Psychometric Properties of a Healthcare Provider Burden Scale: Preliminary Results.

Measures are lacking that assess the clinical burden that healthcare providers perceive in treating chronic conditions. This study presents a preliminary psychometric evaluation of a novel self-report measure of provider burden in the treatment of chronic pain. Data for eight burden items were available from vignette studies examining the effects of patient pain severity and medical evidence on clinical burden and judgments for chronic pain. Participants (N = 922) were 109 physicians and 813 non-physicians, all acting in the role of physician (232 community members without chronic pain, 105 community members with chronic pain, and 476 American Chronic Pain Association members with chronic pain). Factor analyses of burden items yielded one-factor solutions in all samples, with high factor loadings and adequate explained variance. Internal consistency reliability was uniformly high (≥ 0.87). Burden scores were significantly higher among physicians compared to nonphysicians; nonphysician groups did not differ on any burden score. Significant correlations of burden score with indicators of psychosocial complications in patient care supported scale validity. Burden score was not associated with gender, age, or education. Results provide initial support for the psychometric properties of a Healthcare Provider Burden Scale (HPBS). Research utilizing larger and representative healthcare provider groups is needed.

Community Perspectives on Patient Credibility and Provider Burden in the Treatment of Chronic Pain.

OBJECTIVE: This study examined factors influencing lay perceptions of a provider's clinical burden in providing care to a person with chronic pain. DESIGN: In a between-subjects design that varied three levels of pain severity (4, 6, or 8 out of 10) with two levels of medical evidence (low/high), participants rated the credibility of pain reported by a hypothetical patient and the psychosocial factors expected to mediate the effects of evidence and severity on a provider's burden of care. SETTING: A randomized vignette study in which community participants were recruited via Amazon Mechanical Turk. SUBJECTS: 337 community participants. METHODS: Using a Qualtrics platform, participants read one of six vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity and then rated perceived pain severity, pain credibility, psychosocial variables, and burden. RESULTS: Serial mediation models accounted for all effects of medical evidence and pain severity on burden. Low medical evidence was associated with increased burden, as mediated through lower pain credibility and greater concerns about patient depression, opioid abuse, and learning pain management. Higher levels of reported pain severity were associated with increased burden, as mediated through greater pain discounting and concerns about opioid abuse. CONCLUSIONS: The lay public is skeptical of chronic pain that is not supported by medical evidence or is reported at high levels of severity, raising concerns about psychosocial complications and drug seeking and expectations of higher burden of care. Such negative stereotypes can pose obstacles to people seeking necessary care if they or others develop a chronic pain condition.

A Preliminary Study of Provider Burden in the Treatment of Chronic Pain: Perspectives of Physicians and People with Chronic Pain.

This study compared perceptions of the burden of patient care and associated clinical judgments between physicians and people with chronic pain (PWCP) in a 2 × 3 × 2 between-subjects design that varied participant type, patient-reported pain severity (4/6-8/10), and supporting medical evidence (low/high). One hundred and nine physicians and 476 American Chronic Pain Association members were randomly assigned to 1 of 6 conditions. Respondents estimated the clinical burden they would assume as the treating physician of a hypothetical patient with chronic low back pain, and made clinical judgments regarding that patient. Physician burden ratings were significantly higher than PWCP ratings, and clinical impressions (eg, trust in pain report, medical attribution) and management concerns (eg, opioid abuse risk) were relatively less favorable. Neither pain severity nor medical evidence affected burden ratings significantly. High medical evidence was associated with more favorable clinical impressions; higher pain severity led to more discounting of patient pain reports. Burden was significantly correlated with a range of clinical judgments. Results indicate that physicians and PWCP differ in their perceptions of provider burden and related clinical judgments in ways that could impact treatment collaboration. Further research is needed that examines provider burden in actual clinical practice. PERSPECTIVE: Physicians and people with chronic pain (PWCP) estimated the clinical burden of patient care and made judgments about a hypothetical patient with chronic pain. Physician burden ratings were higher and clinical judgments less favorable, relative to PWCP respondents. These differences could impact treatment collaboration and merit study in clinical practice.

Patient Perceptions of Physician Burden in the Treatment of Chronic Pain.

