"Patient-time", "doctor-time", and "institution-time": perceptions and definitions of time among doctors who become patients

OBJECTIVE: To examine views and experiences of conflicts concerning time in healthcare, from the perspective of physicians who have become patients. METHODS: We conducted two in-depth semi-structured 2-h interviews concerning experiences of being health care workers, and becoming a patient, with each of 50 doctors who had serious illnesses. RESULTS: These doctor-patients often came to realize as they had not before how patients experience time differently, and how "patient-time", "doctor-time", and "institution-time" exist and can conflict. Differences arose in both the long and short term, regarding historical time (prior eras/decades in medicine), prognosis (months/years), scheduling delays (days/weeks), daily medical events and tasks (hours), and periods in waiting rooms (minutes/hours). Definitions of periods of time (e.g., "fast", "slow", "plenty", and "soon") also varied widely, and could clash. Professional socialization had heretofore impeded awareness of these differences. Physicians tried to address these conflicts in several ways (e.g., trying to provide test results more promptly), though full resolution remained difficult. CONCLUSIONS: Doctors who became patients often now realized how physicians and patients differ in subjective experiences of time. Medical education and research have not adequately considered these issues, which can affect patient satisfaction, doctor-patient relationships and communication, and care. PRACTICE IMPLICATIONS: Physicians need to be more sensitive to how their definitions, perceptions, and experiences concerning time can differ from those of patients.     

Associations between pain control self-efficacy, self-efficacy for communicating with physicians, and subsequent pain severity among cancer patients

Objective

Coaching patients to be more active in health encounters may improve communication with physicians but does not necessarily improve health outcomes. We explored this discrepancy by examining relationships between self-efficacy for communicating with physicians and pain control self-efficacy and subsequent pain severity among cancer patients participating in a coaching trial.

Methods

We analyzed data from 244 English-speaking adults with various cancer types reporting significant pain, recruited from 49 oncology physicians’ offices. Mixed model linear regression examined relationships between post-intervention communication self-efficacy and pain control self-efficacy and subsequent pain severity over 12 weeks.

Results

Post-intervention pain control self-efficacy (but not communication self-efficacy) was significantly related to subsequent pain severity: a one standard deviation increase was associated with a 0.19 point decrease (95% confidence interval = −0.33, −0.04; p = 0.01) in pain severity over time, approximately 25% of the effect size of the influence of post-intervention pain on subsequent pain.

Conclusion

Among cancer patients enrolled in a coaching trial, post-intervention pain control self-efficacy, but not communication self-efficacy, was significantly related to subsequent pain severity.

Practice implications

Identifying behavioral mediators of cancer pain severity may lead to coaching interventions that are more effective in improving cancer pain control.     

Nitric oxide and pro-inflammatory cytokines correlate with pain intensity in chronic pain patients

Objective: Inflammatory cytokines as well as nitric oxide (NO) play a key role in the pathogenesis of persistent and exaggerated pain states. To document this, we investigated whether a range of cytokines and NO were detectable in the plasma of chronic pain patients and whether cytokine and NO levels correlated with pain severity. Methods: Plasma samples of 94 chronic pain patients and 6 healthy volunteers were obtained. Average pain intensity during the last 24h was assessed on a 11-point numeric rating scale and patients were distributed to three groups: light, moderate and severe pain. The concentrations of TNF-α, GM-CSF, interleukin (IL)-1β, IL-6, IL-8, interferon (IFN)-γ, IL-2, IL-4, IL-5, IL-10 and nitrate/nitrite were determined. Results: Patients with light pain demonstrated significantly increased levels of IL-6 compared to controls. In the severe pain group IL-6 and nitrate/nitrite were significantly increased. Serum concentrations of IL-1β, TNF-α, IL-2 and IL-4 were increased but as we adjusted the level of significance at p = 0.0045, most cytokine plasma levels failed to reach statistical significance. Conclusions: Pro-inflammatory cytokines (IL-1β, IL-2, IL-6, IFN-γ, TNF-α) in the plasma correlate with increasing pain intensity. Chronic pain patients show a significant increase in plasma levels of NO in comparison to healthy controls. Received 30 May 2006; returned for revision 17 July 2006; accepted by G. Geisslinger 7 August 2006     

