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17 Articles in Volume 20, Issue #1
20/20 with Lynn Webster, MD
Analgesics of the Future: Peripheral Kappa Opioid Receptor Agonists
Correspondence: Opioid-Induced Hyperalgesia; Pain Care in Older Adults
Don’t Discount the Role of Diet for Chronic Pain Relief
Editorial: Why Haven’t There Been More Breakthrough Analgesics?
Gasping for Air: Sleep-Disordered Breathing and Chronic Opioids
How can botulinum toxin be used in chronic pain syndromes?
Neurodestructive Interventions for Cancer Pain
Obesity and Pain Care: Multifaceted Considerations for Treatment
Obesity and Rheumatoid Arthritis: What Clinicians Should Know
Sickle Cell Pain Crisis: Clinical Guidelines for the Use of Oxygen
The Complexity of Sickle Cell Pain: An Overview
The Perseverance Loop: The Psychology of Pain and Factors in Pain Perception
The Rapid Rise of Non-Opioid Pain Policies
Treating Pain by Overcoming Communication Barriers
Visual Artists Tackle What Pain Looks Like
Will 2020 Be the Year of Patient Education?

Treating Pain by Overcoming Communication Barriers

How clinicians speak – and listen – to patients affects their engagement, perceptions, and outcomes.
Pages 69-71

A Clinical Commentary


The ability to communicate effectively is a vital trait for healthcare providers, although they often overestimate their abilities in this area. Case in point, one study showed that 75% of orthopedic surgeons believed their patients were satisfied with their communication, while only 21% of the patients reported satisfaction.1 

Common barriers to provider–patient communication involve avoidance behavior and opposition of collaboration. Providers, for instance, often avoid topics that involve psychosocial effects in their patients as they are unsure how to handle the topic or they simply lack time to thoroughly address them. Providers may believe they are discussing patients’ anxiety or fears while patients are less likely to perceive the discussion as such.2

Providers would benefit and provide better care if they continually consider how the patient perceives them, communicates, and translates pain. (Image: iStock)

Another communication barrier in chronic pain management has to do with the different schools of thought in treatment approach. In general, chronic pain management involves two different models: biopsychosocial and biomedical. In 1977, Engel and Romano developed the biopsychosocial model and introduced it into medicine. Over the next 20 years, however, the model was rarely used. By the early 2000s, this changed as patient-centered models gained popularity. By focusing on biological, psychological, and social mechanisms, the model encourages an all-inclusive approach.3  In comparison, the biomedical model, which dates back to the 17th century, focuses on mechanical sensory mechanisms without regard to psychosocial effects.4  In the biopsychosocial model, perceived stimuli and processing response lead to nociceptive pain response whereas the biomedical approach focuses on restrictive advice regarding daily life activities, which frequently leads to fear-avoidance beliefs in patients.

These barriers need to be addressed to improve patient outcomes and economic burden. Chronic pain is also to contribute $560 billion to $635 billion each year to national economic costs, with $297 billion to $336 billion of that total from lost in productivity.This loss in productivity affects patient function and mobility as well as our economy, due to lower labor force participation.

We Need: Trusting Relationships

Improving patient outcomes requires creating more sustainable and trustworthy relationships between providers and patients. We must create a space where patients are able to discuss their questions and concerns. Providers sometimes interrupt patients while stating their concerns after a median of 11 seconds (range of 3 to 234 seconds).6 If patients went uninterrupted, they could state their concerns in a median of 6 seconds (range of 2 to 108 seconds).6 Further, providers tend not to ask their patients the purpose of their visits at 64% of primary care visits and at 80% of specialist visits.6 With patients unable to state their concerns, providers may struggle to effectively diagnose, treat, and manage their disease states.

On the other hand, if unable to speak effectively to their providers, patients may seek information from other sources. With widespread use of the Internet, patients can readily access health information, and many of these sources have been studied to detect their influence. Despite this easy access to health information, patients remain cautious of their online findings, primarily due to a concern of trustworthy sources.7 During medical visits, patients often want to confirm what they found on the web with their provider, although they are typically hesitant to display any disrespect.8

We Need: Collaborative Treatment Plans

Although providers may adhere to a biopsychosocial model, they may face the challenge of convincing patients of the benefits of this model. Often, patients are resistant to believing in the benefits due to involvement of active modalities such as psychotherapy. The challenge is creating patient buy-in of the importance of psychosocial effects on their physical health. As studied, when providers trained in the biopsychosocial model encounter a biomedical-focused chronic low back pain patient, for example, notable differences arise: reducing pain score compared to improving function and the patient’s desire for a definitive diagnosis.9,10 Unfortunately, these differences hinder improvement in communication. To remedy this situation, I would encourage utilizing shared treatment planning. This approach allows for providers and patients to select treatments based on evidence-based medicine and patient preferences.

