Persistent pain of moderate-to-severe intensity that lasts >6 months affects approximately one-fifth of Australian1 and US2 populations. It greatly affects the quality of people’s social and working lives and results in substantial financial costs.3 This high prevalence in the population manifests in the proportion of patients attending health services, with health practitioners’ surveys (predominantly of general practitioners [GPs]) showing that of typical adult appointments, 38% in the USA4 and 18% in Australia5 involved complaints of persistent pain. It is expected that this high incidence of pain will further increase with the ageing population.6
It is estimated that 70% of persistent pain is managed in primary care settings;7 therefore, it would be expected that GPs would be capable and proficient in its management. However, management of persistent pain is a significant challenge to both the patient and the physician.7 The complexity of many chronic conditions, the time-consuming consultations and the proportion of unsuccessful treatment outcomes deter physicians from treating persistent pain7 and reduce the proportion of patients with persistent pain receiving adequate pain management to approximately 60%.7–9
The literature describes substantial evidence that psychological wellbeing is an important, independent factor affecting how patients cope with long-term, significant pain.10–11 The psychological wellbeing of patients with persistent pain is known to be associated with perceived pain severity12–16 and, more recently, with perceived support during care.17 However, few studies investigate patients’ perspectives of the support received from healthcare professionals for persistent pain, particularly from GPs, who are often the primary physicians managing their persistent pain.
This study investigated patients with persistent pain attending a privately-owned Australian GP-managed pain clinic, focusing on their perceived management and support from health professionals (GPs, non-GP specialists and allied health professionals) involved in their care. The aim of this study was to determine if any association exists between the patients’ sense of wellbeing and their perceptions of care received during the management of their condition, and if perceptions of care vary between the type of health professional.
Methods
Design and participants
This cross-sectional study used a self-administered survey distributed to patients with persistent pain to investigate statistical associations between patients’ self-reported wellbeing and their perceptions of care from treating health professionals. The study was conducted at a GP-managed pain clinic in Townsville, North Queensland. The pain clinic is staffed by a single GP and a multidisciplinary team consisting of an occupational therapist, physiotherapist and psychologist, each with a special interest and several years’ experience in pain management. Pain clinic patients had all experienced persistent pain for ≥6 months and had been referred to the clinic by another GP. Only some patients had experienced care from the pain clinic’s occupational therapist, physiotherapist or psychologist. While the lead author worked at this clinic, completion of the survey was assisted by the receptionist, who was trained to answer questions and help patients who were not sufficiently literate.
Patients experiencing pain from a cancer-related issue were excluded from this study into persistent (non-cancer) pain. One hundred and seven patients with non-cancer persistent pain were asked to complete a self-administered survey, with 97 choosing to participate. However, two patients were later found to be ingesting other non-prescribed substances (identified by a routine drug screen testing at the pain clinic) and suspected of having an addiction. These two patients had their data removed from the final analysis and were referred to the local tertiary hospital’s Pain Management Service, which has the capability to treat both persistent pain and addiction problems. Ethical approval for the study was granted by the Human Research Ethics Committee of the James Cook University in North Queensland (approval #H5854).
Survey
The survey asked participants a range of demographic questions (eg age, length of time that they had experienced their persistent pain); their level of satisfaction with ‘their overall life as a whole’ on a five-point Likert scale (1 = ‘completely dissatisfied’, 2 = ‘somewhat dissatisfied’, 3 = ‘neutral’, 4 = ‘somewhat satisfied’, 5 = ‘completely satisfied’). Using a four-point Likert scale (1 = ‘none’, 2 = ‘a little’, 3 = ‘some’, 4 = ‘substantially’), participants were also asked how much their treating GP, allied health professional and non-GP specialist accept they have chronic pain; whether their GP and other healthcare professionals understand their problems and needs; whether their GP is doing all they can to help find solutions to their chronic pain problem; and whether their GP is treating their problem sympathetically.
