Conversations that Matter: Addressing Challenging Topics in the Exam Room

Laura Cooley, PhD: As the Director of Education and Outreach at the American Academy on Communication in Healthcare, I’m very familiar with the challenges to open dialogue faced by healthcare providers and people living with pain in the exam room. I’m so pleased to be joined by Dr. Richard Payne, a practicing pain specialist at Duke University and past president of the American Pain Society, to discuss this important topic. Dr. Payne, considering the challenges that can hinder open, meaningful conversation in pain care, what would you say are clinicians' concerns?

Richard Payne, MD: As a specialist in pain care, I’m acutely familiar with the sense of apprehension I feel from my patients when discussing the impact of their pain during an office visit. Pain cannot be seen or quantified, making the patient interview a key tool for monitoring pain management. Pain, though, continually proves to be a difficult topic of discussion, and the issue of prescription opioid abuse has only compounded the difficulty.

As clinicians, we never want to imply that our patients are less than honest, upstanding, and sincere in their desire for treatment, and we never want to sound presumptuous or accusatory. Conversely, it is our understanding that many patients assume that we suspect them of abuse, and so they underreport their pain. Without an accurate picture of a patient’s pain we are limited in our ability to provide them with the appropriate care.

Laura: The American Academy on Communication in Healthcare has quite a few tools they offer to physicians and patients that focus on an ideal we refer to as “relationship-centered care”. With this focus, we can better ask and listen to patient concerns, respond more empathetically to patient emotions, and share in the decision-making process.

Dr. Payne: Absolutely, Laura. The solution to this multifaceted issue is not a simple one, but it begins by strengthening the relationships between patients and doctors. For clinicians, becoming familiar with simple communication techniques and working to put them into practice can make a big difference. For instance, turning off your cell phone, not fiddling with laptops, listening empathetically, and remembering not to interrupt can help create an environment where patients feel empowered to share their feelings.

Laura: Those are some great insights. I particularly appreciate Dr. Payne’s point of not interrupting. Interestingly, clinicians often interrupt patients during their initial monologue whereas most patients would talk for up to 90 seconds if uninterrupted. Only 23 percent of patients feel they finish sharing their concerns with their clinicians.34, 35 Being mindful of allowing people affected by pain to share their full story can help clinicians and patients work together to find the right pain management plan.

Dr. Payne: Yes, and from this foundation we can start to have more open conversation about how patients can reduce the risks of abuse, misuse, and diversion associated with prescription opioid medications. It’s important to help patients understand that our motivation for having these difficult discussions is to protect not only them, but their families, friends, and communities who may be at risk for intentional or unintentional abuse. It’s important to provide patients with guidelines for appropriate use, storage, and disposal and to discuss the benefits of opioid medications with abuse deterrent properties whenever available. These medications help keep prescriptions in the hands of those who need them.

Laura: PainMatters.com provides information and resources for physicians and people affected by pain to help mitigate the risk of abuse and misuse and support ongoing dialogue. Practical discussion guides and a variety of downloadable resources are available for healthcare professionals in addition to a resource section specifically designed to support people affected by pain.

About the Authors: Laura Cooley, PhD

Laura Cooley, PhD, is the Director of Education and Outreach at the American Academy on Communication in Healthcare (AACH), a non-profit organization with a mission of improving healthcare through education, research, and practice that focuses on communication and relationships with patients, families, and healthcare teams. Additionally, Dr. Cooley guides marketing and development for DocCom, an online communication skills curriculum resource developed by AACH and The Drexel University College of Medicine.

About the Authors: Richard Payne, MD

Richard Payne, MD is the Esther Colliflower Professor of Medicine and Divinity at Duke Divinity School at Duke University, the Medical Director for the Pain Action Alliance, and John B. Francis Chair in Bioethics at the Center for Practical Bioethics. Dr. Payne has directed programs in pain management and palliative care at Memorial Sloan-Kettering Cancer Center and M.D. Anderson Cancer Center, and is a past president of the American Pain Society.

Teva Pharmaceuticals reviewed and edited this post prior to publication.

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