Family Practice Vol. 17, No. 4, 285-287
© Oxford University Press 2000
Editorial |
‘Partners in pain’—the game of painmanship revisited
School of Primary Care, University of Manchester, Rusholme Health Centre, Walmer Street, Manchester M14 5NP, UK.
Chew-Graham CA and May C. ‘Partners in pain’—the game of painmanship revisited. Family Practice 2000; 17: 285–287.
Received 10 December 1999; Accepted 13 March 2000.
Introduction
Chronic low back pain is common in primary care, and there is no doubt that some of its manifestations are demoralizing and dispiriting for the GP.1 Sufferers often present without identifiable organic pathology, and their condition appears intractable. Here we suggest that GPs' own ideas about the consultation and the moral nature of the doctor–patient relationship in general practice may themselves go some way towards constructing this ‘intractable’ state. Our objective is to reflect on the possibility that current ideas about good clinical practice might themselves be iatrogenic.
Doctor–patient interaction
The interaction between doctor and patient, embodied in the ‘consultation’, is the cornerstone of contemporary general practice.2 An average GP, in an average practice, will be involved in some 8000 consultations a year.3 Over time, the consultation has come to be attributed great importance not simply as the occasion for medical work (diagnosis, treatment, management and so forth), but also as an interaction that is structured around a ‘meeting’ of individuals and the presentation of symptoms4—often undifferentiated—to the GP. Through the course of this century, the various dimensions of this interaction, both verbal and non-verbal, moral and technical, have been emphasized increasingly by clinical authorities. In 1927, Peabody stressed its value as an ‘intimate personal relationship’.5 For the embryo National Health Service, it was constituted as an attribute of the ‘good doctor’,6 and, more recently, as the ‘very task of medicine’ itself.7
While clinical authorities have stressed the importance of the consultation as the site of technical–medical work to reveal the patient's problems in their psychosocial depth, other commentators have observed that the emphasis on doctor–patient interaction within medicine derives from political interests too. For example, it has been argued that the embryo Royal College of General Practitioners focused upon the ‘consultation’ as a strategy to differentiate themselves from the harshly reductionist biomedicine of the post-war general hospital.8 As an individualized form of medical practice, that attends to the patient as a subject, rather than an object of clinical practice, the general practice consultation is both inclusive and ‘holistic’ in its orientation. Moreover, within the bounds of its professional rhetoric, general practice has come to see the doctor–patient relationship as intrinsically therapeutic, and to see that effected through ‘patient-centredness’.9 This is reflected in a now well-established focus on the psychosocial dimensions of illness, rather than a reductionist model of disease,10 and a strong commitment to good communications skills in clinical practice.11 Within this very wide ranging and inclusive model of clinical practice, the establishment and maintenance of an ongoing relationship between doctor and patient has come to be seen as an important outcome.12
Over the course of this century, then, the general practice consultation has come to be formed as a very wide ranging encounter with the patient, in which sustaining a continuing inclusive relationship is crucial. Our contention is that this is where the ‘problem’ of chronic low back pain (CLBP) begins.
Chronic low back pain
It is well established that pain is often experienced in the absence of identifiable pathology.13 When there is identifiable organic pathology, it may relate poorly to both the severity of pain and the level of disability consequent upon it.14 In addition, there are complex relationships between the experience of pain, and psychological and social variables.15 CLBP therefore presents the GP with a significant management problem once sinister symptoms and signs have been excluded. GPs themselves seem to find CLBP dispiriting and demoralizing because of this. Extensive investigations and therapeutic regimens rarely conclude successfully. The business of treatment seems to take a chronic and depressing form itself, organized around the provision of sick notes rather than a positive outcome. Despite a very considerable body of clinical and psychosocial research, the outcome for truly chronic cases seems to remain bleak.
Most presentations of CLBP in primary care seem to be of relatively short duration16 in relation to the period that the patient actually suffers pain. One interpretation of this might be that patients quickly come to understand that episodes of back pain elicit neither the sympathy nor interest of many clinicians. Some patients then withdraw from the primary care arena—to seek, if not treatment, then solace and comfort elsewhere. Other people continue to present. This represents a core group of sufferers who may be least amenable to clinical intervention. Indeed, they may be highly resistant to it. Evidence from a qualitative study of sufferers in primary care17 is suggestive of this. Subjects stressed that their symptoms stemmed from biomechanical degeneration. Although they had a good deal of insight into the psychological features of their condition, they regarded these as products of organic pathology, and expected their doctors to act upon this. When doctors failed to do so, or to ‘understand’ their pain in a way that they felt appropriate, they considered them to be confused about the causes and trajectory of CLBP and unenthusiastic about effecting a cure. A parallel study of GPs' constructs of the patient with CLBP18 suggests that these patients were probably right. Subjects in that study discounted sinister symptoms, investigated possible organic causes and then attempted to interpret the patient's symptoms within a psychosocial model. They found it almost impossible to modify patients' lay explanatory models of CLBP. If they did, patients seemed to interpret the process as casting doubt on the reality of their experience and became demoralized and dissatisfied. Both doctors and patients evinced a pessimistic view about the extent to which the other was willing to hear their interpretation of expressed symptoms.
