By:Jonathan Mayer, Univ of Washington
I came across a study yesterday that at first stunned me in its conclusions until I gave it deeper thought. The study aimed to ascertain whether the goals of physicians and patients were the same for pain management in a primary care practice. To my surprise, they were not. What are the broader implications?
This was a small study in a primary care residency practice (citation at end of entry). The visits were for chronic musculoskeletal pain. The top goal for patients was pain reduction. The top two goals for the physicians was restoration of function (back to work, etc), and minimization of medication side effects. In other words, patients and physicians were working at cross purposes, and may not have been communicating these purposes to each other.
This kind of study begs replication in multiple settings. In pain medicine, the field is loaded right now because of opioids and the arguments, legal scrutiny, and public scrutiny surrounding their use. As such, the findings here may only be applicable to pain medicine.
What is going on here, though? Patients want to minimize their suffering. The familiar Loeser model (what I call the “Loeser onion”) posits that nociception leads to pain which leads to suffering which leads to pain behavior, though not inevitably. Regardless, suffering is part of the pain nexus. The physicians, on the other hand, did not have reduction of suffering as a top priority. Rather, they were making a social judgment: get back to work, or whatever your appropriate social function is, and with minimal disruption from medication. This is truly a conflict. Are physicians 1) supposed to be in a position of making these social judgments? 2) are they trained to do this? 3) is it not true that the loyalty–the responsibility–of the physician is to the patient, as medical ethics teaches us? There is a real disconnect here–a tension that needs resolution.
This makes me wonder whether much of the turmoil in pain medicine and related fields between clinician and patient may be over conflicting and unstated goals?
This caused me to recall a classic book by physician/medical ethicist Eric Cassell, The Nature of Suffering and the Goals of Medicine, published originally in 1991. In it, Cassell explores the whole realm of suffering as one of the fundamental foci of medicine, and reduction of suffering in the face of disease as a fundamental goal. As he prefaces the second edition, “The test of a system of medicine should be its adequacy in the face of suffering; this book starts from the premise that modern medicine fails this test.”
I suspect that the residents in the clinic study would be quick to state that of course they wish to help patients reduce their suffering. Somehow, though, this goal got lost in the midst of the social pressures to have patients get back to work and restore function. A more nuanced understanding of the patient would have the clinician discover from the patient what the patient’s priorities are, and then help to realize those priorities. This is not to say that the clinician should necessarily go along with every therapeutic desire. A patient might say “I want 100 mg of morphine to minimize suffering” yet the physician might think that this conflicts with his or her own interpretation of the best path to reach less suffering. That is where professional judgment comes in. But in the actual goal setting, I argue that the patient-centered approach should be dominant. The patient is a client who hires the physician to be a partner in bettering his or her own life to reach goals. Should the clinician be the one setting life priorities? Has the patient ceded this to the clinician? I don’t think so.
Thee are some of the reflections that I had upon reading this paper. The results may be aberrant and very different than other studies assessing patient-phsycian goals in pain medicine. This is enough, though, to be concerning. Clinicians do not set life priorities, nor should they.
Henry G, Bell RA, Fenton RL. Goals of pain management: do patients and primary physicians agree and does it matter? Clinical Journal of Pain 1017;33(11):955-961