Feelings of Clinician-Patient Similarity and Trust Influence Pain: Evidence From Simulated Clinical Interactions


      • The clinician-patient relationship may influence pain experienced in medical care.
      • Simulated clinical interactions were used to investigate this effect.
      • Patient feelings of similarity and trust toward clinicians influenced pain ratings.
      • Findings suggest that increasing patient feelings of similarity/trust may reduce pain report.


      Pain is influenced by many factors other than external sources of tissue damage. Among these, the clinician-patient relationship is particularly important for pain diagnosis and treatment. However, the effects of the clinician-patient relationship on pain remain underexamined. We tested the hypothesis that patients who believe they share core beliefs and values with their clinician will report less pain than patients who do not. We also measured feelings of perceived clinician-patient similarity and trust to see if these interpersonal factors influenced pain. We did so by experimentally manipulating perceptions of similarity between participants playing the role of clinicians and participants playing the role of patients in simulated clinical interactions. Participants were placed in 2 groups on the basis of their responses to a questionnaire about their personal beliefs and values, and painful thermal stimulation was used as an analog of a painful medical procedure. We found that patients reported feeling more similarity and trust toward their clinician when they were paired with clinicians from their own group. In turn, patients' positive feelings of similarity and trust toward their clinicians—but not clinicians' feelings toward patients or whether the clinician and patient were from the same group—predicted lower pain ratings. Finally, the most anxious patients exhibited the strongest relationship between their feelings about their clinicians and their pain report. These findings increase our understanding of context-driven pain modulation and suggest that interventions aimed at increasing patients’ feelings of similarity to and trust in health care providers may help reduce the pain experienced during medical care.


      We present novel evidence that the clinician-patient relationship can affect the pain experienced during medical care. We found that “patients” in simulated clinical interactions who reported feeling more similarity and trust toward their “clinicians” reported less pain, suggesting that increasing feelings of clinician-patient similarity and trust may reduce pain disparities.

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        • AAMC
        Association of American Medical Colleges: Diversity in the Physician Workforce: Facts & Figures 2014.
        Association of American Medical Colleges, Washington, DC2014
        • Arnau J.
        • Bono R.
        • Blanca M.J.
        • Bendayan R.
        Using the linear mixed model to analyze nonnormal data distributions in longitudinal designs.
        Behav Res Methods. 2012; 44: 1224-1238
        • Aslaksen P.M.
        • Myrbakk I.N.
        • Høifødt R.S.
        • Flaten M.A.
        The effect of experimenter gender on autonomic and subjective responses to pain stimuli.
        Pain. 2007; 129: 260-268
      1. World Values Survey Association: World Values Survey wave 5 (2005-2008) Official Aggregate v.20140429. Available at: Accessed April 8, 2017

        • Atlas L.Y.
        • Wager T.D.
        A meta-analysis of brain mechanisms of placebo analgesia: Consistent findings and unanswered questions.
        Handb Exp Pharmacol. 2014; 225: 37-69
      2. Barratt W. The Barratt Simplified Measure of Social Status (BSMSS). Available at: Published June 14, 2012. Accessed April 7, 2017

        • Bartoshuk L.M.
        • Fast K.
        • Snyder D.J.
        Differences in Our Sensory Worlds: Invalid Comparisons With Labeled Scales.
        Curr Dir Psychol Sci. 2005; 14: 122-125
      3. Bates D, Maechler M, Bolker B, Walker S: Fitting Linear Mixed-Effects Models Using lme4. Journal of Statistical Software 67:1-48, 2015

