Original Report| Volume 14, ISSUE 7, P759-766, July 2013

The Effect of Discussing Pain on Patient-Physician Communication in a Low-Income, Black, Primary Care Patient Population

  • Stephen G. Henry
    Address reprint requests to Stephen G. Henry, MD, Division of General Medicine, Geriatrics, and Bioethics, University of California Davis, 4150 V Street Suite 2400, Sacramento, CA 95817.
    Division of General Medicine, Geriatrics, & Bioethics, University of California Davis, Sacramento, California
    Search for articles by this author
  • Susan Eggly
    Department of Oncology, Wayne State University/Karmanos Cancer Institute, Detroit, Michigan
    Search for articles by this author


      Patients and physicians report that discussions about pain are frequently frustrating and unproductive. However, the relationship between discussions about pain and patient-physician communication is poorly understood. We analyzed 133 video-recorded visits and patient self-report data collected at a clinic providing primary care to a low-income, black patient population. We used “thin slice” methods to rate two or three 30-second video segments from each visit on variables related to patient and physician affect (ie, displayed emotion) and patient-physician rapport. Discussions about pain were associated with a .32 increase in patient unease (P < .001) and a .21 increase in patient positive engagement (P = .004; standardized coefficients) compared to discussions about other topics during the same visit. Discussions about pain were not significantly associated with patient-physician rapport, physician unease, or physician positive engagement. Patient pain severity was significantly associated with greater physician and patient unease (P = .01), but not with other variables. Findings suggest that primary care patients, but not their physicians, display significantly greater emotional intensity during discussions about pain compared to discussions about other topics.


      This study used direct observation of video-recorded primary care visits to show that discussions about pain are associated with heightened displays of both positive and negative patient emotions. These displays of emotion could potentially influence pain-related outcomes.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal of Pain
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Ambady N.
        • Bernieri F.J.
        • Richeson J.A.
        Toward a histology of social behavior: Judgmental accuracy from thin slices of the behavioral stream.
        Adv Exp Soc Psychol. 2000; 32: 201-271
        • Ambady N.
        • Koo J.
        • Rosenthal R.
        • Winograd C.H.
        Physical therapists’ nonverbal communication predicts geriatric patients' health outcomes.
        Psychol Aging. 2002; 17: 443-452
        • Ambady N.
        • LaPlante D.
        • Nguyen T.
        • Rosenthal R.
        • Chaumeton N.
        • Levinson W.
        Surgeons’ tone of voice: A clue to malpractice history.
        Surgery. 2002; 132: 5-9
        • Anderson K.O.
        • Green C.R.
        • Payne R.
        Racial and ethnic disparities in pain: Causes and consequences of unequal care.
        J Pain. 2009; 10: 1187-1204
        • Bernieri F.J.
        The expression of rapport.
        in: Manusov V. The Sourcebook of Nonverbal Measures. Laurence Erlbaum Associates, Mahwah, NJ2005: 347-360
        • Blanch D.C.
        • Hall J.A.
        • Roter D.L.
        • Frankel R.M.
        Is it good to express uncertainty to a patient? Correlates and consequences for medical students in a standardized patient visit.
        Patient Educ Couns. 2009; 76: 300-306
        • Cohen J.
        Statistical Power Analysis for the Behavioral Sciences.
        2nd ed. Lawrence Erlbaum Associates, Hillsdale, NJ1988
        • Fiscella K.
        • Franks P.
        • Srinivasan M.
        • Kravitz R.L.
        • Epstein R.
        Ratings of physician communication by real and standardized patients.
        Ann Fam Med. 2007; 5: 151-158
        • Frantsve L.M.E.
        • Kerns R.D.
        Patient-provider interactions in the management of chronic pain: Current findings within the context of shared medical decision making.
        Pain Med. 2007; 8: 25-35
        • Gureje O.
        • Von Korff M.
        • Simon G.E.
        • Gater R.
        Persistent pain and well-being - A World Health Organization study in primary care.
