How much time do low-income patients and primary care physicians actually spend discussing pain? A direct observation study

Abstract

Background: We know little about how much time low-income patients and physicians spend discussing pain during primary care visits.

Objective: To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions.

Design: We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables.

Participants: A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents.

Main measures: Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain.

Key results: Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9 min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously.

Conclusions: Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.

Figure 1.

Relationship between SF-20 pain score and percent of total visit time spent discussing pain. Lines represent predicted values from multiple linear regression. For visits in which the patient and physician had not met previously (dashed line), pain severity was positively associated with the percent of total visit time spent discussing pain. For visits in which the patient and physician had met previously (solid line), the percent of total visit time spent discussing pain was independent of pain severity.