While patient perceptions of burden to caregivers is of recognized clinical significance among people with chronic pain, perceived burden to treating physicians has not been studied. This study examined how people with chronic pain perceived levels of medical evidence (low vs high) and pain severity (4,6,8/10) to influence physician burden and how burden then mediated expected clinical judgments. 476 people with chronic pain read vignettes describing a hypothetical patient with varying levels of medical evidence and pain severity from the perspective of a treating physician, rated the burden that patient care would pose, and made a range of clinical judgments. The effect of pain severity on clinical judgments was expected to interact with medical evidence and be conditionally mediated by burden. Although no associations with burden were found for the pain severity x medical evidence interaction or for pain severity alone, low levels of supporting medical evidence yielded higher burden ratings. Burden significantly mediated medical evidence effects on judgments of symptom credibility, clinical improvement, and psychosocial dysfunction. Results indicate that perceived physician burden negatively influenced judgments of patients with chronic pain, beyond the direct effects of medical evidence. Implications are discussed for clinical practice, as well as future research. PERSPECTIVE: : People with chronic pain expect physicians to view the care of patients without supporting medical evidence as burdensome. Higher burden is associated with less symptom credibility, more psychosocial dysfunction, and less treatment benefit. Perceived physician burden appears to impact how patients approach treatment, with potentially adverse implications for clinical practice.

How to Teach Medical Students About Pain and Dementia: E-Learning, Experiential Learning, or Both?

OBJECTIVE: Pain management in persons with mild to moderate dementia poses unique challenges because of altered pain modulation and the tendency of some individuals to perseverate. We aimed to test the impact of an e-learning module about pain in communicative people with dementia on third-year medical students who had or had not completed an experiential geriatrics course. DESIGN: Analysis of pre- to postlearning changes and comparison of the same across the student group. SETTING: University of Pittsburgh School of Medicine and Saint Louis University School of Medicine. SUBJECTS: One hundred four University of Pittsburgh and 57 Saint Louis University medical students. METHODS: University of Pittsburgh students were randomized to view either the pain and dementia module or a control module on pain during a five-day geriatrics course. Saint Louis University students were asked to complete either of the two modules without the context of a geriatrics course. A 10-item multiple choice knowledge test and three-item attitudes and confidence questionnaires were administered before viewing the module and up to seven days later. RESULTS: Knowledge increase was significantly greater among students who viewed the dementia module while participating in the geriatrics course than among students who viewed the module without engaging in the course (P < 0.001). The modules did not improve attitudes in any group, while student confidence improved in all groups. CONCLUSIONS: Medical students exposed to e-learning or experiential learning demonstrated improved confidence in evaluating and managing pain in patients with dementia. Those exposed to both educational methods also significantly improved their knowledge.

Cultivating emergency physician behavioral empathy to improve emergency department care for pain and prescription opioid misuse.

Clinical empathy is the ability to understand the patient's experience, communicate that understanding, and act on it. There is evidence that patient and physician benefits are associated with more empathic communications. These include higher patient and physician satisfaction, improved quality of life, and decreased professional burnout for physicians, as well as increased patient compliance with care plans. Empathy appears to decline during medical school, residency training, and early professional emergency medicine practice; however, brief training has the potential to improve behavioral measures of empathy. Improvements in emergency department physician empathy seems especially important in managing patients at elevated risk for opioid-related harm. We describe our conceptual approach to identifying and designing a practice improvement curriculum aimed to cultivate and improve behavioral empathy among practicing emergency physicians. Emergent themes from our preliminary study of interviews, focus groups, and workshops were identified and analyzed for feasibility, sensitivity to change, and potential impact. A conceptual intervention will address the following key categories: patient stigmatization, identification of problematic pain-subtypes, empathic communication skills, interactions with family and friends, and techniques to manage inappropriate patient requests. The primary outcomes will be the changes in behavioral empathy associated with training. An assessment battery was chosen to measure physician psychosocial beliefs, attitudes and behavior, communication skills, and burnout magnitude. Additional outcomes will include opioid prescribing practice, naloxone prescribing, and referrals to addiction treatment. A pilot study will allow an estimation of the intervention impact to help finalize a curriculum suitable for web-based national implementation.

Persistent Post-Mastectomy Pain: Risk Factors and Current Approaches to Treatment.

