Highlights
- •People with chronic pain see physicians as burdened if medical evidence is lacking.
- •Perceived burden mediates the effects of medical evidence on clinical judgments.
- •More burdensome patients are perceived as less credible and less likely to improve.
- •More burdensome patients are perceived as more psychosocially dysfunctional.
- •Perceived physician burden may undermine collaboration in chronic pain treatment.
Abstract
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.
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 accessOne-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:
Subscribe to The Journal of PainAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Empathy in the physician's pain practice: Benefits, barriers, and recommendations.Pain Med. 2006; 7: 265-275https://doi.org/10.1111/j.1526-4637.2006.00159.x
- What is a cognitive map? Organizing knowledge for flexible behavior.Neuron. 2018; 100: 490-509https://doi.org/10.1016/j.neuron.2018.10.002
- Assessment of psychological status using interviews and self-report instruments.in: Turk DC Melzack R Handbook of Pain Assessment. The Guilford Press, New York1992: 193-213
- Internist judgments of chronic low back pain.Pain Med. 2000; 1: 231-237https://doi.org/10.1046/j.1526-4637.2000.00029.x
- Accountability and empathy effects on medical students’ clinical judgments in a disability determination context for low back pain.JPain. 2014; 15: 915-924https://doi.org/10.1016/j.jpain.2014.06.001
- Physician judgments and the burden of chronic pain.Pain Med. 2018; 19: 1961-1971https://doi.org/10.1093/pm/pnx342
- The effects of medical evidence and pain intensity on medical student judgments of chronic pain patients.J Behav Med. 1997; 20: 257-271https://doi.org/10.1023/a:1025504827787
- Caregiver burden and patients’ perception of being a burden in ALS.Neurology. 2005; 68: 1780-1792https://doi.org/10.1212/01.WNL.0000162034.06268.37
- Measuring chronic patients’ feelings of being a burden to their caregivers.Med Care. 2003; 41: 110-118https://doi.org/10.1097/00005650-200301000-00013
- Exploding myths about medically unexplained symptoms.J Psychosom Res. 2016; 85: 91-93https://doi.org/10.1016/j.jpsychores.2016.02.007
- Measuring individual differences in empathy: Evidence for a multidimensional approach.J Personal Soc Psychol. 1983; 44: 113-126https://doi.org/10.1037/0022-3514.44.1.113
- Reducing medical patients’ reluctance to participate in psychological therapies: The initial session.Prof Psychol. 1983; 14: 491-502https://doi.org/10.1037/0735-7028.14.5.570
- Discounting pain in the absence of medical evidence is explained by negative evaluation of the patient.Pain. 2013; 154: 669-676https://doi.org/10.1016/j.pain.2012.12.018
- We discount the pain of others when pain has no medical explanation.J Pain. 2012; 13: 1198-1205https://doi.org/10.1016/j.jpain.2012.09.002
- Relationship between social desirability and self-report in chronic pain patients.Clin J Pain. 1995; 11: 189-193https://doi.org/10.1097/01.MLR.0000039832.32412.7D
- Veterans affairs primary care clinicians' attitudes toward chronic pain and correlates of opioid prescribing rates.Pain Med. 2008; 9: 564-571https://doi.org/10.1111/j.1526-4637.2007.00330.x
- Illnesses you have to fight to get: Facts as forces in uncertain, emergent illnesses.Social Sci Med. 2006; 62: 577-590https://doi.org/10.1016/j.socscimed.2005.06.018
- The treatment of patients with medically unexplained symptoms in primary care: A review of the literature.Ment Health Fam Med. 2010; 7 (PMCID: PMC3083260): 209-221
- Duberstein PR: Physicians’ responses to patients’ medically unexplained symptoms.Psychosom Med. 2006; 68: 269-276https://doi.org/10.1097/01.psy.0000204652.27246.5b
- Maps for managers: Where are we?.J Manag Stud. 1992; 29 (Where do we go from here?): 267-285https://doi.org/10.1111/j.1467-6486.1992.tb00665.x
- The perception of being a burden in acute and chronic pain patients is associated with affirmation of different types of suicidality.Pain Med. 2016; 17: 530-538https://doi.org/10.1111/pme.12889
- Core competencies for pain management: Results of an interprofessional consensus summit.Pain Med. 2013; 14: 971-981https://doi.org/10.1111/pme.12107
- Patient-provider interactions in the management of chronic pain: Current findings within the context of shared medical decision making.Pain Med. 2007; 8: 25-35https://doi.org/10.1111/j.1526-4637.2007.00250.x
- Interdisciplinary chronic pain management: Past, present, and future.Am Psychol. 2014; 69: 119-130https://doi.org/10.1037/a0035514
- Correlation of patient and caregiver ratings of cancer pain.J Pain Sympt Manag. 1991; 6: 53-57https://doi.org/10.1016/0885-3924(91)90518-9
- The analysis of mechanisms and their contingencies: PROCESS versus structural equation modeling.Austral Market J. 2017; 25: 76-81https://doi.org/10.1016/j.ausmj.2017.02.001
- Experts’ opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials.Fam Pract. 2011; 28: 444-455https://doi.org/10.1093/fampra/cmr004
- Medically unexplained symptoms: The person, the symptoms and the dialogue.Fam Pract. 2017; 34: 245-251https://doi.org/10.1093/fampra/cmw132