        JAMA. 1998; 280: 147-151
        • Hall J.A.
        • Roter D.L.
        • Blanch D.C.
        • Frankel R.M.
        Nonverbal sensitivity in medical students: Implications for clinical interactions.
        J Gen Intern Med. 2009; 24: 1217-1222
        • Hall J.A.
        • Roter D.L.
        • Blanch D.C.
        • Frankel R.M.
        Observer-rated rapport in interactions between medical students and standardized patients.
        Patient Educ Couns. 2009; 76: 323-327
        • Haskard-Zolnierek K.B.
        Communication about patient pain in primary care: Development of the Physician-Patient Communication about Pain scale (PCAP).
        Patient Educ Couns. 2012; 86: 33-40
        • Haskard K.
        • DiMatteo M.R.
        • Heritage J.
        Affective and instrumental communication in primary care interactions: Predicting the satisfaction of nursing staff and patients.
        Health Commun. 2009; 24: 21-32
        • Henry S.G.
        • Eggly S.
        How much time do low-income patients and primary care physicians actually spend discussing pain? A direct observation study.
        J Gen Intern Med. 2012; 27: 787-793
        • Henry S.G.
        • Fuhrel-Forbis A.
        • Rogers M.A.
        • Eggly S.
        Association between nonverbal communication during clinical interactions and outcomes: A systematic review and meta-analysis.
        Patient Educ Couns. 2012; 86: 297-315
        • Heritage J.
        The interaction order and clinical practice: Some observations on dysfunctions and action steps.
        Patient Educ Couns. 2011; 84: 338-343
        • Howard D.L.
        • Bunch C.D.
        • Mundia W.O.
        • Konrad T.R.
        • Edwards L.J.
        • Amamoo M.A.
        • Jallah Y.
        Comparing United States versus international medical school graduate physicians who serve African-American and white elderly.
        Health Serv Res. 2006; 41: 2155-2181
        • Juslin P.N.
        • Scherer K.R.
        Vocal expression of affect.
        in: Harrigan J.A. Rosenthal R. Scherer K.R. The New Handbook of Nonverbal Behavior Research. 1st ed. Oxford University Press, New York, NY2006: 65-135
        • Kenny D.T.
        Constructions of chronic pain in doctor-patient relationships: Bridging the communication chasm.
        Patient Educ Couns. 2004; 52: 297-305
        • Levinson W.
        • Hudak P.L.
        • Feldman J.J.
        • Frankel R.M.
        • Kuby A.
        • Bereknyei S.
        • Braddock C.
        “It’s Not What You Say…” - Racial disparities in communication between orthopedic surgeons and patients.
        Med Care. 2008; 46: 410-416
        • Levinson W.
        • Stiles W.B.
        • Inui T.S.
        • Engle R.
        Physician frustration in communicating with patients.
        Med Care. 1993; 31: 285-295
        • Matthias M.S.
        • Bair M.J.
        The patient-provider relationship in chronic pain management: Where do we go from here?.
        Pain Med. 2010; 11: 1747-1749
        • Matthias M.S.
        • Parpart A.L.
        • Nyland K.A.
        • Huffman M.A.
        • Stubbs D.L.
        • Sargent C.
        • Bair M.J.
        The patient-provider relationship in chronic pain care: Providers' perspectives.
        Pain Med. 2010; 11: 1688-1697
        • McCormack L.A.
        • Treiman K.
        • Rupert D.
        • Williams-Piehota P.
        • Nadler E.
        • Arora N.K.
        • Lawrence W.
        • Street R.L.
        Measuring patient-centered communication in cancer care: A literature review and the development of a systematic approach.
        Soc Sci Med. 2011; 72: 1085-1095
        • McIver J.P.
        • Carmines E.G.
        Unidimensional scaling.
        Sage Publications, Beverly Hills, CA1981
        • Penner L.A.
        • Dovidio J.F.
        • Edmondson D.
        • Dailey R.K.
