not reflect contemporary theories of assessment. Assessments were predominantly undertaken using written tests or clinical simulation methods. The most common pain medicine education topics assessed were pain pharmacology and the management of cancer and low-back pain. Most studies focussed on assessment of cognitive levels of learning as opposed to more challenging domains of demonstrating skills and attitudes or developing and implementing pain management plans.

Conclusion:

This review highlights the need for more robust assessment tools that effectively measure the abilities of medical students to integrate pain-related competencies into clinical practice. A Pain Medicine Assessment Framework has been developed to encourage systematic planning of pain medicine assessment at medical schools internationally and to promote continuous multidimensional assessments in a variety of clinical contexts based on well-defined pain medicine competencies.

Patients' Non-Medical Characteristics Contribute to Collective Medical Decision-Making at Multidisciplinary Oncological Team Meetings

Background

The contribution of patients’ non-medical characteristics to individual physicians’ decision-making has attracted considerable attention, but little information is available on this topic in the context of collective decision-making. Medical decision-making at cancer centres is currently carried out using a collective approach, at MultiDisciplinary Team (MDT) meetings. The aim of this study was to determine how patients’ non-medical characteristics are presented at MDT meetings and how this information may affect the team’s final medical decisions.

Design

Observations were conducted at a French Cancer Centre during MDT meetings at which non-standard cases involving some uncertainty were discussed from March to May 2014. Physicians’ verbal statements and predefined contextual parameters were collected with a non-participant observational approach. Non numerical data collected in the form of open notes were then coded for quantitative analysis. Univariate and multivariate statistical analyses were performed.

Results

In the final sample of patients’ records included and discussed (N = 290), non-medical characteristics were mentioned in 32.8% (n = 95) of the cases. These characteristics corresponded to demographics in 22.8% (n = 66) of the cases, psychological data in 11.7% (n = 34), and relational data in 6.2% (n = 18). The patient’s age and his/her “likeability” were the most frequently mentioned characteristics. In 17.9% of the cases discussed, the final decision was deferred: this outcome was positively associated with the patients’ non-medical characteristics and with uncertainty about the outcome of the therapeutic options available.

Limitations

The design of the study made it difficult to draw definite cause-and-effect conclusions.

Conclusion

The Social Representations approach suggests that patients’ non-medical characteristics constitute a kind of tacit professional knowledge that may be frequently mobilised in physicians’ everyday professional practice. The links observed between patients’ attributes and the medical decisions made at these meetings show that these attributes should be taken into account in order to understand how medical decisions are reached in difficult situations of this kind.