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Medical Factors
Chronic pain can be a struggle for everyone

At a glance:
Chronic pain is a distressing problem for patients. Doctors can find management of patients with chronic
chronic
continuing a long time or recurring frequently
 pain difficult and frustrating. Patients are looking for a diagnosis
diagnosis
The process of identifying a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of various diagnostic procedures.
 and the cause of their pain. In this study the doctors' focus was on patients' beliefs and the psychological
psychological
Refers to a person's perceptions, thought processes, emotions, personality and behaviour. Psychologists can treat mental health problems.
 approach to pain management. When doctors and patients are not working in partnership, both are frustrated and the outcomes are less successful.
Perspectives:
Employee
Dealing with chronic pain is difficult. In this study the doctors considered the patients had become entrenched in their pain and did not want to listen to what they had to say. Patients felt their doctors were not interested. The patients considered they needed a specific diagnosis before they were able to find a way forward.

People expect that medicine can fix most problems. They suppose that a test, x-ray, or scan will show the cause of their condition and a cure can then be provided. Unfortunately medicine is not well equipped to identify and deal with many pain problems. A visible cause for low back pain can only be found in 20% of cases. Whether the condition is low back pain or some other form of long-term pain, tests to identify the source of the pain are often unhelpful or misleading.

When a patient is suffering with pain, doctors will try to test for a cause. When one cannot be found doctors will conclude that the pain is psychological, while the patient will continue to seek a physical explanation. Both the patient and doctor can become frustrated.

Over the last 20 years doctors have learnt a great deal about pain. They have learnt that most problems will improve with the passage of time and it is important that people are given realistic expectations about how long it will take for their condition to improve. If the patient expects the problem will be better within two months, but they still experience significant pain at four months it is understandable that they will be frustrated, distressed, and looking for a cure.

Long-term chronic pain problems are minimised when people:

are given good advice about the condition
understand what they can do to help themselves
are provided with treatment to lessen their pain
understand realistic timeframes for improvement
are encouraged to remain active and to continue with everyday tasks
are supported at home and in the workplace and they feel their condition is acknowledged
Employer
Having long-term or chronic pain is a difficult situation for anyone. It is made worse when a person feels their condition is not being taken seriously. This can happen in the workplace when co-workers or supervisors do not understand their difficulties. This study shows that it can also happen within the doctor-patient relationship.

It is more difficult to deal with people who are distressed. They often require more time, return to work can be disjointed, and their productivity at work may be less. However chronic pain sufferer can develop deeper, long-term suffering if they avoid returning to daily tasks and activity.

Notwithstanding the difficulties, people in this group can do well if they are given support, clear advice and explanation, and all parties work together to support return to work.

If an employee is distressed with their ongoing condition, make sure they are getting good advice and have confidence in their treating practitioners. Seeking a complete cure is often unsuccessful. However when people feel supported and have an understanding of their condition they are more able to remain functional and be reintegrated with their work colleagues.
Treater
Treating patients with long-term pain is challenging. Early effective management of patients with pain has been shown to reduce long-term problems.

It is important patients are given appropriate advice about the natural history of the condition. People often expect their musculoskeletal
musculoskeletal
Involving the muscles and the skeleton. This term includes the limbs, neck, shoulders and back. 'Musculoskeletal problem' refers to many different conditions that can affect the tendons, muscles and related structures.
 problems to resolve quickly and frustrations occur when they have ongoing pain. We know many musculoskeletal problems take some time to settle.

Simple regular analgesics, appropriate short-term treatment, and encouraging people to remain active are the appropriate steps for many non specific musculoskeletal conditions. Other people need early specific medical treatment. Treating practitioners
treating practitioner
A health professional that treats patients. In return to work this may include doctors, physiotherapists, chiropractors, osteopaths, psychologists, masseurs, etc.
  and other parties should work proactively to ensure patients receive rapid access to appropriate medical and surgical care when required.
Insurer
Patients are more likely to develop long-term or chronic health problems when there is poor communication in the early stages of a condition. When the condition is acknowledged, appropriate advice about the normal course of it is given, and emotional support and treatment are provided, there are less long-term or chronic pain problems.

Providing high-quality treatment can be a challenge. Patients need relevant investigations done without delay. Some conditions can be missed if the appropriate investigations and treatment are not provided. On the other hand, problems can be caused through over investigation and overtreatment. Finding the right balance is not easy.

The WorkCover agent or insurer can support best practice by making sure delays in providing treatment are avoided. Support the employee to ask questions and to be confident in the advice they are being given by the treating practitioners.
Original Article, Authors & Publication Details:
D. Kenny* (2004).

Construction of chronic pain in doctor-patient relationships: bridging the communication chasm. Patient Education and Counseling; 52:297-305

*School of Behavioural and Community Health Sciences, Faculty of Health Sciences, The University of Sydney
Background, Study Objectives, How It Was Done:
Chronic pain causes enormous suffering in patients and significant frustration for doctors. Management of chronic pain is often expensive, confusing and distressing. It is important to recognise that doctors and patients approach chronic pain from different perspectives and that this can cause conflict.

For patients, a biological explanation for their pain is important to legitimise their experience and provide hope. However, a medical cause for a patient's symptoms is only found in less than 15% of visits to the doctor. When patients with low-back pain are referred to an orthopaedic specialist a medical cause for their pain is only found in 20% of cases.

For doctors, pain without a visible cause is usually believed to have a psychological cause. This means that the medical approach to diagnosis and treatment that the patient expects is at odds with the doctors' beliefs about the problem.

