An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis

Webster, Fiona; Rice, Kathleen; Katz, Joel; Bhattacharyya, Onil; Dale, Craig; Upshur, Ross

doi:10.1371/journal.pone.0215148

Cited by 52 publications

(54 citation statements)

References 41 publications

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“…This study is part of an ongoing institutional ethnography (IE) aimed at investigating how primary care physicians define, encounter and manage complex patients with chronic pain [22]. As reported elsewhere [22–25], our overarching research question was: How do primary care physicians describe the work they do in caring for patients with complex chronic conditions, especially pain? This study included ethnographic observation in primary care, textual analysis, and key informant interviews.…”

Section: Methodsmentioning

confidence: 99%

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

Webster

Rice

Bhattacharyya

et al. 2019

Int J Equity Health

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Purpose Chronic disease is a global concern. While ample research has aimed to identify the epidemiology of multimorbidity and patient complexity using administrative data, little attention has been paid to the processes of care that treating complex patients entail. Consequently, the concept of patient complexity itself does not directly speak to how challenging it may be to care for a given patient. The purpose of this study was to investigate how primary care providers define, encounter, and manage complex patients, especially those with chronic pain. To our knowledge, this is the first study to move beyond general narrative descriptions of complexity towards an interrogation that is grounded in the work practices of caring for these patients. Methods We undertook an institutional ethnography (IE) in Ontario, Canada. IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that orient experiences. Grounded in the everyday experience of primary care providers, we draw here on 51 interviews that were collected as part of our larger IE study, to interrogate the utility of definitions of patient complexity as medical multimorbidity. Findings Care providers consider patients challenging due to their socio-economic status more so than their medical problems alone. Our data shows that patients’ issues are often bound up with poverty, trauma, and mental health concerns, and are challenging for health care providers in part because the interventions needed exceed the scope of their medical expertise, while social issues render the treatment of potentially straightforward medical problems complicated. This was especially so for patients with chronic pain. Conclusion Defining patient complexity as morbidity alone is inadequate; such models neglect syndromes and conditions that are not included in formal disease classifications. Chronic pain should be included among the chronic conditions that are considered to constitute multimorbidity. In order to provide effective patient-centered care, discussions of patient complexity must also attend to the complex social and economic circumstances in which many patients live and include broader issues of inequity and social justice. This approach would enable policies to better support primary care providers who struggle to manage their patients with complex needs across domains of physiological health, mental health, and the quality of their living conditions, and in so doing improve the care that patients receive.

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Section: Methodsmentioning

confidence: 99%

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

Webster

Rice

Bhattacharyya

et al. 2019

Int J Equity Health

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“…Much of what we know about the meaning and experience of pain, including understanding the experience of providers, 1 has been facilitated through qualitative research conducted over several decades. Through the robust examination of personal narratives, institutional processes, and lived experiences, qualitative research has advanced our understanding in areas such as the multidimensional experience of living with pain, [2][3][4][5] barriers to evidence-based pain care, [6][7][8] and approaches to pain education 9,10 in populations across the life span. Despite the strengths of qualitative research and its contributions to the study of pain, qualitative inquiry continues to be underrepresented in the pain literature relative to quantitative approaches.…”

Section: Introductionmentioning

confidence: 99%

Qualitative research and pain: Current controversies and future directions

Tutelman

Webster

2020

Canadian Journal of Pain

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Much of what we know about the meaning and experience of pain has been facilitated through qualitative research. However, qualitative inquiry continues to be underrepresented in the pain literature relative to quantitative approaches. In this Commentary and Introduction to the Special Issue on Qualitative Research and Pain, we present a collection of high-quality, cutting-edge qualitative studies in pain that highlight theoretical and methodological advancements in the field. The articles included in this Special Issue feature a range of designs (e.g., grounded theory, phenomenology, qualitative description), methods of data collection (e.g., interviews, object elicitation, photovoice), and populations (e.g., immigrant women, individuals with heart disease). Throughout this Commentary we also address three common controversies regarding the quality of qualitative research and the stance we took on them for the Issue. These primarily deal with the procedure-related issues of sample size, generalizability, and saturation. We discuss how a more substantive-centered approach to evaluation-that is, an approach that considers the methodological and theoretical significance of the work-is crucial for advancing qualitative research in pain. RÉSUMÉ Une grande partie de ce que nous savons sur la signification et l'expérience de la douleur a été facilitée par la recherche qualitative. Cependant, l'enquête qualitative continue d'être sousreprésentée dans la littérature sur la douleur en ce qui concerne les approches quantitatives. Dans ce commentaire et introduction au numéro spécial sur la recherche qualitative et la douleur, nous présentons un recueil de haute qualité d'études qualitatives de pointe sur la douleur qui mettent en évidence les avancées théoriques et méthodologiques dans le domaine. Les articles inclus dans ce numéro spécial présentent une gamme de conceptions (p. ex., la théorie ancrée, la phénoménologie, la description qualitative), de méthodes de collecte de données (p. ex., les entretiens, l'élicitation d'objets, le photovoice) et de populations (par exemple, les femmes immigrantes, les personnes atteintes de maladie cardiaque). Tout au long de ce commentaire, nous abordons également trois controverses courantes concernant la qualité de la recherche qualitative et la position que nous avons adoptée à leur égard pour ce numéro. Celles-ci traitent principalement de problèmes liés à la procédure, notamment la taille de l'échantillon, la généralisabilité et la saturation. Nous discutons de la façon dont une approche de l'évaluation davantage centrée sur le fond-c'est-à-dire une approche qui tient compte de la signification théorique et méthodologique des travaux-est primordiale pour faire avancer la recherche qualitative sur la douleur.