Persistent Post-Mastectomy Pain (PPMP) is a common condition that can follow surgeries for breast cancer, the most common cancer in women. Because of the frequency of PPMP and its potential severity, it has received increasing research attention. This manuscript reviews the recent research literature, beginning with a brief history and then relevant medical, surgical, demographic, and psychosocial risk factors. Subsequently, social, psychological, and functional sequelae that have been linked to PPMPS are considered, as is research on current pharmacological, psychological, and rehabilitative approaches to treatment. The review concludes with a discussion of directions for future research and treatment that might reduce the incidence and impact of PPMP on breast cancer survivors. PERSPECTIVE: This article describes current research literature involving mechanisms, risks, and treatments related to persistent post-mastectomy pain. Implications of research findings also are discussed for pre- and post-surgical approaches to pain management, current treatments, and promising research directions.

Physician Judgments and the Burden of Chronic Pain.

Objective: In a moderated mediation model, this study examined the interaction effect of pain severity and medical evidence on physician judgments of chronic pain. The effects of higher pain severity on physician judgments were expected to be mediated through anticipated clinical burden, but only when medical evidence was low. Design: Participants were randomly assigned to one of six case descriptions of a chronic pain patient in a 3 × 2 design that varied by reported pain severity (4, 6, 8/10) and medical evidence (low vs high). Setting: An academic training program for medical residents/fellows. Subjects: Residents/fellows in clinical departments at postgraduate year 2 or higher (N = 109). Methods: Participants read case descriptions and then made judgments about the patient and rated the level of burden they expected to assume in treating the patient. Results: Higher pain severity occasioned greater pain discounting and higher likelihood of prescribing opioid medication. When medical evidence was low, participants had less trust in the patient's pain report, attributed pain more to psychosocial than medical factors, and were less likely to refer for possible surgery. Analyses yielded no support for moderated mediation as expected burden was high across all conditions. Significant associations were found between expected burden and multiple clinical judgments. Conclusions: Results did not support the proposed moderated mediation model as all patients were expected to be burdensome across clinical presentations, reflecting negative expectations of patients with chronic pain. Such expectations can have adverse implications for patient-provider communication, shared decision-making, and the delivery of personalized care.

The Professionalism and Integrity in Research Program: Description and Preliminary Outcomes.

Violations of rules and regulations in research can cause significant problems for human participants, animal subjects, data integrity, institutions, and investigators. The Professionalism and Integrity in Research Program (PI Program) provides remediation training that addresses the root causes of violations of rules and regulations in research. Through assessments, a three-day workshop, and follow-up coaching calls, the PI Program teaches evidence-based decision-making strategies designed to help researchers to compensate for bias, uncertainty, and work-related stress, and foster the skills needed to oversee research projects in today's complex regulatory environments. Across its first three years (2013-2015), the program trained 39 researchers from 24 different institutions in the United States. Participant evaluations of the program's faculty and workshop content were highly positive (4.7-4.8 and 4.5-4.6, respectively, on a 5-point scale). Preliminary program outcome assessment using validated measures of professional decision making and cognitive distortions in a pre- and postworkshop design indicated significant improvements. A follow-up survey of participants found statistically significant increases in a variety of target behaviors, including training research staff members to foster compliance and research quality, using standard operating procedures to support compliance and research integrity, performing self-audits of research operations, reducing job stressors, actively overseeing the work of the research team, and seeking help when experiencing uncertainty. Assessment of the PI Program was conducted with modest sample sizes, yet evaluation, outcome assessment, and self-reported survey data provided statistically significant evidence of effectiveness in achieving program goals.

Chronic Orofacial Pain: Burning Mouth Syndrome and Other Neuropathic Disorders.

Chronic orofacial pain is a symptom associated with a wide range of neuropathic, neurovascular, idiopathic, and myofascial conditions that affect a significant proportion of the population. While the collective impact of the subset of the orofacial pain disorders involving neurogenic and idiopathic mechanisms is substantial, some of these are relatively uncommon. Hence, patients with these disorders can be vulnerable to misdiagnosis, sometimes for years, increasing the symptom burden and delaying effective treatment. This manuscript first reviews the decision tree to be followed in diagnosing any neuropathic pain condition, as well as the levels of evidence needed to make a diagnosis with each of several levels of confidence: definite, probable, or possible. It then examines the clinical literature related to the idiopathic and neurogenic conditions that can occasion chronic orofacial pain, including burning mouth syndrome, trigeminal neuralgia, glossopharyngeal neuralgia, post-herpetic neuralgia, and atypical odontalgia. Temporomandibular disorders also are examined as are other headache conditions, even though they are not neurologic conditions, because they are common and can mimic symptoms of the latter disorders. For each of these conditions, the paper reviews literature regarding incidence and prevalence, physiologic and other contributing factors, diagnostic signs and symptoms, and empirical evidence regarding treatments. Finally, in order to improve the quality and accuracy of clinical diagnosis, as well as the efficiency with which effective treatment is initiated and delivered, criteria are offered that can be instrumental in making a differential diagnosis.