        • Markova T.
        • Albrecht T.L.
        • Gaertner S.L.
        The experience of discrimination and black-white health disparities in medical care.
        J Black Psychol. 2009; 35: 180-203
        • Penner L.A.
        • Dovidio J.F.
        • West T.V.
        • Gaertner S.L.
        • Albrecht T.L.
        • Dailey R.K.
        • Markova T.
        Aversive racism and medical interactions with black patients: A field study.
        J Exp Soc Psychol. 2010; 46: 436-440
        • Prkachin K.M.
        • Schultz I.Z.
        • Hughes E.
        Pain behavior and the development of pain-related disability: The importance of guarding.
        Clin J Pain. 2007; 23: 270-277
      1. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Institute of Medicine, Washington, DC2011
        • Rosenthal R.
        Conducting judgment studies: Some methodological issues.
        in: Harrigan J.A. Rosenthal R. Scherer K.R. The New Handbook of Methods in Nonverbal Behavior Research. Oxford University Press, New York, NY2005: 199-234
        • Roter D.
        • Larson S.
        The Roter interaction analysis system (RIAS): Utility and flexibility for analysis of medical interactions.
        Patient Educ Couns. 2002; 46: 243-251
        • Roter D.L.
        • Hall J.A.
        • Blanch-Hartigan D.
        • Larson S.
        • Frankel R.M.
        Slicing it thin: New methods for brief sampling analysis using RIAS-coded medical dialogue.
        Patient Educ Couns. 2011; 82: 410-419
        • Russell J.A.
        A circumplex model of affect.
        J Pers Soc Psychol. 1980; 39: 1161-1178
        • Shavers V.L.
        • Bakos A.
        • Sheppard V.B.
        Race, ethnicity, and pain among the US adult population.
        J Health Care Poor Underserved. 2010; 21: 177-220
        • Snijders T.
        • Bosker R.
        Multilevel Analysis.
        2nd ed. SAGE Publications, Washington, DC2012
        • Stewart A.L.
        • Hays R.D.
        • Ware J.E.
        The MOS Short-Form General Health Survey: Reliability and validity in a patient population.
        Med Care. 1988; 26: 724-732
        • Street Jr., R.L.
        • Gordon H.
        • Haidet P.
        Physicians’ communication and perceptions of patients: Is it how they look, how they talk, or is it just the doctor?.
        Soc Sci Med. 2007; 65: 586-598
        • Street R.L.
        • Makoul G.
        • Arora N.
        • Epstein R.M.
        How does communication heal? Pathways linking clinician-patient communication to health outcomes.
        Patient Educ Couns. 2009; 74: 295-301
        • Streiner D.L.
        • Norman G.R.
        Health measurement scales: A practical guide to their development and use.
        3rd ed. Oxford University Press, New York, NY2003
        • Sullivan M.
        • Ferrell B.
        Ethical challenges in the management of chronic nonmalignant pain: Negotiating through the cloud of doubt.
        J Pain. 2005; 6: 2-9
        • Turk D.C.
        • Okifuji A.
        What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients?.
        Clin J Pain. 1997; 13: 330-336
        • Upshur C.C.
        • Bacigalupe G.
        • Luckmann R.
        “They don't want anything to do with you”: Patient views of primary care management of chronic pain.
        Pain Med. 2010; 11: 1791-1798
        • Varkey A.B.
        • Manwell L.B.
        • Williams E.S.
        • Ibrahim S.A.
        • Brown R.L.
        • Bobula J.A.
        • Horner-Ibler B.A.
        • Schwartz M.D.
        • Konrad T.R.
        • Wiltshire J.C.
        • Linzer M.
        MEMO Investigators: Separate and unequal: Clinics where minority and nonminority patients receive primary care.
        Arch Intern Med. 2009; 169: 243-250
        • von Baeyer C.L.
        Social and pain behavior in the first 3 min of a pain clinic medical interview.
        Pain Clinic. 1994; 7: 169-177