Likert scale questions were kept as short and simple as possible because a significant proportion of patients attending the pain clinic were known to have literacy issues. For this reason, only a single-item question was used to measure wellbeing. While the ‘Personal Wellbeing Index – Adult’ states that single-item measures are less reliable than multi-item scales, it also notes that the single-item question used in the present study (How satisfied are you with your life as a whole?) is ‘an excellent measure of subjective wellbeing’.18
In addition, an open-ended question asked respondents to give examples of how their treating GP understands their chronic pain issue and provides care. While ‘chronic pain’ and ‘persistent pain’ are equivalent terms, ‘chronic pain’ was used in the survey as patients are more familiar with this terminology; however, ‘persistent pain’ is used in the text as the accepted terminology because ‘chronic pain’ has potential negative connotations.
Quantitative data analysis and statistics
All data were coded numerically and entered into the computerised statistical package for social sciences, SPSS Release 20 for Windows (IBM Corp, Release 2011). Patients with persistent pain were assessed for bivariate relationships (chi-square tests) between perceived overall wellbeing (dichotomised into ‘satisfied’ versus ‘dissatisfied’ + ‘neutral’) and perceptions of how their GPs, allied health professionals and non-GP specialists accept they have persistent pain; how sympathetically their GPs treat their condition; and how well their GPs understand their condition (Table 1). Multivariate logistic regression analysis then identified independent predictors of patients with persistent pain being ‘satisfied’ with their overall wellbeing, with all variables considered in the multivariate logistic regression analysis but only independent significant predictors were accepted into the final model. Results of the multivariate logistic regression analysis are presented as prevalence odds ratios (PORs) together with 95% confidence intervals (CIs). Tests were considered significant at P <0.05.
| Table 1. Bivariate associations between the wellbeing of 82 patients with chronic pain and perceived support from general practitioners (GPs) and other healthcare professionals |
| |
‘Dissatisfied’ or ‘neutral’ with overall wellbeing
(n = 53) |
‘Satisfied’ with overall wellbeing
(n = 29) |
P value* |
| Male sex |
49% |
62% |
0.259 |
| I feel my GP treating my pain ‘substantially’ accepts that I am suffering from chronic pain |
67% |
93% |
0.009 |
| I feel my GP ‘substantially’ understands my chronic pain problem and my needs |
36% |
71% |
0.002 |
| I feel healthcare professionals in general ‘substantially’ understand my chronic pain problem and my needs |
20% |
44% |
0.020 |
| I feel my GP ‘substantially’ treats my chronic pain problem and needs sympathetically |
36% |
75% |
0.001 |
| My GP did ‘substantially’ all they could to help me find solutions to my chronic pain problem |
63% |
86% |
0.030 |
| My GP acknowledges that my pain is ‘substantially’ affecting my work and life |
67% |
93% |
0.009 |
| I feel non-GP specialists ‘substantially’ accept I am suffering from chronic pain and that it is affecting my work and life |
35% |
63% |
0.016 |
| I feel allied health professionals ‘substantially’ accept that I am suffering from chronic pain and that it is affecting my work and life |
24% |
63% |
0.001 |
| *Two-sided chi-square test (statistically significant P values bolded) |
Content analysis of the open-ended question
A priori content analysis was undertaken to group the variety of responses given in the open-ended question asking for personal experiences of the care and support patients with persistent pain received from GPs during treatment for their complaint (which usually had lasted for many years). Content analysis was undertaken to group responses, including both good and bad examples of care and support, into key themes (Table 2). Where possible, patients’ comments were included verbatim if they specifically referred to the pain clinic GP or to a ‘regular’ (non–pain clinic) GP as the treating GP. The content analysis was conducted by TW, and this analysis was checked by FM; differences were resolved through discussion between authors.
| Table 2. Personal examples of patients with persistent pain regarding support from their treating general practitioner (GP), divided into comments on their pain clinic GP versus comments on their previous GP or regular GP (for other health issues not related to persistent pain) |
| Description |
n |
Comments about patient’s pain clinic GP |
Comments about patient’s previous or long-term GP for other health issues |
| GP provides good management of their patient’s problem (including multidisciplinary care options) |
37 |
‘Very helpful and I feel well looked after. [Pain clinic GP] referred me to specialists and very proactive with EPC [Enhanced Primary Care], X-rays, etc. Gives me more information so better equipped to deal with chronic pain.’