        • Benedetti F.
        Placebo and the new physiology of the doctor-patient relationship.
        Physiol Rev. 2013; 93: 1207-1246
        • Benedetti F.
        • Mayberg H.S.
        • Wager T.D.
        • Stohler C.S.
        • Zubieta J.K.
        Neurobiological mechanisms of the placebo effect.
        J Neurosci. 2005; 25: 10390-10402
        • Bollen K.A.
        • Jackman R.W.
        Regression diagnostics an expository treatment of outliers and influential cases.
        Sociol Methods Res. 1985; 13: 510-542
        • Brown J.L.
        • Sheffield D.
        • Leary M.R.
        • Robinson M.E.
        Social support and experimental pain.
        Psychosom Med. 2003; 65: 276-283
        • Bushnell M.C.
        • Ceko M.
        • Low L.A.
        Cognitive and emotional control of pain and its disruption in chronic pain.
        Nat Rev Neurosci. 2013; 14: 502-511
        • Campbell C.M.
        • Edwards R.R.
        Ethnic differences in pain and pain management.
        Pain Manag. 2012; 2: 219-230
        • Chassany O.
        • Boureau F.
        • Liard F.
        • Bertin P.
        • Serrie A.
        • Ferran P.
        • Keddad K.
        • Jolivet-Landreau I.
        • Marchand S.
        Effects of training on general practitioners’ management of pain in osteoarthritis: A randomized multicenter study.
        J Rheumatol. 2006; 33: 1827-1834
        • Cikara M.
        • Van Bavel J.J.
        The neuroscience of intergroup relations: An integrative review.
        Perspect Psychol Sci. 2014; 9: 245-274
        • Cooper L.A.
        • Roter D.L.
        • Johnson R.L.
        • Ford D.E.
        • Steinwachs D.M.
        • Powe N.R.
        Patient-centered communication, ratings of care, and concordance of patient and physician race.
        Ann Intern Med. 2003; 139: 907-915
        • Craig K.D.
        The social communication model of pain.
        Can Psychol. 2009; 50: 22-32
        • Cremeans-Smith J.K.
        Fear of pain and the frequency with which healthy individuals engage in physical activity.
        Int J Sport Exerc Psychol. 2016 Sept 16; ([Epub ahead of print])
        • David R.A.
        • Rhee M.
        The impact of language as a barrier to effective health care in an underserved urban Hispanic community.
        Mt Sinai J Med. 1998; 65: 393-397
        • Descartes R.
        Treatise of Man [1664].
        Harvard University Press, Cambridge, MA1972
        • Di Blasi Z.
        • Harkness E.
        • Ernst E.
        • Georgiou A.
        • Kleijnen J.
        Influence of context effects on health outcomes: A systematic review.
        Lancet. 2001; 357: 757-762
        • Doescher M.P.
        • Saver B.G.
        • Franks P.
        • Fiscella K.
        Racial and ethnic disparities in perceptions of physician style and trust.
        Arch Fam Med. 2000; 9: 1156-1163
        • Edwards R.R.
        The association of perceived discrimination with low back pain.
        J Behav Med. 2008; 31: 379-389
        • Edwards R.R.
        • Fillingim R.B.
        Ethnic differences in thermal pain responses.
        Psychosom Med. 1999; 61: 346-354
        • Enck P.
        • Benedetti F.
        • Schedlowski M.
        New insights into the placebo and nocebo responses.
        Neuron. 2008; 59: 195-206
        • Greffrath W.
        • Baumgärtner U.
        • Treede R.D.
        Peripheral and central components of habituation of heat pain perception and evoked potentials in humans.
        Pain. 2007; 132: 301-311
        • Gurka M.J.
        • Edwards L.J.
        • Muller K.E.
        • Kupper L.L.
        Extending the Box–Cox transformation to the linear mixed model.
        J R Stat Soc Ser A Stat Soc. 2006; 169: 273-288
        • Hall M.A.
        • Zheng B.
        • Dugan E.
        • Camacho F.
        • Kidd K.E.
        • Mishra A.
        • Balkrishnan R.
        Measuring patients trust in their primary care providers.
        Med Care Res Rev. 2002; 59: 293
        • Jepma M.
        • Jones M.
        • Wager T.D.
        The dynamics of pain: Evidence for simultaneous site-specific habituation and site-nonspecific sensitization in thermal pain.
        J Pain. 2014; 15: 734-746
        • Johnson R.L.
        • Roter D.
        • Powe N.R.
        • Cooper L.A.
        Patient race/ethnicity and quality of patient-physician communication during medical visits.
        Am J Public Health. 2004; 94: 2084
        • Kaptchuk T.J.
        • Kelley J.M.
        • Conboy L.A.
        • Davis R.B.
        • Kerr C.E.
        • Jacobson E.E.
        • Kirsch I.
        • Schyner R.N.
        • Nam B.H.
        • Nguyen L.T.
        • Park M.
        • Rivers A.L.
        • McManus C.
        • Kokkotou E.
        • Drossman D.A.
        • Goldman P.
        • Lembo A.J.
        Components of placebo effect: Randomised controlled trial in patients with irritable bowel syndrome.
        BMJ. 2008; 336: 999-1003
        • Kaptchuk T.J.
        • Miller F.G.
        Placebo effects in medicine.
        N Engl J Med. 2015; 373: 8-9
        • Kelley J.M.
        • Kraft-Todd G.
        • Schapira L.
        • Kossowsky J.
        • Riess H.
        The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and meta-analysis of randomized controlled trials.
        PLoS One. 2014; 9: e94207
        • Knight R.G.
        • Waal-Manning H.J.
        • Spears G.F.
        Some norms and reliability data for the State-Trait Anxiety Inventory and the Zung Self-Rating Depression scale.
        Br J Clin Psychol. 1983; 22: 245-249
        • Koban L.
        • Wager T.D.
        Beyond conformity: Social influences on pain reports and physiology.
        Emotion. 2016; 16: 24-32
        • Koenig H.G.
        • Büssing A.
        The Duke University Religion Index (DUREL): A five-item measure for use in epidemological studies.
        Religions. 2010; 1: 78-85
        • Koerber A.
        • Gajendra S.
        • Fulford R.L.
        • BeGole E.
        • Evans C.A.
        An exploratory study of orthodontic resident communication by patient race and ethnicity.
        J Dent Educ. 2004; 68: 553-562
      4. Kuznetsova A, Brockhoff PB, Christensen RHB: Package ‘ImerTest’: Tests in Linear Mixed Effects Models. Version 2.0-33. Available at: Published December 3, 2016. Accessed April 8, 2017

