Health Care Professionals' Reactions to Patient Pain: Impact of Knowledge About Medical Evidence and Psychosocial Influences

Published:November 25, 2013DOI:


      This study examined the impact of evidence concerning the presence of 1) a biomedical basis for pain and 2) psychosocial influences on practitioner appraisals of patient pain experiences. Furthermore, the potential moderating role of patient pain behavior was examined. In an online study, 52 general practitioners and 46 physiotherapists viewed video sequences of 4 patients manifesting pain, with accompanying vignettes describing presence or absence of medical evidence and psychosocial influences. Participants estimated pain intensity, daily interference, sympathy felt, effectiveness of pain medication, self-efficacy, their likability, and suspicions of deception. Primary findings indicated lower perceived pain and daily interference, less sympathy, lower expectations of medication impact, and less self-efficacy when medical evidence was absent. The same results were found when psychosocial influences were present, but only when the patient displayed higher levels of pain behavior. Furthermore, absence of medical evidence was related to less positive evaluations of the patients and to higher beliefs in deception in both professions. The presence of psychosocial influences was related to less positive evaluations and higher beliefs in deception in both professions. In sum, a range of contextual factors influence health care practitioner responses to patient pain. Implications for caregiving behavior are discussed.


      The present study indicates that in the absence of clear medical evidence and in the presence of psychosocial influences, patient pain might be taken less seriously by health care practitioners. These findings are important to further understand the difficulties that relate to the clinical encounter between pain patients and health care practitioners.

      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


        • Airaksinen O.
        • Brox J.I.
        • Cedraschi C.
        • Hildebrandt J.
        • Klaber-Moffett J.
        • Kocavs F.
        • Mannion A.F.
        • Reis S.
        • Staal J.B.
        • Ursin H.
        • Zanoli G.
        European guidelines for the management of chronic nonspecific low back pain.
        Eur Spine J. 2006; 15: S192-S300
        • Allegretti A.
        • Borkan J.
        • Reis S.
        • Griffiths F.
        Paired interviews of shared experiences around chronic low back pain: Classic mismatch between patients and their doctors.
        Fam Pract. 2010; 27: 676-683
        • Bandura A.
        Self-efficacy mechanisms in human agency.
        Am Psychol. 1982; 37: 122-147
        • Blackburn M.S.
        • Cowan S.M.
        • Cary B.
        • Nall C.
        Physiotherapy-led triage clinic for low back pain.
        Aust Health Rev. 2009; 33: 663-670
        • Borrell-Carrio F.
        • Epstein R.M.
        Preventing errors in clinical practice: A call for self-awareness.
        Ann Fam Med. 2004; 2: 310-316
        • Breivik H.
        Opioids in chronic non-cancer pain, indications and controversies.
        Eur J Pain. 2005; 9: 127-160
        • Carragee E.J.
        Persistent low back pain.
        N Engl J Med. 2005; 352: 1891-1898
        • Chibnall J.T.
        • Tait R.C.
        Observer perceptions of low back pain: Effects of pain report and other contextual factors.
        J Appl Soc Psychol. 1995; 25: 418-439
        • Chibnall J.T.
        • Tait R.C.
        Social and medical influences on attributions and evaluations of chronic pain.
        Psychol Health. 1999; 14: 719-729
        • Chibnall J.T.
        • Tait R.C.
        • Ross L.R.
        The effects of medical evidence and pain intensity on medical student judgments of chronic pain patients.
        J Behav Med. 1997; 20: 257-271
        • Chou R.
        • Qaseem A.
        • Snow V.
        • Casey D.
        • Cross T.
        • Shekelle P.
        • Owens D.K.
        Diagnosis and treatment of low back pain: A joint clinical practice guideline from the American College of Physicians and the American Pain Society.
        Ann Intern Med. 2007; 147: 478-491
        • Craig K.D.
        • Badali M.A.
        Introduction to the special series on pain deception and malingering.
        Clin J Pain. 2004; 20: 377-382
        • Craig K.D.
        • Hill M.L.
        • McMurtry B.W.
        Detecting deception and malingering.
        in: Block A.R. Kremer E.F. Fernandez E. Handbook of Pain Syndromes. Biopsychosocial Perspectives. Lawrence Erlbaum, Mahwah, NJ1999: 41-58
        • Craig K.D.
        • Prkachin K.M.
        • Grunau R.V.E.
        The facial expression of pain.
        in: Turk D.C. Melzack R. Handbook of Pain Assessment. 3rd ed. Guilford Press, New York, NY2011: 117-133
        • De Ruddere L.
        • Goubert L.
        • Prkachin K.M.
        • Stevens M.A.L.
        • Van Ryckeghem D.M.L.
        • Crombez G.
        When you dislike patients, pain is taken less seriously.
        Pain. 2011; 152: 2342-2347
        • De Ruddere L.
        • Goubert L.
        • Stevens M.A.L.
        • Deveugele M.
        • Crombez G.
        Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient.
        Pain. 2013; 145: 669-676
        • De Ruddere L.
        • Goubert L.
        • Vervoort T.
        • Prkachin K.M.
        • Crombez G.
        We discount the pain of others when pain has no medical explanation.
        J Pain. 2012; 13: 1198-1205
        • Engel G.L.
        The need for a new medical model: A challenge for biomedicine.
        Science. 1977; 196: 129-136
        • Epstein R.M.
        • Shields C.G.
        • Meldrum S.C.
        • Fiscella K.
        • Carroll J.
        • Carney P.A.
        • Duberstein P.R.
        Physicians' responses to patients' medically unexplained symptoms.
        Psychosom Med. 2006; 68: 268-276
        • Ferrell B.R.
        • Eberts M.T.
        • McCaffery M.
        • Grant M.
        Clinical decision making and pain.
        Cancer Nurs. 1991; 14: 289-297
      1. FOD, Volksgezondheid, Veiligheid van de Voedselketen en Leefmilieu, 2012. Jaarstatistieken. Available at Accessed August 7, 2012