‘[Pain clinic GP’s] experience in spinal education, treatment and referral has been invaluable. Someone that understands!’
‘My regular GP was sympathetic but with limited knowledge of chronic pain. Told me to see a physiotherapist. Dr [pain clinic GP] works with me to develop a pain management plan that works for me.’
‘[Pain clinic GP] manages my pain medication. I wanted stronger medications and was told no, and now I’m thankful for that.’
‘Current [pain clinic GP] and specialist are very helpful and offer assistance regularly. Previous seven years been told there is nothing wrong with me.’ |
‘Did not provide treatment or provide help, had no understanding of pain.’
‘My regular GP stated that he didn’t know what to do next.’
‘I have a long-term GP who knows my history and has usually pointed me in the right direction to get appropriate help.’
‘GP sent me for CT [computed tomography] scan then referred me to [tertiary hospital]. Waited nine months for appointment then had physio[therapy] specialist referral. Became more painful so referred to pain GP. ‘
‘Feels like they give me medication just to get me out the door.’
‘Just sits there and listens – I might mention my high blood pressure and they don’t even check it. If you are sick they just give you antibiotics and hope you don’t come back.’
‘Recently changed from another GP who didn’t diagnose correctly or send me for a CT [computed tomography] scan [until] much later.’
‘I don’t believe GPs understand nor sympathise with chronic pain.’
‘They were only prepared to go so far in treating the pain even though I went back over and over again. One doctor said it was just age wear and tear.’ |
| GP has empathy for their patient’s condition and/or believes the patient is suffering significant pain from a physical condition |
38 |
‘[Pain clinic GP] has been very compassionate with my chronic pain and she listens to what I have to say. I feel like I am in capable, caring hands.’
‘Very professional. I need more attention and Dr [pain clinic GP] is being cruel to be kind by limiting my meds [medications].’
‘Good empathy. My treating pain doctor [GP] provides adequate and helpful information regarding my problems and also provides very good feedback to my questions and enquiries.’
‘[Pain clinic GP] and my [regular] GP have always been understanding of my condition.’ |
‘Did not want to know, brushed me off – “Go see another doctor”’.
‘[Regular GP] does not actually know what the injuries are like to live with as he hasn’t experienced what it’s like. Be different if he could do a day in my shoes.’
‘My [regular] GP says it’s all in my head.’
‘My original GP was fantastic. Now he has left the other GPs don’t understand. They look at me like I’m faking it.’
‘My first GP was very unsympathetic and disbelieving. [My] new GP has prescribed morphine, gave cortisone injections and referred me to the pain clinic.’
‘Dr [previous GP] believed it was neuropathic pain, not actual physical impairment – lots of scripts.’
‘Often dismissed – as scans, X-rays didn’t show anything, so not believed. Continually had to re-iterate my problems, etc even though it [is] all on file.’ |
| GP takes adequate time to explain their patient’s condition and treatment options |
8 |
‘[Pain clinic GP] provides adequate and helpful information regarding my problems and also provides very good feedback to my questions.’
‘[Pain clinic GP] takes time to talk and offers other therapies.’ |
‘My [regular] GP is time constrained and sometimes needs to finish my appointment.’
‘Doesn’t have enough time in one appointment, so I need to come back the next week. I am always one week behind needs.’ |
| GP takes an interest in their patient’s mental health |
4 |
‘[Pain clinic GP] understands the nature of pain and how it affects your body and mind.’ |
‘[Regular GP] was patient and understands that I do struggle to maintain a balance between mental and physical health.’
