Pain Assessment: The Roles of Physician Certainty and Curiosity

Abstract

Undertreatment of pain is common even when caused by serious illness. We examined whether physician–patient communication (particularly language indicating physician certainty) was associated with incomplete (i.e., premature closure) of pain assessment among patients with serious illness. Standardized patients (SPs) trained to portray patients with serious illness conducted unannounced, covertly audio-recorded visits to 20 consenting family physicians and 20 medical specialists. We coded extent of pain assessment, physician voice tone, and a measure of the degree to which physicians explored and validated patient concerns. To assess physician certainty, we searched transcripts for use of words that conveyed certainty using the Linguistic Inquiry and Word Count program. SP role fidelity was 94%, and few physicians were suspicious that they had seen an SP (14% of visits). Regression analyses showed that physicians who used more certainty language engaged in less thorough assessment of pain (β = −0.48, p < .05). Conversely, physicians who engaged in more exploring and validating of patient concerns (β = 0.27, p < .05) had higher ratings on anxiety/concerned voice tone (β = 0.25, p <.01) and engaged in more thorough assessment of pain. Together, these three factors accounted for 38% of the variance in pain assessment. Physicians who convey certainty in discussions with patients suffering from pain may be more likely to close prematurely their assessment of pain. We found that expressions of physician concern and responsiveness (curiosity) were associated with superior pain assessment. Further study is needed to determine whether these associations are causal and mutable.

The Role of Nurses’ Uncertainty in Decision-Making Process of Pain Management in People with Dementia

“…Articles relatedness to the focus of describing nurse decision-making models on pain treatment in NH residents with dementia was evaluated. The retrieved articles discussed only three main theoretical models including cognitive continuum theory (CCT) [ 31 ], adaptive pain management (APM) [ 32 ], Shields et al [ 33 ] model, and RCP model [ 12 ].…”

“…Two theories have directly addressed the role of uncertainty in pain management in PWD. A model by Shields et al [ 33 ] states that the decision-making process is a complex intellectual process of clinical reasoning or judgment that includes making explanations regarding what level of certainty nurses have in taking action. Action means the implementations the nurse decides or does not decide to do.…”

The association of nurses' assessment and certainty to pain management and outcomes for nursing home residents in Jordan

“…It was chosen for this study to compare the characteristics of groups according to selected variables. The variables of this study were selected on the basis of theory and previous studies where assessment scope and nurses' certainty/uncertainty have been associated with pain and agitation (Chen et al, 2010;Gilmore-Bykovskyi & Bowers, 2013;Shega et al, 2006;Shields et al, 2013;Tait et al, 2009). This study would add to nursing knowledge of PWD by examining how clinical variables that predict pain and agitation in people who have known pain or a painful diagnosis and a change in behavior or condition.…”

“…To take no action is a conscious decision not to initiate an intervention. Both actions and non-actions are the result of the decision-making process, and both involve a process of interpretation (Shields et al, 2013). While the work of Shields et al posits that when recall of nursing education and training, theoretical and experiential knowledge, personal experiences, culture, values, and beliefs to the situation may increase or decrease the level a nurse's level of certainty about pain in PWD, explanations within the model are not well developed, and lack direct applicability to clinical situations of complex assessment of pain in PWD.…”

The Influence of Patient Race and Activation on Pain Management in Advanced Lung Cancer: a Randomized Field Experiment

“…The recordings of the SP visits were professionally transcribed and research assistants coded the transcripts using the Measure of Physician Pain Assessment (MPPA), which captures physicians' responses to patients' expressions of concerns about pain. This measure was previously developed, piloted, and validated by our research team for use in outpatient cancer consultations 20 to capture patient-centered exploration of topics such as the onset, location, and quality of pain.…”