By providing patients with up-to-date evidence-based medicine and autonomy, providers can also enable patients to be active participants in their healthcare. Patient activation improves interest in being involved in their healthcare and includes the following:

  • importance of the patient role
  • confidence to act in their health
  • participation in their health
  • continuation of treatment under stress.

Patients with higher patient activation scores in chronic disease management have been shown more likely to report high patient-satisfaction, quality-of-life, and physical and mental functional status scores, compared to patients with the lowest scores.11

Clinicians should also ask patients how they see their role in their own healthcare and work to establish outcomes (most often related to function) are important to them. When providing patients with treatment options, tools such as the teach-back method can help to assure providers that the patient understands the treatment plan.

We Need: To Reshape Conversations

Patients rely on us to translate not only Internet findings and medical literature but also their physiological findings, such as radiologic imaging. I will use chronic low back pain as an example.

Frequently, imaging of the lumbar spine displays degeneration. Translation and communication of this information to patients remains problematic. Terms such as “degeneration” and associated terms/phases such as “wear and tear,” “aging,” and “narrowing” are associated with a poor perceived patient prognosis despite a positive prognosis.10,12

Chronic low back pain is typically treated in a primary care setting, leaving PCPs to communicate imaging results and to provide a treatment plan. If the imaging report states the high prevalence and commonality of findings among those with low back pain, the PCP is less likely to prescribe narcotics as a part of this plan.13 In these situations, prevalence rates allow for greater understanding of the imaging results by the provider, therefore leading to less harmful treatment plans for patients.

Sometimes, imaging reports are often given to patients in written form without interpretation. When original reports were reworded to below an 8th-grade reading level, as recommended by the CDC, patients reported more satisfaction and understanding of the reports.14 Using less distressing language and more understanding of patients’ health, we can help decrease patients’ catastrophic thoughts. I challenge us to first listen carefully to our patients and their complaints as a way of working collaboratively, particularly before suggesting complaints based on radiologic imaging that does not relate the entire picture of a patient.

The fear-avoidance model is commonly used to explain how negative beliefs about pain may lead to a catastrophizing response of avoidance of activity, which further worsens the prognosis reinforcing the original catastrophizing response in a continuous cycle. The fear-avoidance model also proposes that patients without these beliefs are more likely to address their pain complaints and to be more active in the coping process.15 A systemic review demonstrated that beliefs of patients with chronic low back pain were associated with beliefs displayed by the consulted provider. Furthermore, providers displaying fear-avoidance beliefs were associated with fear-avoidance beliefs in their patients.16  Fortunately, further findings found that providers can influence the importance of physical movement by reassurance their patients’ prognosis and safety of movement.17  If providers encourage particular practices, such as individual strength, positivity in life, acceptance of chronic pain, and acceptance of help, they can lead patients toward a positive prognosis.18

Moving Forward

As healthcare providers, we are viewed as trustworthy sources of information, which can be a heavy weight to bear. The medical visit frequently involves the patient and provider shaping their discourse to persuade the other: on one hand, the patient looks to persuade the provider of the severity or validity of their ailment; on the other hand, the provider works to convince the patient of their treatment plan and beliefs. This back and forth between providers and patients does not mean trusting, productive, and valuable relationships are out of reach. But to develop such relationships, we must be mindful of how we speak to our patients if we want positive patient outcomes and sustainable communication.

Providers would benefit and provide better care if they continually consider how the patient perceives them, communicates, and translates pain. To maintain and strengthen trust, we also need to integrate shared treatment planning, listen to patients’ concerns, and develop a vocabulary that promotes coping instead of avoidance. In doing so, we can offer opportunities for patients to be empowered and take ownership of their lives and those around them. •

Last updated on: February 4, 2020
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