Chronic pain (CP) affects more than 100 million Americans and is estimated to cost society $635 billion a year. Chronic low back pain (cLBP) is one of its most prevalent manifestations. There is evidence that both opioid prescribing and imaging are overused in primary care of cLBP, contrary to guidelines. Patients often report that they feel their physicians are skeptical or dismissive of their complaints. They may perceive physicians' explanations that their pain does not have a physiological mechanism as invalidating or blaming; and they are commonly frustrated by lack of benefit of treatment. Patient adherence to behavioral therapies such as exercise is often poor, as the natural response to pain is to protect the seemingly injured body. Individuals with cLBP may experience disability and social withdrawal, but will fare better in the long run if they remain active and engaged. Hence the physician wants to encourage the patient to overcome the natural response to pain. Communication with the patient is the most important tool for a physician in managemen of CP, but physicians, often find patients with CP to be emotionally demanding, or manipulative. Extant studies of physician-patient interaction around cLBP are based on self-reports, and little direct observation. To improve clinical care, it is essential to understand features of the interaction that enhance shared decision?making and subsequent patient understanding, satisfaction, treatment adherence, and function and pain outcomes. In the current proposal, we will, for the first time, apply validated, proven methods for categorizing communication processes to cLBP management. We will classify provider and patient verbal behaviors to measure such constructs as patient engagement, informed and autonomous choice, patient centered and facilitative communication by the provider, and patient commitment to health related behaviors, while also labeling the subject matter of interaction, such as opioid use; and match behaviors to outcomes. The long term goals of this research are to develop provider and patient-focused interventions that can improve clinical communication in chronic pain, and achieve better outcomes, while reducing harms from opioid misuse and other sub-optimal clinical practices. We propose to recruit a cohort of 50 patients with cLBP receiving care in 2 sites, audio-record and transcribe multiple encounters with each patient over a 15 month period, conduct follow-up interviews with the patient after each encounter, code and analyze the interactions. We hypothesize that patient engagement and facilitative provider practices, as operationalized by our methods, will be associated with patient function and pain outcomes. This work will support the development of promising, testable interventions, to improve clinical communication in cLBP, based on our newly developed knowledge of effective and ineffective practices.
This proposed project will address a critical gap in understanding of the content and interaction process of communication in primary care management of chronic pain, and their relationship to outcomes. Results will lay the foundation for improved clinical communication, diagnosis of non-adherence and effective responses, and improved outcomes including less pain and better social functioning.