        • Laveist T.A.
        • Nuru-Jeter A.
        Is doctor-patient race concordance associated with greater satisfaction with care?.
        J Health Soc Behav. 2002; 43: 296-306
        • Lee L.J.
        • Batal H.A.
        • Maselli J.H.
        • Kutner J.S.
        Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic.
        J Gen Intern Med. 2002; 17: 640-645
        • Levine F.M.
        • De Simone L.L.
        The effects of experimenter gender on pain report in male and female subjects.
        Pain. 1991; 44: 69-72
        • Loeser J.D.
        • Melzack R.
        Pain: An overview.
        Lancet. 1999; 353: 1607-1609
        • Losin E.A.
        • Cross K.A.
        • Iacoboni M.
        • Dapretto M.
        Neural processing of race during imitation: Self-similarity versus social status.
        Hum Brain Mapp. 2014; 35: 1723-1739
        • Lyby P.S.
        • Aslaksen P.M.
        • Flaten M.A.
        Is fear of pain related to placebo analgesia?.
        J Psychosom Res. 2010; 68: 369-377
        • Lyby P.S.
        • Aslaksen P.M.
        • Flaten M.A.
        Variability in placebo analgesia and the role of fear of pain–an ERP study.
        Pain. 2011; 152: 2405-2412
        • MacKinnon D.P.
        Introduction to Statistical Mediation Analysis.
        Routledge, New York2008
        • McNeil D.W.
        • Rainwater 3rd, A.J.
        Development of the Fear of Pain Questionnaire–III.
        J Behav Med. 1998; 21: 389-410
        • Merskey H.
        • Albe-Fessard D.
        • Bonica J.
        • Carmon A.
        • Dubner R.
        • Kerr F.
        • Lindblom U.
        • Mumford J.
        • Nathan P.
        • Noordenbos W.
        • Pagni C.
        • Renaer M.
        • Sternbach R.
        • Sunderland S.
        Pain terms: A list with definitions and notes on usage. Recommended by the IASP Subcommittee on Taxonomy.
        Pain. 1979; 6: 249
        • Metzger R.L.
        Reliability and validity study of the State-Trait Anxiety Inventory.
        J Clin Psychol. 1976; 32: 276-278
        • Mistiaen P.
        • van Osch M.
        • van Vliet L.
        • Howick J.
        • Bishop F.L.
        • Di Blasi Z.
        • Bensing J.
        • van Dulmen S.
        The effect of patient–practitioner communication on pain: A systematic review.
        Eur J Pain. 2016; 20: 675-688
        • Nieuwenhuis R.
        • te Grotenhuis M.
        • Pelzer B.
        influence.ME: Tools for detecting influential data in mixed effects models.
        R Journal. 2012; 4: 38-47
        • Osman A.
        • Breitenstein J.L.
        • Barrios F.X.
        • Gutierrez P.M.
        • Kopper B.A.
        The Fear of Pain Questionnaire-III: Further reliability and validity with nonclinical samples.
        J Behav Med. 2002; 25: 155-173
        • Piercy M.A.
        • Sramek J.J.
        • Kurtz N.M.
        • Cutler N.R.
        Placebo response in anxiety disorders.
        Ann Pharmacother. 1996; 30: 1013-1019
        • Pitkin Derose K.
        • Hays R.D.
        • McCaffrey D.F.
        • Baker D.W.
        Does physician gender affect satisfaction of men and women visiting the emergency department?.
        J Gen Intern Med. 2001; 16: 218-226
        • RCoreTeam
        R: A language and Environment for Statistical Computing.
        R Foundation for Statistical Computing, Vienna, Austria2014
        • Roberts M.H.
        • Klatzkin R.R.
        • Mechlin B.
        Social support attenuates physiological stress responses and experimental pain sensitivity to cold pressor pain.
        Ann Behav Med. 2015; 49: 557-569
        • Roelofs J.
        • Peters M.L.
        • Deutz J.
        • Spijker C.
        • Vlaeyen J.W.
        The Fear of Pain Questionnaire (FPQ): Further psychometric examination in a non-clinical sample.
        Pain. 2005; 116: 339-346
        • Shapiro A.K.
        • Mike V.
        • Barten H.
        • Shapiro E.
        Study of the placebo effect with a self-administered placebo test.
        Compr Psychiatry. 1973; 14: 535-548
        • Shapiro A.
        • Shapiro E.
        Patient-provider relationship than the placebo effect.
        in: Matrazzo J. Behavioral Health: A Handbook of Health Enhancement and Disease Prevention. Wiley-Interscience, New York1984: 371-383
        • Siminoff L.A.
        • Graham G.C.
        • Gordon G.H.
        Cancer communication patterns and the influence of patient characteristics: Disparities in information-giving and affective behaviors.
        Patient Educ Couns. 2006; 62: 355-360
        • Sitzia J.
        How valid and reliable are patient satisfaction data? An analysis of 195 studies.
        Int J Qual Health Care. 1999; 11: 319-328
      5. Spielberger CD, Gorsuch RL, Lushene R, Vagg PR, Jacobs GA: Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, Consulting Psychologists Press,1983