When a medical explanation can't be found but a patient's pain does not go away, they can become alienated, anxious and depressed if they are not reassured that their experience is legitimate. They might seek a medical explanation even more fiercely. Ineffective treatments, including the use of drugs and even surgery, are costly and can be dangerous to the patient's health. Months and years of these treatments with no improvement leave the patient with no path forward.

Ultimately, patients can feel as though their doctors do not believe that their condition is genuine, and that their character and integrity are in question. Doctors can feel helpless when treatments and investigations fail to bring about any improvement, and frustrated when patients continue wanting these procedures.
In this study, interviewed 20 patients with extreme chronic pain (6 males and 14 females), and 22 doctors who specialised in chronic pain (21 males and 1 female) and analysed the information given. The interviews were unstructured and lasted for between 45 minutes and 2 hours. The two groups were considered separately, it was not patients and their doctors, but rather a group of patients and an unrelated group of doctors. The patients had undergone all relevant medical tests and treatments without finding an explanation for their condition and without improving their symptoms. They had not been able to lessen the impact of their pain on their social and work lives.
Study Findings:
A few main themes emerged from the interviews. Patients and doctors both talked about the cause and meaning of the patient's pain, conflict caused by differences in these beliefs, and communication.

The cause and meaning of the patient's pain

Doctors were focused on the task of convincing patients that their pain had a psychological cause rather than a biological one. This was personally important for the doctors, who had no more medical tests or treatments to draw on. For patients, finding a biological cause was essential to their feelings of credibility. None of the patients interviewed accepted the psychological explanation for their pain. About a quarter of doctors commented on the importance of listening to patients and taking their beliefs on board, but this was in order to “turn these beliefs around.'

All 20 patients reported that their doctor believed the pain was “all in the mind.' They felt that doctors did not think their pain was “really happening.' The doctor's responses to the interview showed that this was in fact the case. The doctors believed that the pain could not be physical because there was no visible evidence of a physical problem.

Conflict

When patients do not get better, they don't follow expectations about what a “good' or “normal' patient should do. In society they can become isolated and ashamed and for doctors it is disheartening to treat them. In this study, one doctor described chronic pain management as a “thankless task,' and one said “I am no longer interested in people who don't get better.' Four of the doctors in this study left the field, and reported that they always referred chronic pain patients to another specialist straight away.

The interviews highlighted other difficulties faced by doctors. “So much damage has been done already. There's a limit to what we can do.' Doctors can feel powerless when tests and treatments fail. The accepted medical approach to this situation is that the pain is psychological, and doctors run out of options when they can't convince patients that this approach is reasonable.

Both doctors and patients typecast each other. Patients felt they were treated like “just another chronic pain case.' Patients who sought compensation for their pain were in particular described by doctors as “all the same.' Some patients felt as though they were helplessly referred to endless treatments, when following their doctor's instructions only seemed to make their pain worse. About half the patients were more assertive and, for example, “interviewed' their doctor before deciding whether or not to find a new one. Doctors did not approve of patients who “thought they were experts in the field' or sought more information about their condition from sources such as the internet.

In this study, traditional medical treatment had become less important for both patients and doctors. For patients, anger at their lack of care and respect was more important. The doctors saw their patients as having unhelpful false beliefs about their pain, and their focus was to make them let go of these beliefs.

The author described some patients as eventually taking on “pain as their career,' spending all their time being tested and treated. Others gave up on the medical system altogether and sought alternative medicine such as naturopathy and osteopathy instead.

Communication

The interviews showed that in conversations between doctors and patients, both parties wanted to be the "speaker' and became frustrated when the other person was not perceived as a good listener. Both felt the other had “fixed ideas' or were “hard to educate,' and attempts to be heard caused more conflict.

When their words were not enough to convince doctors, and tests could not confirm their pain, patients sometimes tried to make themselves understood by behaving as though they were in pain. These “pain behaviours' made doctors more likely to believe the patients' pain was psychological.
Conclusions:
Doctors and patients have different beliefs and expectations about the causes and management of chronic pain. These can cause significant conflict and distress.
distress
Severe suffering, pain, anxiety or sorrow
 

For both doctors and patients, diagnostic
diagnostic
Used to identify a medical condition or disease by its symptoms, the findings from a medical examination, and from the results of X-rays, scans, or other tests.
 tests “prove the condition is real,' but when tests do not give an explanation of a patient's pain the two groups respond differently. Doctors conclude that the pain is psychological or “in the mind,' whereas patients continue seeking a diagnosis in order to confirm to themselves that their experience is legitimate, and in order to demonstrate this to others. “Medical proof' is essential for their self-respect and social acceptance.

Importantly, neither can prove their opinion is correct. Patients' faith in diagnostic tests in this situation is unlikely to bring about the evidence they desire, but the psychological explanation for their pain cannot be proved by doctors either.

Faced with their patients' demands, desperation and hostility, doctors can order inappropriate tests and treatments that can cause harm. Eventually, the failure to reach a common understanding about the patient's pain causes doctors and patients become dissatisfied with each other. Patients can feel victimised and blamed. Doctors can feel demoralised and frustrated. In the most extreme cases some patients give up on traditional medicine altogether, and some doctors give up on treating chronic pain patients.

The researcher draws on the interviews and on other studies to conclude that a different way of describing unexplained pain may be needed. They suggest that the problem should not be viewed in such black-and-white terms, especially since psychological factors influence how patients experience their symptoms in all illnesses. They advise that a cooperative partnership between doctors and patients to improve treatment outcomes.
References:
No PubMed Abstract available
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