‘GPs need more understanding about pain management and not just the “take a pill” attitude. More mental and physical health support.’ |
Results
Description
Ninety-five patients with persistent pain attending a GP-managed pain clinic participated in the study, from 105 eligible patients (response rate = 89%). Eighty-four percent of participants were aged >40 years (mean age of 46 years), 53% were male, and the average length of time patients had experienced severe persistent pain was 10 years. Eighty-nine percent of the participants were taking strong painkiller medication, including 78% of patients taking opioid medication. Fifty-five per cent of patients with persistent pain were ‘dissatisfied’ with their life as a whole (wellbeing) to some extent and 10% were ‘neutral’, with 30% ‘somewhat satisfied’ and 5% ‘completely satisfied’.
For the question, ‘How much do health professionals accept you are suffering from persistent pain?’, patients reported for:
- GPs: 22% from ‘a little’ to ‘some’, 78% ‘substantially’
- non-GP specialists: 54% from ‘a little’ to ‘some’, 46% ‘substantially’
- allied health professionals: 65% from ‘a little’ to ‘some’, 39% ‘substantially’.
For the question, ‘How much do you feel your health professional understands your problems and needs?’, patients reported for:
- GPs: 49% from ‘a little’ to ‘some’, 51% ‘substantially’
- allied health professionals: 71% from ‘a little’ to ‘some’, 29% ‘substantially’.
Patients with persistent pain also reported whether their treating GP treated their problem sympathetically (49% from ‘a little’ to ‘some’, 51% ‘substantially’) and had done all they could to help find solutions to the problem (28% from ‘a little’ to ‘some’, 72% ‘substantially’).
Bivariate and multivariate analysis
Patients who reported being ‘satisfied’ with their overall wellbeing were more likely to ‘substantially’ believe that:
- GPs treat their problem sympathetically (P = 0.001)
- GPs accept they are suffering from chronic pain (P = 0.009)
- allied health professionals accept they are suffering from chronic pain (P = 0.001)
- their non-GP specialist accepts they are suffering from chronic pain (P = 0.016)
- GPs understand their problem (P = 0.002)
- GPs did all they could to help them find solutions to their problem (P = 0.030)
- GPs acknowledge their pain is substantially affecting their life (P = 0.009)
- healthcare professionals substantially understand their chronic pain problem and needs (P = 0.020).
The multivariate logistic regression identified that patients with persistent pain being at least satisfied with their overall wellbeing was solely predicted by believing their GPs ‘substantially’ treat their problem sympathetically (P = 0.001; POR = 5.4; 95% CI: 1.9, 14.9).
Content analysis
Four common themes arose from the open-ended question asking patients with persistent pain to provide examples of treatment experiences from past or current treating GPs (Table 2; available online only). Comments were taken verbatim from the transcripts and included in the table if they both effectively illustrated an example of good or bad care and support, and also specifically referred to either the pain clinic GP or a previous GP involved in the patients’ treatment. The four themes (with their frequency reported) were: the GP has empathy for their condition and/or believes they are experiencing significant pain from a physical condition (38); the GP provides good management of their problem, including multidisciplinary care options (37); the GP takes adequate time to explain their condition and treatment options (8); and the GP takes an interest in their mental health (4). The specific comments described in Table 2, while anecdotal, were voluntarily disclosed and often showed a more positive response across each of the four key themes toward the care and support received from the pain clinic GP than care received from other GPs recently or currently involved in their persistent pain treatment.