United States National Pain Strategy for Population Research: Concepts, Definitions, and Pilot Data.

UNLABELLED: National Pain Strategy population research objectives include: estimating chronic pain prevalence, studying pain treatment with electronic health care data, and developing metrics to assess progress in reducing chronic pain impact. In this article, the National Pain Strategy Population Research Workgroup reviews concepts relevant to achieving these aims. High-impact chronic pain was defined as persistent pain with substantial restriction of life activities lasting 6 months or more. In pilot work, we tested a brief assessment of high-impact chronic pain, and used electronic health records data to describe pain-related health care. A mail survey of adult health plan enrollees (N = 770) reported that 14% had high-impact chronic pain. Relative to persons with lower-impact chronic pain, those with high-impact chronic pain were more often frequent users of health care for pain, reported lower quality of life, greater pain-related interference with activities, and more often reported pain at multiple anatomic locations. Analyses of health care data (N = 289,464) reported that pain patients had higher health care costs compared with others and that pain services were typically delivered in primary care. These results support the feasibility of developing data on chronic pain through national health interview surveys and large electronic health care databases. PERSPECTIVE: Pilot analyses supported the feasibility of brief chronic pain assessments suitable for national health surveys and use of electronic health care databases to develop data regarding trends in the delivery of pain treatments, costs, and effectiveness. These methods are relevant to achieving the aims of the US National Pain Strategy.

Making Professional Decisions in Research: Measurement and Key Predictors.

The professional decision-making in research (PDR) measure was administered to 400 National Institutes of Health (NIH)-funded and industry-funded investigators, along with measures of cynicism, moral disengagement, compliance disengagement, impulsivity, work stressors, knowledge of responsible conduct of research (RCR), and socially desirable response tendencies. Negative associations were found for the PDR and measures of cynicism, moral disengagement, and compliance disengagement, while positive associations were found for the PDR and RCR knowledge and positive urgency, an impulsivity subscale. PDR scores were not related to socially desirable responding, or to measures of work stressors and the remaining impulsivity subscales. In a multivariate logistic regression analysis, lower moral disengagement scores, higher RCR knowledge, and identifying the United States as one's nation of origin emerged as key predictors of stronger performance on the PDR. The implications of these findings for understanding the measurement of decision-making in research and future directions for research and RCR education are discussed.

Medical Judgments Across the Range of Reported Pain Severity: Clinician and Lay Perspectives.

BACKGROUND: While increasing evidence suggests that observers discount high-severity chronic pain, factors that occasion such discounting are poorly understood, particularly regarding health provider vs lay perspectives. OBJECTIVE: This study examined the effects of supporting medical evidence and comorbid psychological distress (pain behavior) on medical student and lay clinical judgments of increasingly severe patient pain reports. DESIGN: In a 2 × 2 × 2 × (7) mixed between- and within-subject design, participants (medical students vs lay) made clinical judgments after reading vignettes describing a hypothetical patient that varied in levels of medical evidence and pain behavior (low vs high) and pain severity (4/10-10/10). SUBJECTS: Fourth-year medical students (N = 115) and lay persons in the community (N = 300) participated in this research. RESULTS: While both medical student and lay judgments plateaued at high levels of pain severity, judgments regarding cause (medical vs psychological), treatment (opioid prescription), and disability showed growing divergence as levels of reported pain severity increased. Divergence relative to medical and psychological causes of pain was found irrespective of the level of supporting medical evidence; divergence relative to opioid treatment and support for a disability claim was found when supporting medical evidence was low. CONCLUSIONS: The results indicate differing expectations of chronic pain treatment for health care providers relative to the lay public that could impact clinical care, especially at high pain severity levels, where lay expectations diverge significantly from those of health professionals.