CLBP often seems inexplicable in terms of current knowledge about the body as a biomechanical system. The conventional approach from within biomedicine has been to search for particular organic or psychogenic processes and behavioural variables that might indicate a cause for suffering. The frequent absence of organic signs means that such pain is now itself frequently explained by contemporary medicine as a manifestation of psychological distress. In primary care, however, the notion of somatization proves more useful perhaps as a means of disposal, rather than as a robust diagnosis that might lead to treatment. We have already noted that patients in primary care might be hostile to the notion that pain has a psychogenic origin, in part because the biomechanical model that frames their understanding of illness experiences does not accommodate such an explanation: it is simply incomprehensible within such a model.
We have observed above that only a minority of patients continue to consult the doctor regularly in the face of apparent ‘confusion’ and ‘pessimism’. In this context, we need to ask what the patient's objective is here. After all, patients exercise their own (often very considerable) expertise around impressing the doctor with a set of unimpeachable explanations for their pain19 in these encounters. However, operating within a psychosocial model, the doctor is forced to collude with those definitions since they represent the patient's view, and since these are located within a biomedical model of degeneration. Within this model, confrontation actually moves to ‘fix’ further the patient's attribution of degeneration and pain, for, as one commentator has noted, "if you have to prove you are ill, you can't get well".20 The doctor has to attempt to retrieve a satisfactory outcome to the consultation, and does this by permitting the patient to maintain their own ‘sick role’.
Partners in pain?
So far, we have pointed out the ways that current clinical practice around CLBP in primary care seems to divide off a group of patients who will neither accept the doctor's explanations for their pain, nor cease to call upon the doctor to accept their own definition of ill-health. We now have to ask what these patients are actually seeking.
In a classic interpretation of the ‘problem’ of patients presenting with chronic pain where organic pathology is not visible, the sociologist Thomas Szasz21 emphasized that the ‘clinical’ component of their presentation (i.e. experiences of pain, and feelings of suffering) took second place to the social competition between them over the quality and power of their explanations. This is a struggle that such patients invariably win, in part because their individualized expertise about their own experiences is more potent than the GP's generalized accounts of aetiology and natural history. However, even if those do not apply to the patient, the latter demands an audience or, more productively, a partner. In this partnership, both sides authenticate each other's misery or pessimism while attending closely to the business of defining sickness. Below we show the key elements of Szasz's model of the ‘partners in pain’. It is the element of partnership that is crucial because, without authentification of the ‘sick role’, the patient cannot proceed to a career of suffering.
Although long-term CLBP sufferers represent a significant problem for GPs, they are proportionally few in number. Most people with back pain consult once or twice, and then do not reappear for some time. In the most chronic encounters, the doctor is faced not with CLBP, but with a chronic patient. Although the doctor may seek psychological explanations, these are often rejected by the patient, who is focused on the business of suffering. The doctor is quite unable to influence those social factors that may shape the patient's presentation, and both parties become trapped in a cycle of manifestations of pain and pessimism, in which the doctor accedes to the patient's model in order to avoid disturbing the doctor–patient relationship further. In our study, doctors resisted doing so, often on the grounds that it might cause a diminution of ‘trust’, or that the patient would simply move to another practice. Even so, we might justifiably ask, in such circumstances, whether this is a relationship that is worth saving?
Conclusion
Suffering, of the kind to which we refer here, involves a contest between the production of undiagnosable and untreatable pain on the part of the patient, and the application of clinical knowledge and practice on the part of the doctor. The primary aim of the doctor within the consultation is not only to deal with the immediate presentation, but also to fashion an ongoing therapeutic relationship with the patient.
A small proportion of CLBP patients form their personal experiences and accounts of suffering in such a way as to be unamenable to medical help. Locked into a restricted biomechanical model of pain, they may not wish to relinquish this, and come to compete for expert authority to define their condition and reject the doctor's wider model. In doing so, they actively deny themselves relief and demoralize their doctor. This is not to blame the victim—for there is no doubt that most patients are eager to have anything but a partner in pain—but rather to pose a serious question about who the victim is. It might be that it is the doctor.
| Box 1. Szasz's notion of the ‘partner in pain’
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References
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