        • Stewart M.A.
        Effective physician-patient communication and health outcomes: A review.
        CMAJ. 1995; 152: 1423-1433
        • Street R.L.
        • O’Malley K.J.
        • Cooper L.A.
        • Haidet P.
        Understanding concordance in patient-physician relationships: Personal and ethnic dimensions of shared identity.
        Ann Fam Med. 2008; 6: 198-205
        • Sullivan M.J.
        • Thorn B.
        • Haythornthwaite J.A.
        • Keefe F.
        • Martin M.
        • Bradley L.A.
        • Lefebvre J.C.
        Theoretical perspectives on the relation between catastrophizing and pain.
        Clin J Pain. 2001; 17: 52-64
        • Tajfel H.
        Experiments in intergroup discrimination.
        Sci Am. 1970; 223: 96-102
        • Tajfel H.
        The social psychology of intergroup relations.
        Annu Rev Psychol. 1982; 33: 1-39
      6. Tajfel H, Turner JC: An integrative theory of intergroup conflict. In: Austin WG and Worchel S (eds). The social psychology of intergroup relations. Monterey, CA, Brooks/Cole Publishing Co., 1979, pp 33-47

        • Thom D.H.
        • Wong S.T.
        • Guzman D.
        • Wu A.
        • Penko J.
        • Miaskowski C.
        • Kushel M.
        Physician trust in the patient: Development and validation of a new measure.
        Ann Fam Med. 2011; 9: 148-154
        • Van Bavel J.J.
        • Cunningham W.A.
        A social identity approach to person memory: Group membership, collective identification, and social role shape attention and memory.
        Pers Soc Psychol Bull. 2012; 38: 1566-1578
        • Williams B.
        Patient satisfaction: A valid concept?.
        Soc Sci Med. 1994; 38: 509-516
        • Zuur A.F.
        • Ieno E.N.
        • Elphick C.S.
        A protocol for data exploration to avoid common statistical problems.
        Methods Ecol Evol. 2010; 1: 3-14