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“…102 Lack of social support has been clearly associated with poor pain outcomes in other populations. [103][104][105] Possible strategies to facilitate social connections include counseling, social support groups, and palliative care consultation. 59 Interventions aimed at decreasing loneliness may simultaneously reduce pain.…”

Section: Implications For Pain Carementioning

confidence: 99%

A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease

Gorospe

Istanboulian

Puts

et al. 2020

Canadian Journal of Pain

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Background: Pain is a significant problem in adults living with advanced liver disease, having limited guidance available for its clinical management. While pain is considered a multidimensional experience, there have been limited reviews of the pain literature in advanced liver disease conducted with a multidimensional framework. Aims: The goal of this scoping review was to identify and map the multidimensional domains of pain in adults with advanced liver disease using the biopsychosocial model. Methods: We used Arksey and O'Malley's scoping framework. A search was conducted in MEDLINE, Embase, AMED, and CINAHL databases and the gray literature using specific eligibility criteria (1990-2019). Citation selection and data extraction were performed by two independent reviewers and in duplicate. Results: Of the 43 studies that met inclusion criteria, 51% were from North America and 93% utilized quantitative methods. The combined studies reported on 168,110 participants with ages ranging between 23 to 87 years. Only 9% reported an objective scoring system for liver disease severity. Few studies reported pain classification (9%) and intensity (16%). Pain prevalence ranged between 18% and 100%, with pain locations including joint, abdomen, back, head/neck, and upper/ lower extremities. We identified and mapped 115 pain factors to the biopsychosocial model: physical (81%), psychological (65%), and sociocultural (5%). Only 9% measured pain using validated multidimensional tools. Pharmacological intervention (92%) prevailed among pain treatments. Conclusions: Pain is not well understood in patients with advanced liver disease, having limited multidimensional pain assessment and treatment approaches. There is a need to systematically examine the multidimensional nature of pain in this population. RÉSUMÉ Contexte: Bien que la douleur soit un problème important chez les adultes atteints d'une maladie hépatique avancée, les orientations disponibles pour sa prise en charge clinique sont limitées. Alors que la douleur est considérée comme une expérience multidimensionnelle, peu de revues de la littérature sur la douleur dans les maladies hépatiques avancées ont été menées à l'aide d'un cadre multidimensionnel. Objectifs: L'objectif de cette revue exploratoire était de déterminer et de cartographier les aspects multidimensionnels de la douleur chez les adultes atteints d'une maladie hépatique avancée en utilisant le modèle biopsychosocial. Méthodes: Nous avons utilisé le cadre d'Arksey et O'Malley. Une recherche a été effectuée dans les bases de données MEDLINE, Embase, AMED et CINAHL et dans la littérature grise, en utilisant des critères d'admissibilité précis (1990-2019). La sélection des citations et l'extraction des données ont été effectuées en double par deux examinateurs indépendants. Résultats: Sur les 43 études répondant aux critères d'inclusion, 51 % provenaient d'Amérique du Nord et 93 % avaient utilisé des méthodes quantitatives. Les études combinées ont porté sur 168 110 participants dont l'âge variait entre 23 et...

show abstract

An ethnography of chronic pain management in primary care: The social organization of physicians’ work in the midst of the opioid crisis

Cited by 52 publications

References 41 publications

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

The mismeasurement of complexity: provider narratives of patients with complex needs in primary care settings

Qualitative research and pain: Current controversies and future directions

A scoping review to identify and map the multidimensional domains of pain in adults with advanced liver disease

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