Discussion
This is the first reported study that obtained patient perspectives of the support received from healthcare professionals when seeking treatment for their persistent pain. Overall, the quantitative findings show that patients with persistent pain believe their GPs, compared with non-GP specialists and allied health professionals also involved in their treatment, are more accepting of the fact that they have a chronic condition and that persistent pain is significantly affecting their lives, and are more understanding of their needs. In addition, the study found that two-thirds of patients with persistent pain were not satisfied with their life overall; however, if patients believed that their GPs treated their condition very sympathetically, then they were more than five times more likely to feel satisfied with their life than if they did not believe their GP treated their condition sympathetically.
Psychological support was also a key theme in the content analysis, where perceptions of good care provided by the patients’ treating GPs were described in terms of psychological support received (or not received) equally as much as provision of appropriate pain management. The voluntarily disclosed free-form comments made by the patients also appear to indicate that pain clinic GPs provide more consistent psychological and management support than their personal, regular GPs. Many patients’ recollections of a poor experience with a non–pain clinic GP involved being treated with suspicion or feeling the physician was dismissive of their complaints. Mittinty and colleagues similarly found that for patients with persistent pain, their most commonly stated positive experience of their treatment at a pain clinic was the support and validation staff provided for their condition.19 Thus, this pilot study confirms a supportive physician–patient relationship is particularly important in the care and management of patients with persistent pain, where physician empathy and good understanding can assist patients with persistent pain to maintain a positive sense of wellbeing.
While the patient comments in the present study suggests a lack of psychological support provided by health practitioners has a negative impact on the psychological wellbeing of patients with persistent pain, it must be noted that practitioners face significant challenges when managing patients with severe chronic pain. For example, in the present study, the majority of participants (>80%) were taking opioid medication; however, a recent 2017 survey in the USA has found that decreasing numbers of doctors are wanting to treat patients with chronic pain because of regulatory guidelines regarding prescription of opioids.20 Other known reasons for primary practitioners’ reluctance to see patients with persistent pain include burnout due to feeling unable to help patients overcome their complex challenges,21 lack of confidence when managing patients with persistent pain with opiates7 or insufficient training in medical school regarding management of persistent pain.7,22 However, given the many positive patient comments about the care and support received from pain clinic GPs in the present study, GP-managed pain clinics may be an important development in overcoming the many challenges GPs face when managing patients with persistent pain.
It must be noted that this article only considers the responses of patients at the pain clinic. It does not represent those who are well managed by their regular GP and/or specialist service and hence do not require referral, or those who may have chosen not to attend a pain clinic when offered referral. Hence, this article can only comment that in this specific sample, patients with persistent pain felt, in their personal experience, that the pain clinic GP was more caring. However, the paper is unable to comment more broadly on patients’ experiences of care from GPs, as the patients who responded to the open-ended question may have self-selected if they did not feel valued or respected by other health practitioners, and hence accepted referral to the pain clinic.
Limitations
The major limitations of this study are that the cross-sectional nature of the design provides only self-reported findings, and given that the study was undertaken at only one pain clinic, it is effectively a pilot study. Additionally, the survey instrument was not evaluated for reliability and validity. However, a significant proportion of the findings presented in this study derive from analysis of the open-ended question. The responses have a high degree of content validity as these questions are clear and easy to answer, and allow participant responses to cover the full range of each individual’s thoughts and experiences. Last, while this study involved patients attending a pain clinic that solely treats persistent pain, the questions were focused towards the recent care these patients received from a range of health professionals involved over the duration of treatment for their persistent pain condition.
Conclusion
The findings of this pilot study suggest that patients with persistent pain generally perceive that GPs to provide better empathy and understanding than non-GP specialists or allied health professionals also involved in their treatment. While two-thirds of the patients with persistent pain were not satisfied with their overall wellbeing, those who reported being satisfied were more than five times more likely to report that their GPs treat their problem very sympathetically. The free-form comments appear to indicate that GPs specialising in pain management provided more consistent psychological and management support for the participants than their regular GPs.
Thus, the findings of this study suggest that the psychological support provided by GPs to patients with persistent pain is an important factor in these patients maintaining a positive sense of wellbeing.