        • Foster N.E.
        • Hartvigsen J.
        • Croft P.R.
        Taking responsibility for the early assessment and treatment of patients with musculoskeletal pain: A review and critical analysis.
        Arthritis Res Ther. 2012; 14: 205
        • Gatchel R.J.
        • Peng Y.B.
        • Peters M.L.
        • Fuchs P.N.
        • Turk D.C.
        The biopsychosocial approach to chronic pain: Scientific advances and future directions.
        Psychol Bull. 2007; 133: 581-624
        • Gerrity M.S.
        • DeVellis R.F.
        • Earp J.A.
        Physicians' reactions to uncertainty in patient care.
        Med Care. 1990; 28: 724-736
        • Gordon G.H.
        • Joos S.K.
        • Byrne J.
        Physician expressions of uncertainty during patient encounters.
        Pat Educ Couns. 2000; 40: 59-65
        • Hadjistavropoulos T.
        • Craig K.D.
        • Duck S.
        • Cano A.
        • Goubert L.
        • Jackson P.L.
        • Mogil J.S.
        • Rainville P.
        • Sullivan M.
        • Williams ACdeC.
        • Vervoort T.
        • Fitzgerald T.D.
        A biopsychosocial formulation of pain communication.
        Psychol Bull. 2011; : 910-939
        • Hiller W.
        • Rief W.
        • Brähler E.
        Somatization in the population: From mild bodily misperceptions to disabling symptoms.
        Soc Psychiatry Psychiatr Epidemiol. 2006; 41: 704-712
        • Holloway I.
        • Sofaer-Bennett B.
        • Walker J.
        The stigmatization of people with chronic back pain.
        Disabil Rehabil. 2007; 29: 1456-1464
      2. Ekman P. Friesen W. Investigator's Guide to the Facial Action Coding System. Consulting Psychologists Press, Palo Alto, CA1978
        • Jacobi F.
        • Wittchen H.U.
        • Hölting C.
        • Höfler M.
        • Pfister H.
        • Müller N.
        • Lieb R.
        Prevalence, co-morbidity and correlates of mental disorders in the general population: Results from the German Health Interview and Examination Survey (GHS).
        Psychol Med. 2004; 34: 597-611
        • Kahneman D.
        A Perspective on judgment and choice.
        Am Psychol. 2003; 58: 697-720
        • Kent P.M.
        • Keating J.L.
        • Taylor N.F.
        Primary care clinicians use variable methods to assess acute nonspecific low back pain and usually focus on impairments.
        Man Ther. 2009; 14: 88-100
        • Lahmann C.
        • Henningsen P.
        • Noll-Hussong M.
        Somatoform pain disorder—Overview.
        Psychiatr Danub. 2010; 22: 453-458
        • Lieb R.
        • Pfister H.
        • Mastaler M.
        • Wittchen H.U.
        Somatoform syndromes and disorders in a representative population sample of adolescents and young adults: Prevalence, comorbidity and impairments.
        Acta Psychiatr Scand. 2000; 101: 194-208
      3. West B.T. Welch K.B. Galecki A.T. Linear Mixed Models: A Practical Guide Using Statistical Software. Chapman & Hall/CRC, London2007
        • Linton S.J.
        A review of psychological risk factors in back and neck pain.
        Spine. 2000; 25: 1148-1156
        • Ludvigsson M.L.
        • Entohoven P.
        Evaluation of physiotherapists as primary assessors of patients with musculoskeletal disorders seeking primary health care.
        Physiotherapy. 2012; 98: 131-137
        • MacNeela P.
        • Gibbons A.
        • McGuire B.
        • Murphy A.
        “We need to get you focused”: General practitioners' representations of chronic low back pain patients.
        Qual Health Res. 2010; 20: 977-986
        • Mannion R.J.
        • Woolf C.J.
        Pain mechanisms and management: A central perspective.
        Clin J Pain. 2000; 16: S144-S156
        • 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' perspective.
        Pain Med. 2010; 11: 1688-1697
        • Melzack R.
        • Wall P.D.
        Pain mechanisms: A new theory.
        Science. 1965; 150: 971-979
      4. Pinheiro J.C. Bates D.M. Mixed-Effects Models in S and S-PLUS. Springer-Verlag, New York2000
        • Nilsen S.
        • Werner E.L.
        • Maeland S.
        • Eriksen H.R.
        • Magnussen L.H.
        Considerations made by the general practitioner when dealing with sick-listing of patients suffering from subjective and composite health complaints.
        Scand J Prim Health Care. 2011; 29: 7-12