- Interagency Pain Research Coordinating Committee.Department of Health and Human Services: National Pain Strategy, 2017 (Available at:) (Accessed March 31, 2021)
- The effects of experimenter characteristics on pain reports in women and men.Pain. 2004; 112: 142-147https://doi.org/10.1016/j.pain.2004.08.008
- Characteristics of physicians with participatory decision-making styles.Ann Intern Med. 1995; 124: 497-504https://doi.org/10.7326/0003-4819-124-5-199603010-00007
- Self-perceived burden in chronic pain: Relevance, prevalence, and predictors.Pain. 2012; 153: 1735-1741https://doi.org/10.1016/j.pain.2012.05.009
- Changes in and modifiable patient- and family caregiver-related factors associated with cancer patients’ high self-perceived burden to others at the end of life: A longitudinal study.Eur J Cancer Care. 2018; 27: e12942https://doi.org/10.1111/ecc.12942
- Medical evaluation of the patient with pain.in: Loeser JD Butler SH Chapman R Turk DC Bonica's Management of Pain. 3rd ed. Lippincott Williams & Wilkins, New York2001: 267-278
- Losing face: Sources of stigma as perceived by chronic facial pain patients.J Behav Med. 1990; 13: 583-604https://doi.org/10.1007/BF00844736
- Self-perceived burden to others: Patient and family caregiver correlates.J Palliat Care. 2007; 23 (PMID: 18069434): 135-142
- The balance of give and take in caregiver-partner relationships: An examination of self-perceived burden, relationship equity, and quality of life from the perspective of care recipients following stroke.Rehabil Psychol. 2010; 2: 194-203https://doi.org/10.1037/a0019359
- Diagnostic experience of patients with fibromyalgia—A meta-ethnography.Chronic Illness. 2018; 14: 194-211https://doi.org/10.1177/1742395317718035
- The disparagement of pain: Social influences on medical thinking.Pain Res Manag. 2000; 5: 259-270https://doi.org/10.1155/2000/565309
- The impact of pain invisibility on patient-centered care and empathetic attitude in chronic pain management.Pain Res Manag. 2018; 6375713https://doi.org/10.1155/2018/6375713
- The power of the visible: The meaning of diagnostic tests in chronic back pain.Soc Sci Med. 1999; 48: 1189-1203https://doi.org/10.1016/S0277-9536(98)00418-3
- Physician burnout and well-being: A systematic review and framework for action.Dis Colon Rectum. 2017; 60: 567-576https://doi.org/10.1097/DCR.0000000000000844
- Good patients cope with their pain: Postoperative analgesia and nurses' perceptions of their patients' pain.Pain. 1996; 68: 63-68https://doi.org/10.1016/S0304-3959(96)03171-5
- Patients' perceptions of medical explanations for somatisation disorders: Qualitative analysis.BMJ. 1999; 318: 372-376https://doi.org/10.1136/bmj.318.7180.372
- Medical evaluation of the chronic pain patient.in: Aronoff GM Evaluation and Treatment of Chronic Pain. Urban & Schwarzenberg, Baltimore-Munich1985: 39-60
- Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes.Rheumatol. 2008; 47: 670-678https://doi.org/10.1093/rheumatology/ken021
- Health care providers' judgments in chronic pain: The influence of gender and trustworthiness.Pain. 2016; 157: 1618-1625https://doi.org/10.1097/j.pain.0000000000000536
- Racial/ethnic disparities in the assessment and treatment of pain: Psychosocial perspectives.Am Psychol. 2014; 69 (131-14)https://doi.org/10.1037/a0035204
- Provider judgments of patients in pain: Seeking symptom certainty.Pain Med. 2009; 10: 11-34https://doi.org/10.1111/j.1526-4637.2008.00527.x
- Impact of high self-perceived burden to others with preferences for end-of-life care and its determinants for terminally ill cancer patients: A prospective cohort study.Psycho-Oncol. 2017; 26: 102-108https://doi.org/10.1002/pon.4107
- Patients’ experiences of chronic non-malignant musculoskeletal pain: A qualitative systematic review.Brit J Gen Pract. 2013; 63: e829-e841https://doi.org/10.3399/bjgp13X675412
- Patient-related barriers to management of cancer pain.Pain. 1993; 52: 319-324https://doi.org/10.1016/0304-3959(93)90165-l
- Interventions to prevent and reduce physician burnout: A systematic review and meta-analysis.Lancet. 2016; 388: 2272-2281https://doi.org/10.1016/0304-3959(93)90165-l
- Clinician burnout and satisfaction with resources in caring for complex patients.Gen Hosp Psychiat. 2017; 44: 91-95https://doi.org/10.1186/s12875-018-0809-3
- Assessor status influences pain recall.J Pain. 2007; 8: 343-348https://doi.org/10.1016/j.jpain.2006.10.00556
- Chronic pain and the interpersonal theory of suicide.Rehabil Psychol. 2013; 58: 111-115https://doi.org/10.1037/a0031390
- Self-perceived burden, perceived burdensomeness, and suicidal ideation in patients with chronic pain.Can J Pain. 2017; 1: 127-136https://doi.org/10.1080/24740527.2017.1368009
Article info
Publication history
Published online: March 13, 2021
Accepted:
March 1,
2021
Received in revised form:
February 22,
2021
Received:
January 4,
2021
Footnotes
Funding: This study was supported by institutional funding from Saint Louis University.
Conflict of Interest Statement: None of the authors of this manuscript has relevant conflicts of interest to disclose.
Identification
Copyright
© 2021 by United States Association for the Study of Pain, Inc.