Professional Decision-Making in Research (PDR): The Validity of a New Measure.

In this paper, we report on the development and validity of the Professional Decision-Making in Research (PDR) measure, a vignette-based test that examines decision-making strategies used by investigators when confronted with challenging situations in the context of empirical research. The PDR was administered online with a battery of validity measures to a group of NIH-funded researchers and research trainees who were diverse in terms of age, years of experience, types of research, and race. The PDR demonstrated adequate reliability (alpha = .84) and parallel form correlation (r = .70). As hypothesized, the PDR was significantly negatively correlated with narcissism, cynicism, moral disengagement, and compliance disengagement; it was not correlated with socially desirable responding. In regression analysis, the strongest predictors of higher PDR scores were low compliance disengagement, speaking English as a native language, conducting clinical research with human subjects, and low levels of narcissism. Given that the PDR was written at an eighth grade reading level to be suitable for use with English as a second language participants and that only one-fourth of items focused on clinical research, further research into the possible roles of culture and research ethics training across specialties is warranted. This initial validity study demonstrates the potential usefulness of the PDR as an educational outcome assessment measure and a research instrument for studies on professionalism and integrity in research.

Accountability and empathy effects on medical students' clinical judgments in a disability determination context for low back pain.

UNLABELLED: Accountability has been shown to affect clinical judgments among health care providers in several ways. It may increase a provider's motivation for accuracy, leading to more deliberative judgments, or it may enhance biases that evaluators consistently demonstrate with patients with chronic pain. In this study, medical students read a vignette about a hypothetical patient referred for evaluation of severe low back pain by the Office of Vocational Rehabilitation. Accountability to the patient was either weak (consultative 1-time evaluation) or strong (ongoing primary care provision); societal accountability was either weak (evaluation information as secondary source for disability determination) or strong (evaluation information primary to disability determination). Participants then made judgments regarding validity of the patient's presentation, influence of psychosocial factors on the presentation, and patient's level of pain, distress, and disability, and completed an empathy measure. Results showed that empathy had strong associations with symptom validity and severity judgments. With empathy as a covariate, 3 crossover interactions emerged. Judgments of symptom validity were lower when the 2 forms of accountability were inconsistent (ie, one weak and the other strong) than when they were consistent (ie, both weak or both strong). Likewise, judgments of psychosocial factors and pain/distress/disability were higher under consistent accountability conditions than when accountability conditions were inconsistent. This pattern may imply conflict avoidance or self-protection as a motivation for judgments under inconsistent accountability. This study demonstrated that role demands can affect symptom judgments in complex ways, and that empathy may play both direct and moderating roles. Because physicians are the primary gatekeepers regarding disability determination in both consultative and treating roles, accountability may have significant mediating effects on such determinations. PERSPECTIVE: This study demonstrated that medical student judgments of pain-related symptoms were strongly associated with their levels of empathic concern. Student judgments of symptom validity and psychosocial influences on patient adjustment were differentially affected by their level of accountability to the patient and society in a disability determination process.

Racial/ethnic disparities in the assessment and treatment of pain: psychosocial perspectives.

Racial/ethnic disparities not only are prevalent throughout the U.S. health care system but also have proved refractory to change. Such disparities are evident and similarly persistent in the treatment of patients with chronic pain conditions, exacting high personal and societal costs. While psychosocial factors contribute significantly to this intractable problem, an integrated examination of the literature is lacking. This article provides an overview of psychosocial factors that contribute to disparities in the treatment of chronic pain patients and in their adjustment to pain. It focuses initially on aspects of pain assessment that can occasion disparate care. Because pain is a subjective phenomenon that often defies objective medical assessment, it is particularly susceptible to social psychological influences, such as stereotypes. We pay particular attention to negative racial/ethnic stereotypes as well as to the circumstances that are likely to trigger stereotype-driven judgments. Subsequent sections review psychosocial factors that can influence a patient's experience of pain, those that can influence the patient-provider interaction, and those that operate in the public health environment. After each section, we suggest actions that could address identified issues related to clinical care, research, and policy. Policy recommendations generally are linked to provisions of the Affordable Care Act. We conclude with a discussion of the role that psychology should play in future efforts to address the persistent problem of racial/ethnic disparities in pain care.