        • Osborne T.L.
        • Jensen M.P.
        • Ehde D.M.
        • Hanley M.A.
        • Kraft G.
        Psychosocial factors associated with pain intensity, pain-related interference, and psychological functioning in persons with multiple sclerosis and pain.
        Pain. 2007; 127: 52-62
        • Peters S.
        • Stanley I.
        • Rose M.
        • Salmon P.
        Patients with medically unexplained symptoms: Sources of patients' authority and implications for demands on medical care.
        Soc Sci Med. 1998; 46: 559-565
        • Pincus T.
        • Burton A.K.
        • Vogel S.
        • Fiels A.P.
        A systematic review of psychological factors as predictors of chronicity/disability in prospective cohorts of low back pain.
        Spine. 2002; 27: E109-E120
        • Prkachin K.M.
        The consistency of facial expressions of pain: A comparison across modalities.
        Pain. 1992; 51: 297-306
        • Rief W.
        • Hessel A.
        • Braehler E.
        Somatization symptoms and hypochondriacal features in the general population.
        Psychosom Med. 2001; 63: 595-602
        • Rocha E.
        • Prkachin K.M.
        • Beaumont S.L.
        • Hardy C.
        • Zumbo B.D.
        Pain reactivity and illness behavior in kindergarten-aged children.
        J Pediatr Psychol. 2003; 28: 47-57
        • Scott W.
        • Sullivan M.J.
        Perceived injustice moderates the relationship between pain and depressive symptoms among individuals with persistent musculoskeletal pain.
        Pain Res Manage. 2012; 17: 335-340
        • Sinatra R.
        Causes and consequences of inadequate management of acute pain.
        Pain Med. 2010; 11: 1859-1871
        • Solomon P.E.
        • Prkachin K.M.
        • Farewell V.
        Enhancing sensitivity to facial expression of pain.
        Pain. 1997; 71: 279-284
        • Spacek A.
        Modern concepts of acute and chronic pain management.
        Biomed Pharmacother. 2006; 60: 329-335
        • Tait R.C.
        • Chibnall J.T.
        Observer perceptions of chronic low back pain.
        J Appl Soc Psychol. 1994; 24: 415-431
        • Tait R.C.
        • Chibnall J.T.
        Physician judgments of chronic pain patients.
        Soc Sci Med. 1997; 45: 1199-1205
        • Tait R.C.
        • Chibnall J.T.
        • Kalauokalani D.
        Provider judgments of patients in pain: Seeking symptom certainty.
        Pain Med. 2009; 10: 11-34
        • Taylor A.G.
        • Skelton J.A.
        • Butcher J.
        Duration of pain condition and physical pathology as determinants of nurses' assessments of patients in pain.
        Nurs Res. 1984; 33: 4-8
        • Toye F.
        • Barker K.
        “Could I be imagining this?”—The dialectic struggles of people with persistent unexplained back pain.
        Disabil Rehabil. 2010; 32: 1722-1732
        • van Tulder M.
        • Becker A.
        • Bekkering T.
        • Breen A.
        • Gil del Real M.T.
        • Hutchinson A.
        • Koes B.
        • Laerum E.
        • Malmivaara A.
        European guidelines for the management of acute nonspecific low back pain in primary care.
        Eur Spine J. 2006; 15: S169-S191
        • Verbruggen F.
        • Aron A.R.
        • Stevens M.A.
        • Chambers C.D.
        Theta burst stimulation dissociates attention and action updating in human inferior frontal cortex.
        Proc Natl Acad Sci U S A. 2010; 107: 13966-13971
        • Vowles K.E.
        • Thompson M.
        The patient-provider relationship in chronic pain.
        Curr Pain Headache Rep. 2012; 16: 133-138
        • Wasan A.D.
        • Wootton J.
        • Jamison R.N.
        Dealing with difficult patients in your pain practice.
        Reg Anesth Pain Med. 2005; 30: 184-192
        • Werner A.
        • Malterud K.
        It is hard work behaving as a credible patient: Encounters between women with chronic pain and their doctors.
        Soc Sci Med. 2003; 57: 1409-1419
        • Williams ACdeC.
        Facial expression of pain: An evolutionary account.
        Behav Brain Sci. 2002; 25: 439-488
        • Williams ACdeC.
        Assessing chronic pain and its impact.
        in: Psychosocial Aspects of Pain: A Handbook for Health Care Providers, Progress in Pain Research and Management. Vol. 27. IASP Press, Seattle, WA2004: 97-115