How much time do low-income patients and primary care physicians actually spend discussing pain? a direct observation study

Background: We know little about how much time low-income patients and physicians spend discussing pain during primary care visits. Objective: To measure the frequency and duration of pain-related discussions at a primary care clinic serving mostly low-income black patients; to investigate variables associated with these discussions. Design: We measured the frequency and duration of pain-related discussions using video-recorded primary care visits; we used multiple regression to evaluate associations between discussions and patient self-report variables. Participants: A total of 133 patients presenting to a primary care clinic for any reason; 17 family medicine residents. Main Measures: Independent variables were pain severity, health status, physical function, chief complaint, and whether the patient and physician had met previously. Dependent variables were presence of pain-related discussions and percent of total visit time spent discussing pain. KEY RESULTS: Sixty-nine percent of visits included pain-related discussions with a mean duration of 5.9 min (34% of total visit time). Increasing pain severity [OR 1.69, 95% CI (1.18, 2.41)] and pain-related chief complaints [OR 4.10, 95% CI (1.39, 12.12)] were positively associated with the probability of discussing pain. When patients discussed pain, they spent 4.5% more [95% CI (0.60, 8.37)] total visit time discussing pain for every one-point increase in pain severity. Better physical function was negatively associated with the probability of discussing pain [OR 0.65, 95% CI (0.48, 0.86)], but positively associated with the percent of total visit time spent discussing pain [3% increase; 95% CI (0.32, 5.75)] for every one-point increase in physical function). Patients and physicians who had met previously spent 11% less [95% CI (-21.65, -0.55)] total visit time discussing pain. Pain severity was positively associated with time spent discussing pain only when patients and physicians had not met previously. Conclusions: Pain-related discussions comprise a substantial proportion of time during primary care visits. Future research should evaluate the relationship between time spent discussing pain and the quality of primary care pain management.