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      The Impact of Pain Invisibility on Patient-Centered Care and Empathetic Attitude in Chronic Pain Management

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          Abstract

          Objectives

          The use of interdisciplinary patient-centered care (PCC) and empathetic behaviour seems to be a promising avenue to address chronic pain management, but their use in this context seems to be suboptimal. Several patient factors can influence the use of PCC and empathy, but little is known about the impact of pain visibility on these behaviours. The objective of this study was to investigate the influence of visible physical signs on caregiver's patient-centered and empathetic behaviours in chronic pain context.

          Methods

          A convenience sample of 21 nurses and 21 physicians participated in a descriptive study. PCC and empathy were evaluated from self-assessment and observer's assessment using a video of real patients with chronic pain.

          Results

          The results show that caregivers have demonstrated an intraindividual variability: PCC and empathetic behaviours of the participants were significantly higher for patients who have visible signs of pain (rheumatoid arthritis and complex regional pain syndrome) than for those who have no visible signs (Ehler–Danlos syndrome and fibromyalgia) ( p < 0.001). Participants who show a greater difference in their patient-centered behaviour according to pain visibility have less clinical experience.

          Discussion

          The pain visibility in chronic pain patients is an important factor contributing to an increased use of PCC and empathy by nurses and physicians, and clinical experience can influence their behaviours. Thus, pain invisibility can be a barrier to quality of care, and these findings reinforce the relevance to educating caregivers to these unconscious biases on their behaviour toward chronic pain patients.

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          Most cited references34

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          Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians.

          Michael Krasner, Ronald M Epstein, Howard Beckman … (2009)
          Primary care physicians report high levels of distress, which is linked to burnout, attrition, and poorer quality of care. Programs to reduce burnout before it results in impairment are rare; data on these programs are scarce. To determine whether an intensive educational program in mindfulness, communication, and self-awareness is associated with improvement in primary care physicians' well-being, psychological distress, burnout, and capacity for relating to patients. Before-and-after study of 70 primary care physicians in Rochester, New York, in a continuing medical education (CME) course in 2007-2008. The course included mindfulness meditation, self-awareness exercises, narratives about meaningful clinical experiences, appreciative interviews, didactic material, and discussion. An 8-week intensive phase (2.5 h/wk, 7-hour retreat) was followed by a 10-month maintenance phase (2.5 h/mo). Mindfulness (2 subscales), burnout (3 subscales), empathy (3 subscales), psychosocial orientation, personality (5 factors), and mood (6 subscales) measured at baseline and at 2, 12, and 15 months. Over the course of the program and follow-up, participants demonstrated improvements in mindfulness (raw score, 45.2 to 54.1; raw score change [Delta], 8.9; 95% confidence interval [CI], 7.0 to 10.8); burnout (emotional exhaustion, 26.8 to 20.0; Delta = -6.8; 95% CI, -4.8 to -8.8; depersonalization, 8.4 to 5.9; Delta = -2.5; 95% CI, -1.4 to -3.6; and personal accomplishment, 40.2 to 42.6; Delta = 2.4; 95% CI, 1.2 to 3.6); empathy (116.6 to 121.2; Delta = 4.6; 95% CI, 2.2 to 7.0); physician belief scale (76.7 to 72.6; Delta = -4.1; 95% CI, -1.8 to -6.4); total mood disturbance (33.2 to 16.1; Delta = -17.1; 95% CI, -11 to -23.2), and personality (conscientiousness, 6.5 to 6.8; Delta = 0.3; 95% CI, 0.1 to 5 and emotional stability, 6.1 to 6.6; Delta = 0.5; 95% CI, 0.3 to 0.7). Improvements in mindfulness were correlated with improvements in total mood disturbance (r = -0.39, P < .001), perspective taking subscale of physician empathy (r = 0.31, P < .001), burnout (emotional exhaustion and personal accomplishment subscales, r = -0.32 and 0.33, respectively; P < .001), and personality factors (conscientiousness and emotional stability, r = 0.29 and 0.25, respectively; P < .001). Participation in a mindful communication program was associated with short-term and sustained improvements in well-being and attitudes associated with patient-centered care. Because before-and-after designs limit inferences about intervention effects, these findings warrant randomized trials involving a variety of practicing physicians.
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            Measuring patient-centered communication in patient-physician consultations: theoretical and practical issues.

