Communication and Clinician Relationships to Improve Care for Patients With Chronic Pain

Introduction

In March 1927, Dr. Francis Peabody, Harvard Medical School educator and Boston surgeon, published a seminal article in the Journal of the American Medical Association with the oft-quoted maxim, “One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.” Caring, by optimizing therapeutic relationships between clinicians and patients, has since been characterized as the practice of “patient-centered” medical care. In 2001, patient-centered care was described by the National Academy of Medicine’s (formerly Institute of Medicine) Crossing the Quality Chiasm: A New Health System for the 21st Century as “respectful of and responsive to individual patient preferences, needs and values, and ensuring that patients’ values guide all clinical decisions.” Patient-centered care consists of two essential components: 1) taking the patients’ perspective on their illness and their life and 2) activating the patient for self-care. Both of these components are essential in the care of patients with chronic pain.

All clinically directed health care involves interpersonal interactions of patients with their treatment providing clinicians. So, why is this therapeutic relationship especially important in the context of caring for patients with chronic pain? Chronic pain, a biopsychosocial condition, by its very nature, includes more than just a straightforward communication of biomedical objective information. Unlike some other medical conditions, pain is not itself visible. Therefore individuals with chronic pain often struggle to have their condition recognized and legitimated. The comprehensive assessment and effective treatment of chronic pain also entails an understanding of its impact, so we must also understand our patients within the broader context of their pain experience and how they see themselves managing, or more likely struggling, with their persistent and intrusive painful sensations. This includes relationships with families and communities. It also includes managing home and work responsibilities and striving for life goals that offer meaning and purpose in their lives.

Hearing the patient identify personal goals of pain care and providing a space and an opportunity to comfortably disclose their beliefs and expectations and how it is that they really feel means that the management of patients with chronic pain requires a trusting relationship with a clinician. This type of relationship requires communicating with patients in their own words and recognizing their behaviors from their unique perspectives, and also by acknowledging that their pain is “real.” Treatment relationships begin with therapeutically effective communication. This chapter will describe why empathic communication is especially important for chronic pain management, how a strong therapeutic alliance can improve chronic pain care outcomes, and what specific clinical competencies have been demonstrated to improve patient engagement in their treatment.

Listening and Narrative Medicine

In 2010, Eloise Carr, RN PhD, a researcher studying patient experiences of chronic pain, recalled a patient’s statement: “Stop trying to cure me and start listening.” Clearly, this individual’s prior experience of pain treatment did not include “being heard.” Being heard means being acknowledged. Being heard means being understood. Listening to the patient is fundamental to establishing the clinician-patient relationship.

However, demonstrating that you have listened and that you understand is another essential part. Check with your patient if you have understood their predicament with their pain. Restate what you have heard and ask the patient if you have it right. Acknowledge the pain and its impact on their life. When pain becomes chronic and therefore complex, objective physical exam findings, imaging, and laboratory studies are insufficient to capture the nature and effects of the illness for the patient. Patient self-reported pain intensity has long been a component of chronic pain evaluation. But it is a gross oversimplification of a chronic illness and leaves many questions unanswered. In 2014, an undergraduate journalism major enrolled in an elective course titled “Pain” was asked, “What does 12/10 pain intensity mean?” He replied, “Maybe the patient is shouting.” So, with a maximum score of “10” to rate an unimaginably severe pain experience, this “unheard” patient felt there was no other option than to increase the numeric volume to “12/10.” A patient who feels understood will be more likely to trust their provider, be more likely to follow suggested treatment recommendations, and be more satisfied with their care.

Communication begins with an action , such as a patient sending a message of distress, followed by an interaction whereby the physician responds with a message of understanding, and a transaction , such as commitments to a future course of action. The style and techniques for effective listening will vary based on the differences of personality, temperament, and cultural and racial experiences of clinicians and their patients. Communication is also much like a dance since each partner strives to follow the other’s cues. Although conversations with patients struggling with chronic pain do follow a classical choreography, it often requires a jazz-like improvisation.

Published recommendations now call for a wider range of questions beyond quantification of pain intensity, including interference with function, enjoyment of life, sleep, mood, treatment expectations, and goals. Above all, patients want to tell the story of their pain, and they want to know that their clinicians have understood it. Chronic pain is experienced within an individual’s unique life events, preformed and yet changeable social context, and subjective cognitive and emotional states. Pain neuroscience researchers describe a so-called “dynamic pain connectome” based on fMRI evidence of “brain-wide network communication on multiple timescales,” and that “attentional states are in constant fluctuation.” According to pain neuroimaging researcher Irene Tracey, “Pain is not a unitary thing, and no two pains are the same, even in the same individual.” Scientific medicine relies upon measurement to both diagnose and track treatment outcomes. Without specific biomarkers that can describe, record, measure, and track the variable and dynamic human experience of pain, validated patient reported outcome questionnaires are necessary. So too is listening.