持续躯体形式疼痛障碍临床症状与述情障碍的关系

目的探讨持续的躯体形式疼痛障碍患者临床症状与述情障碍状况的关系。方法 58例持续的躯体形式疼痛障碍患者与41例对照者共同完成一般资料调查表、多伦多述情障碍量表中文版(TAS-20-C)和症状自评量表(SCL-90),对所得数据进行统计分析。结果 58病例组除了难以描述自己的情感因子分两组差异无统计学意义(t=1.70,P0.05),TAS-20-C总分、难以识别自己的情感因子分及外向性思维因子分均显著高于对照组(t=4.32,3.55,4.29;P0.01);SCL-90量表评分总均分及各因子得分均显著高于对照组(t=6.98,11.40,6.34,3.41,4.63,4.78,5.05,4.87,5.17,4.40,5.8;P0.01)。病例组TAS-20-C总分与SCL-90总均分、躯体化因子得分、人际关系敏感因子分、敌对因子分及精神病性因子分均正相关(P0.05或0.01);而难以识别自己的情感因子得分与躯体化因子分和人际关系敏感因子分正相关(P0.01和0.05),难以描述自己的情感因子得分和人际关系敏感因子分和敌对因子分正相关(P0.05和0.01);外向性思维因子得分与SCL-90总均分、躯体化因子得分及焦虑因子得分正相关(P0.05或0.01)。结论持续的躯体形式疼痛障碍患者存在明显的述情障碍,且与临床症状相互影响;心理治疗应更关注情绪的识别和处理方面。     

Pain catastrophizing,physiological indexes,and chronic pain severity: tests of mediation and moderation models

Catastrophizing about pain is related to elevated pain severity and poor adjustment among chronic pain patients, but few physiological mechanisms by which pain catastrophizing maintains and exacerbates pain have been explored. We hypothesized that resting levels of lower paraspinal muscle tension and/or lower paraspinal and cardiovascular reactivity to emotional arousal may: (a) mediate links between pain catastrophizing and chronic pain intensity; (b) moderate these links such that only patients described by certain combinations of pain catastrophizing and physiological indexes would report pronounced chronic pain. Chronic low back pain patients (N = 97) participated in anger recall and sadness recall interviews while lower paraspinal and trapezius EMG and systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were recorded. Mediation models were not supported. However, pain catastrophizing significantly interacted with resting lower paraspinal muscle tension to predict pain severity such that high catastrophizers with high resting lower paraspinal tension reported the greatest pain. Pain catastrophizing also interacted with SBP, DBP and HR reactivity to affect pain such that high catastrophizers who showed low cardiovascular reactivity to the interviews reported the greatest pain. Results support a multi-variable profile approach to identifying pain catastrophizers at greatest risk for pain severity by virtue of resting muscle tension and cardiovascular stress function.     

Pain centrality mediates pain self-efficacy and symptom severity among individuals reporting chronic pain

Chronic pain is consistently associated with the presence of mental health disorders. Although previous research has shown relations between low levels of self-efficacy with chronic pain severity as well as comorbid mental health symptoms, the link between self-efficacy and mental health symptoms in chronic pain is not well understood. This study examined whether pain centrality, the extent to which pain is viewed as central to self-identity, may underlie these associations. Individuals with a diagnosis of chronic pain (N = 89) recruited through MTurkcompleted self-report measures including demographics, self-efficacy, pain centrality, pain severity, depression, and anxiety. Pain severity was associated with higher levels of pain centrality, depression, anxiety, and lower levels of self-efficacy. Path analysis demonstrated pain centrality significantly mediated the relationship between self-efficacy and pain severity, depression, and anxiety. Future studies would benefit from testing whether modifying pain centrality beliefs shift perceptions of control as well as pain and psychological outcomes.     

Mechanism-based Classification and Physical Therapy Management of Persons with Cancer Pain: A Prospective Case Series

Context:

Mechanism-based classification (MBC) was established with current evidence and physical therapy (PT) management methods for both cancer and for noncancer pain.

Aims:

This study aims to describe the efficacy of MBC-based PT in persons with primary complaints of cancer pain.

Settings and Design:

A prospective case series of patients who attended the physiotherapy department of a multispecialty university-affiliated teaching hospital.