            Ronald M Epstein, Peter Franks, Kevin Fiscella … (2005)
            The goal of patient-centered communication (PCC) is to help practitioners provide care that is concordant with the patient's values, needs and preferences, and that allows patients to provide input and participate actively in decisions regarding their health and health care. PCC is widely endorsed as a central component of high-quality health care, but it is unclear what it is and how to measure it. PCC includes four communication domains: the patient's perspective, the psychosocial context, shared understanding, and sharing power and responsibility. Problems in measuring PCC include lack of theoretical and conceptual clarity, unexamined assumptions, lack of adequate control for patient characteristics and social contexts, modest correlations between survey and observational measures, and overlap of PCC with other constructs. We outline problems in operationalizing PCC, choosing tools for assessing PCC, choosing data sources, identifying mediators of PCC, and clarifying outcomes of PCC. We propose nine areas for improvement: (1) developing theory-based operational definitions of PCC; (2) clarifying what is being measured; (3) accounting for the communication behaviors of each individual in the encounter as well as interactions among them; (4) accounting for context; (5) validating of instruments; (6) interpreting patient ratings of their physicians; (7) doing longitudinal studies; (8) examining pathways and mediators of links between PCC and outcomes; and (9) dealing with the complexity of the construct of PCC. We discuss the use of observational and survey measures, multi-method and mixed-method research, and standardized patients. The increasing influence of the PCC literature to guide medical education, licensure of clinicians, and assessments of quality provides a strong rationale for further clarification of these measurement issues.
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              Clinical empathy as emotional labor in the patient-physician relationship.

              Eric Larson, Xin L Yao (2005)
              Empathy should characterize all health care professions. Despite advancement in medical technology, the healing relationship between physicians and patients remains essential to quality care. We propose that physicians consider empathy as emotional labor (ie, management of experienced and displayed emotions to present a certain image). Since the publication of Hochschild's The Managed Heart in 1983, researchers in management and organization behavior have been studying emotional labor by service workers, such as flight attendants and bill collectors. In this article, we focus on physicians as professionals who are expected to be empathic caregivers. They engage in such emotional labor through deep acting (ie, generating empathy-consistent emotional and cognitive reactions before and during empathic interactions with the patient, similar to the method-acting tradition used by some stage and screen actors), surface acting (ie, forging empathic behaviors toward the patient, absent of consistent emotional and cognitive reactions), or both. Although deep acting is preferred, physicians may rely on surface acting when immediate emotional and cognitive understanding of patients is impossible. Overall, we contend that physicians are more effective healers--and enjoy more professional satisfaction--when they engage in the process of empathy. We urge physicians first to recognize that their work has an element of emotional labor and, second, to consciously practice deep and surface acting to empathize with their patients. Medical students and residents can benefit from long-term regular training that includes conscious efforts to develop their empathic abilities. This will be valuable for both physicians and patients facing the increasingly fragmented and technological world of modern medicine.
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                Author and article information

                Contributors
                Sylvie Lafrenaye:
                ORCID: http://orcid.org/0000-0001-7342-7353
                Journal
                Journal ID (nlm-ta): Pain Res Manag
                Journal ID (iso-abbrev): Pain Res Manag
                Journal ID (publisher-id): PRM
                Title: Pain Research & Management
                Publisher: Hindawi
                ISSN (Print): 1203-6765
                ISSN (Electronic): 1918-1523
                Publication date Collection: 2018
                Publication date (Electronic): 24 September 2018
                Volume: 2018
                Electronic Location Identifier: 6375713
                Affiliations
                1School of Nursing, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
                2Centre de Recherche de L'Institut Universitaire en Santé Mentale de Montréal, Department of Psychiatry, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
                3Department of Pediatrics, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, QC, Canada
                Author notes

                Academic Editor: Carlo Lai

                Author information
                http://orcid.org/0000-0003-0147-6804
                http://orcid.org/0000-0003-1624-378X
                http://orcid.org/0000-0001-7342-7353
                Article
                DOI: 10.1155/2018/6375713
                PMC ID: 6174788
                PubMed ID: 30344801
                SO-VID: b4810b97-cb25-4f66-bc03-c7a18a196a9e
                Copyright © Copyright © 2018 Emilie Paul-Savoie et al.
                License:

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 11 April 2018
                Date accepted : 29 August 2018
                Funding
                Funded by: Canadian Institutes of Health Research
                Funded by: Université de Sherbrooke
                Funded by: Centre de recherche de l'Institut universitaire en santé mentale de Montréal
                Funded by: Louis-H Lafontaine Hospital Foundation
                Funded by: Fonds de Recherche du Québec - Santé
                Funded by: Ministère de l'éducation supérieure, de la recherche et des sciences (MESRS)-Universités
                Funded by: Réseau de recherche en interventions en sciences infirmières du Québec
                Categories
                Subject: Research Article

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