The biopsychosocial evaluation and treatment of chronic pain also depend upon an in-depth exploration of the patient’s own beliefs and attributions, what it is they understand to be causing their pain and why it persists even after extensive biomedical evaluations and many treatments have been tried and failed. What does the patient believe to be the cause for their persistent pain? It may be that the cause for their pain has so far simply been missed. Why do they believe prior treatments have failed? It may be a conviction that their prior doctors just do not know, or worse, do not care. What are their worries? Often it is being told “ there is nothing left to be done ” or thinking, “ it’s all in my head. ” What might other family members and friends be thinking? Maybe “ I’m just making it up ,” “I’m a burden on everyone,” or “ I’m not someone they want to be with anymore. ” What expectations will define a successful outcome? Maybe the doctor “ could do the correct surgery ,” the “ right procedure ,” or prescribe the “ best medication ” and everything would be how it was before their pain began. What else is going on in the patient’s life? Might it be: “ All my time is spent finding a way to get better,” or “Since nothing else matters but my pain, there’s no point in planning ahead ”? What are the patient’s own goals? It is important to know whether it is to become pain-free or if it is to be able to return to improved function and begin to recover their life. Since many pain treatments will require an effortful and patient-directed commitment to a range of behavior changes and self-management approaches, treatment will need to be tailored to the patient’s perceived needs and hopes. Interpreting pain, function, and mood numeric ratings are, of course, important. For many complex chronic pain presentations, such as those more complex patients referred to pain specialists, much depends upon the patient’s own story. Pain, a biopsychosocial condition, requires more than just the “medical story.” Knowing how patients experience their pain requires effective patient-centered communication. The mystery is in the history.

Clinician-Patient Relationships: Empathy and Therapeutic Alliance

Empathic listening to the patient’s story using the techniques of “narrative medicine” is a long established approach to advance care and improve chronic illness treatment outcomes. “Not only is diagnosis encoded in the narratives patients tell of symptoms but deep and therapeutically consequential understandings of the persons who bear symptoms are made possible in the course of hearing the narratives told of illness.” Intentional and directed attention to what our patients say, active listening is not merely kind and courteous but will increase the likelihood of a more effective treatment outcome. Effective communication explicitly acknowledges patients as persons: “The clinician must know the patient well enough to be able to answer the patient’s question ‘What would you do, if you were me?’” Empathy is commonly described as the ability to understand the inner experiences of patients, to communicate this understanding, and to respond therapeutically. Empathy is distinct from sympathy. Sympathy names the ability to feel someone else’s emotions, especially by feeling sad about their misfortune. Empathy names the ability to understand other people’s feelings as if we were having them ourselves.

Empathic listening and compassionate clinical care date to antiquity, long before medicine had developed as a scientific profession (e.g. Hippocrates, 5th century BCE: “Cure sometimes, treat often, comfort always”; Ovid, 1st century: “When the mind is ill at ease, the body is affected.”) More recently, Abraham Verghese, physician and author of the widely acclaimed 2009 novel Cutting for Stone, wrote, “‘Tell us please, what treatment in an emergency is administered by ear?’…I met his gaze and I did not blink. ‘Words of comfort’….” The same unblinking response applies to clinicians caring for patients with chronic pain, which for many patients represents an unrelenting emergency.

Modern scientific medicine has since elevated the role of clinical objectivity and technical competency. However, technical access to objective disease can displace empathic concern for what our patients tell us about their individual illness experience. This competing tension has reportedly led to an overall decline in empathy as trainees progress through medical school and residency training. Efforts are underway in medical school curricula to improve medical student empathy and narrative competency, ^, but these efforts encounter competition for space in the crowded time to cover other crucial biomedical topics, technical competencies, and other recommended pain topics.

Empathy, in its most basic form, is described as “emotional contagion,” characterized by unconscious state-matching (the contagious yawn!). Neuroimaging studies in humans, and even electrophysiologic and behavioral findings in rodents, suggest that empathy for pain is evolutionarily conserved. Therefore we are hard-wired for empathic behavior; we need only harness this natural capacity to show that we understand our patients’ feelings as if we were having them ourselves. The significance of empathy is even more striking in pain medicine since chronic pain is a complex social phenomenon that often leaves individuals with chronic pain socially isolated from family and friends and feeling misconceived and misunderstood by their doctors. Neuroscience research has shown that social exclusion and physical pain also share neuroanatomic structures and functions. The clinician has a unique opportunity to provide a “social buffer” that, even in the absence of any other intervention, may positively impact the patient’s pain experience.

In a busy clinic setting, it is challenging to take adequate time to listen, sit down, look directly at our patients rather than their electronic health record, and not interrupt patients who may be attempting to understand our questions. However, it is possible to allow more time by scheduling longer or more frequent visits or by dedicating periodic visits to pain exclusively so as not to be distracted by the many other general health and preventative medicine concerns also needing attention. If such measures are not feasible, we can introduce even very brief breaks from our intensive data-gathering agenda to practice active listening. Look our patients in the eye; patients notice these actions, particularly those who have had a long history of feeling ignored. Listen without judgment and pay attention to nonverbal cues. Take a few moments to paraphrase what we have heard and demonstrate to our patient that they have been heard. If we fail to listen, patients may register negative feelings of clinicians’ disinterest and disdain rather than empathic concern, in other words, “They don’t want anything to do with you.” Hurried and tightly scheduled primary care and pain specialty practices are challenged by system-related (e.g. too little time ^, ), patient-related (e.g. difficult communication, particularly when opioid management is involved ), and physician-related barriers (e.g. compassion fatigue ) that may lead to reduced empathic behaviors. Empathic failure can reduce patient satisfaction and compliance with treatment guidelines, worsen clinical outcomes, reduce ratings of clinical competence, and increase burnout, medical-legal risk, and overall healthcare costs from excess diagnostic test expenditures. Demonstrating empathy may also improve the accuracy of clinical decisions since pain related medical decision making is so often based on personal features and values of the patient that extend beyond objective medical evidence.