Material and Methods:

A total of 24 adults (18 female, 6 male) aged 47.5 ± 10.6 years, with primary diagnosis of heterogeneous group of cancer, chief complaints of chronic disabling pain were included in the study on their consent for participation The patients were evaluated and classified on the basis of five predominant mechanisms for pain. Physical therapy interventions were recommended based on mechanisms identified and home program was prescribed with a patient log to ensure compliance. Treatments were given in five consecutive weekly sessions for five weeks each of 30 min duration.

Statistical Analysis Used:

Pre–post comparisons for pain severity (PS) and pain interference (PI) subscales of Brief pain inventory-Cancer pain (BPI-CP) and, European organization for research and treatment in cancer-quality of life questionnaire (EORTC-QLQ-C30) were done using Wilcoxon signed-rank test at 95% confidence interval using SPSS for Windows version 16.0 (SPSS Inc, Chicago, IL).

Results:

There were statistically significant (P < 0.05) reduction in pain severity, pain interference and total BPI-CP scores, and the EORTC-QLQ-C30.

Conclusion:

MBC-PT was effective for improving BPI-CP and EORTC-QLQ-C30 scores in people with cancer pain.     

Pain mechanisms: a commentary on concepts and issues

This commentary on ideas about neural mechanisms underlying pain is aimed at providing perspective for a reader who does not work in the field of mammalian somatic sensation. It is not a comprehensive review of the literature. The organization is historical to chronicle the evolution of ideas. The aim is to call attention to source of concepts and how various ideas have fared over time. One difficulty in relating concepts about pain is that the term is used to refer to human and animal reactions ranging from protective spinal reflexes to complex affective behaviors. As a result, the spectrum of "pain"-related neural organization extends to operation of multiple neuronal arrangements. Thinking about pain has shadowed progress in understanding biological mechanisms, in particular the manner of function of nervous systems. This essay concentrates on the evolution of information and concepts from the early 19th century to the present. Topics include the assumptions underlying currently active theories about pain mechanisms. At the end, brief consideration is given to present-day issues, e.g., chronic pain, central pain, and the view of pain as an emotion rather than a sensation. The conceptual progression shows that current controversies have old roots and that failed percepts often resurface after seemingly having been put to rest by argument and evidence.     

Effects of the Expression of Pain on Autonomic and Pain Tolerance Responses to Subject-Controlled Pain

A within-subjects experiment was performed to investigate the effect of various levels of pain expression on autonomic and tolerance responses to electrical shocks which were terminated by the subjects at their tolerance level. Ten male undergraduates posed three levels of pain expression while being shocked by a constant current source that was turned up rapidly, slowly, or not at all. It was found that skin conductance responses to shock are monotonically and positively related to the level of expression; skin conductance is not significantly affected by expression in the absence of shock; pain tolerance levels are not related to the level of expression; and tolerance levels are higher for rapidly ascending shock than for slowly ascending shock. The implications of these results for theories of the expression of emotion are discussed.     

疼痛护理干预对肛肠患者术后舒适度和疼痛的影响研究

目的 观察疼痛护理干预对肛肠科患者术后舒适度和疼痛的影响。方法 选择我院2016年10月~2017年10月收治90例肛肠科患者,随机分为观察组和对照组,各45例。对照组为常规护理模式,观察组在对照组的基础上进行疼痛护理干预。比较两组患者术后疼痛情况和舒适度。结果 观察组患者疼痛度为11.11%,低于对照组的33.33%,差异具有统计学意义（P＜0.05）;观察组低度舒适患者少于对照组,中度、高度舒适患者多于对照组,差异均有统计学意义（P＜0.05）。结论 肛肠科患者术后实施疼痛护理干预,能提升患者的术后舒适度,降低疼痛率,临床效果显著。     

Presence, communication and treatment of fatigue and pain complaints in incurable cancer patients

OBJECTIVE: This study describes the experiences of fatigue and pain in incurable cancer patients and the treatment they receive. METHODS: Patients were recruited via medical specialists from hospitals in the South and Southwest of the Netherlands. Hundred and twenty-five incurable cancer patients filled out a written questionnaire and were also interviewed at home. RESULTS: Ninety percent reported to suffer from fatigue and 48% had pain. Forty-five percent had discussed fatigue with a healthcare professional and 55% had discussed pain. Fifteen percent reported to receive medical treatment for their fatigue and 29% received pain treatment. Treatment for fatigue and pain treatment had been recently adjusted in 4% of the patients with fatigue complaints and 21% of the patients with pain complaints. CONCLUSION: Although fatigue is a more common problem than pain in patients with incurable cancer, less attention in the care is paid to fatigue and its treatment than to pain. PRACTICE IMPLICATIONS: Fatigue deserves more attention in the care policy for incurable cancer patients and more research should be focused on interventions to address fatigue in this group of cancer patients.     

