Pain management is a persistent and pervasive problem in healthcare and has been identified as an area of high priority by the VHA. Existing research has clearly documented ongoing problems with both quality and equity in pain management across a variety of treatment settings and disease types. Yet the processes by which pain routinely goes undertreated remain poorly understood. Although researchers agree that clinical decision-making in pain management is strongly influenced by nonclinical factors such as provider knowledge, attitudes, beliefs and values regarding pain and its treatment, little empirical data are available on these sociocultural dimensions of pain management. Pain management is a persistent and pervasive problem in healthcare and has been identified as an area of high priority by the VHA. Existing research has clearly documented ongoing problems with both quality and equity in pain management across a variety of treatment settings and disease types. Yet the processes by which pain routinely goes undertreated remain poorly understood.
This project aims to advance understanding of the factors critical to improving the quality and equity of pain management for veterans by studying the sociocultural factors involved in provider decision-making about pain management. With this in mind, our specific objectives are: 1) to describe key patient, provider and practice-setting factors that influence provider decision-making about the assessment, diagnosis and treatment of nonmalignant pain; 2) to assess the relationships between and relative importance of identified patient, provider and practice-setting factors in shaping provider decision-making in nonmalignant pain management; and 3) to identify key patient, provider and/or practice-setting factors (or sets of factors) as priorities for intervention-targeted work to improve the quality and equity of pain management.
This is a prospective ethnographic study of provider decision-making in pain management. The study approach combines qualitative and quantitative methods, including 1) shadow observation of provider interactions with patients and with other members of the clinical team, 2) in-depth interviewing with providers, and 3) quantitative coding of key provider-patient encounter data. A sample of 50 healthcare providers was drawn from VA primary care, emergency care, surgery and pain clinic services in two urban VA hospitals for intensive ethnographic study of clinical decision-making about pain management as it occurs in real-world settings
Both qualitative and quantitative data analyses are ongoing. Quantitative data analysis to date confirms that pain is a ubiquitous feature of clinical practice, with nearly two thirds of primary care visits involving pain, and at least one pain therapy being prescribed in 78.4% of those visits involving pain. Significant variation exists between our two study sites in terms of therapies prescribed, including a nearly two-fold difference in opioid prescription rates in primary care by site (46.2% vs. 24.2%). Ongoing analysis of qualitative data provides insight into this observed variation, revealing three key and inter-related factors shaping these divergent pain management practices: 1) individual providers' pain-related beliefs, attitudes and "index" pain experiences, 2) the local clinical team cultures regarding pain management, and 3) the organizational structure and clinical mandate of the pain service at each site.
Given the ubiquity of suboptimal pain management across treatment settings and disease types, the potential impact of research designed to better understand - and thus improve - problems of quality and equity in pain management is particularly high. This ethnographic research has produced a new framework for conceptualizing the sociocultural factors that influence provider decision-making about pain management not available through standard quantitative approaches. Findings from this research will inform both future research and intervention efforts, as well as the development of policy to improve the overall quality and equity of pain management within the VA Healthcare System and beyond. Initial results have been reported at several national meetings, as well as through the publication of several related manuscripts and the preparation of several more to be forthcoming.
- Crowley-Matoka M, True JG. No one wants to be the candyman: ambivalent medicalization and clinician subjectivity in pain management. Cultural Anthropology. 2012 Nov 12; 27(4):689-712.
- Crowley-Matoka M, Saha S, Dobscha SK, Burgess DJ. Problems of quality and equity in pain management: exploring the role of biomedical culture. Pain medicine (Malden, Mass.). 2009 Oct 1; 10(7):1312-24.
- Burgess DJ, Crowley-Matoka M, Phelan S, Dovidio JF, Kerns R, Roth C, Saha S, van Ryn M. Patient race and physicians' decisions to prescribe opioids for chronic low back pain. Social science & medicine (1982). 2008 Dec 1; 67(11):1852-60.
- Mangione MP, Crowley-Matoka M. Improving pain management communication: how patients understand the terms "opioid" and "narcotic". Journal of general internal medicine. 2008 Sep 1; 23(9):1336-8.
- True JG, Crowley-Matoka M. Exploring variability in primary care providers approaches to non-cancer pain. Paper presented at: Society of General Internal Medicine Annual Meeting; 2010 Apr 28; Minneapolis, MN.
- Crowley-Matoka M. Pharmaceutical relations of care and subjectivity in pain medicine. Paper presented at: American Anthropological Association Annual Meeting; 2009 Dec 2; Philadelphia, PA.
- Crowley-Matoka M. Learning pain management? Clinical communication and culture. Paper presented at: University of Chicago Center for Health and the Social Sciences MacLean Center for Clinical Medical Ethics Annual Conference; 2007 Nov 9; Chicago, IL.