Chronic pain and pattern of health care utilization among Malaysian elderly population: National Health and Morbidity Survey III (NHMS III, 2006)

Objective

The aims of this study were to report prevalence of chronic pain and to examine whether chronic pain influence healthcare usage among elderly Malaysian population.

Methods

This was a sub-population analysis of the elderly sample in the Malaysia's Third National Health and Morbidity Survey (NHMS III) 2006, a nation-wide population based survey. A subset of 4954 elderly aged 60 years and above was used in the analysis. Chronic pain, pain's interference and outcome variables of healthcare utilization (hospital admission and ambulatory care service) were all measured and determined by self-report.

Results

Prevalence of chronic pain among elderly Malaysian was 15.2% (95% CI: 14.5, 16.8). Prevalence of chronic pain increased with advancing age, and the highest prevalence was seen among the old-old group category (21.5%). Across young-old and old-old groups, chronic pain was more prevalent among females, Indian ethnicity, widows/widowers, rural residency and those with no educational background. Our study showed that chronic pain alone increased hospitalization but not visits to ambulatory facilities. Presence of chronic pain was significantly associated with the frequency of hospitalization (aIRR 1.11; 95% CI 1.02, 1.38) but not ambulatory care service.

Conclusions

Chronic pain is a prevalent health problem among the elderly in Malaysia and is associated with higher hospitalization rate among the elderly population. This study provides insight into the distribution of chronic pain among the elderly and its relationship with the patterns of healthcare utilization.     

Attentional Strategy Moderates Effects of Pain Catastrophizing on Symptom-Specific Physiological Responses in Chronic Low Back Pain Patients

In the present study, we examined whether experimentally-manipulated attentional strategies moderated relations between pain catastrophizing and symptom-specific physiological responses to a cold-pressor task among sixty-eight chronic low back patients. Patients completed measures of pain catastrophizing and depression, and were randomly assigned to sensory focus, distraction or suppression conditions during a cold pressor. Lumbar paraspinal and trapezius EMG, and cardiovascular responses to the cold pressor were assessed. Attentional strategies moderated the relation between pain catastrophizing and lumbar paraspinal muscle, but not trapezius muscle or cardiovascular responses. Only for participants in the suppression condition was catastrophizing related significantly to lumbar paraspinal muscle responses. Depressed affect did not account for this relation. These findings indicate that ‘symptom-specific’ responses among pain catastrophizers with chronic low back depend on how they attend to pain-related information. Specifically, it appears that efforts to suppress awareness of pain exaggerate muscular responses near the site of injury.     

Pain pressure threshold algometry of the abdominal wall in healthy women

The objective of this study was to determine the inter- and intra-examiner reliability of pain pressure threshold algometry at various points of the abdominal wall of healthy women. Twenty-one healthy women in menacme with a mean age of 28 ± 5.4 years (range: 19-39 years) were included. All volunteers had regular menstrual cycles (27-33 days) and were right-handed and, to the best of our knowledge, none were taking medications at the time of testing. Women with a diagnosis of depression, anxiety or other mood disturbances were excluded. Women with previous abdominal surgery, any pain condition or any evidence of inflammation, hypertension, smoking, alcoholism, or inflammatory disease were also excluded. Pain perception thresholds were assessed with a pressure algometer with digital traction and compression and a measuring capacity for 5 kg. All points were localized by palpation and marked with a felt-tipped pen and each individual was evaluated over a period of 2 days in two consecutive sessions, each session consisting of a set of 14 point measurements repeated twice by two examiners in random sequence. There was no statistically significant difference in the mean pain threshold obtained by the two examiners on 2 diferent days (examiner A: P = 1.00; examiner B: P = 0.75; Wilcoxon matched pairs test). There was excellent/good agreement between examiners for all days and all points. Our results have established baseline values to which future researchers will be able to refer. They show that pressure algometry is a reliable measure for pain perception in the abdominal wall of healthy women.