Family Practice Advance Access first published online on March 28, 2008
This version published online on April 15, 2008
Family Practice, doi:10.1093/fampra/cmn012
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GPs' experience of managing chronic pain in a South Asian community—a qualitative study of the consultation process
a Clinical Trials Unit, Warwick Medical School, University of Warwick Gibbet Hill, Coventry CV4 7AL
b Pain Clinic, Milton Keynes General NHS Trust, Standing Way, Eaglestone, Milton Keynes, Buckinghamshire MK6 5LD
c Keele University Medical School, Keele, Staffordshire ST5 5BG
d Department of Psychology, Staffordshire University, College Road, Stoke on Trent ST4 2DE
e Department of Health Sciences, Academic Unit, University of Leicester, Leicester LE5 4PW, UK
Correspondence to S Patel, Clinical Trials Unit, Warwick Medical School, University of Warwick Gibbet Hill, Coventry CV4 7AL, UK; Email: shilpa.patel{at}warwick.ac.uk
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Abstract |
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Background. Chronic pain is one of the most common reasons for seeking primary care consultations. GPs' experience of managing patients with pain from a multicultural community has not previously been examined.
Objectives. We explored GPs' experiences of managing patients with chronic pain from a South Asian community in Leicester.
Methods. Qualitative semi-structured interviews were conducted with GPs from practices in two primary care trusts within Leicester. Eighteen GPs (11 males and 7 females) were interviewed in this study.
Results. Several emerging themes were identified from the data including consulting behaviour, presentation of pain, GPs personal challenges, psychosomatic interpretations and communication. Overall, GPs find that managing South Asian patients with chronic pain can be challenging as a consequence of the way in which patients present with pain. Difficulties for GPs were created not only by language differences but also by cultural differences, which were not seen in second or third generation South Asians. GPs felt that self-management was difficult to address, and compliance with medication difficult to determine. In such consultations, GPs perceived that patients were more likely to present with psychosomatic symptoms.
Conclusions. Cultural influences play an important role in the consultation process where patients' behaviour is often bound in their cultural view of health care. Patients' presentation of their condition makes diagnosis difficult but can also lead to miscommunication. Whether South Asian people are more likely to present mental health problems as chronic pain is not clear and warrants further investigation.
Keywords. Chronic pain, ethnicity, general practice, primary care, qualitative research.
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Introduction |
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Populations today are more culturally diverse than ever before with many different cultures, languages and traditions living together as multicultural societies. In UK, the minority ethnic population makes up 7.9% of the total population with Indians being the largest minority group followed by Pakistanis.1
Cultural factors influence beliefs, behaviour, perceptions and emotions, all of which have important implications for health and health care.2 Culture influences illness behaviour in a number of ways including definitions of ‘normal’ and ‘abnormal’, beliefs about the cause of illness, decision making and control in health settings and impacts on health-seeking behaviour.2 Regardless of linguistic competence, illness and well-being as culturally derived concepts can be challenging when patients and doctors do not share understandings.3
Consultations with patients who have limited English may be viewed as ‘difficult’ by practitioners and may lead to negative judgements and stereotyping.4 Language and cultural differences are reported to cause misunderstandings in 20% of consultations.5 However, communication failure cannot solely be attributed to language difficulties6 but rather the context within which communication takes place. It is difficult to separate issues of communication from wider cultural factors as all GP consultations take place in the context of culture.3
Chronic or persistent pain is one of the commonest reasons for consulting a GP.7 Chronic pain is generally reported and largely presented8 and treated in primary care and only a small proportion is managed through specialist pain clinics.9 South Asian patients report more frequently to general practice compared to the White population.10 Despite the high rates of primary care consulting, the use of outpatient services remains significantly lower in Asian patients.11
This study explored GPs' experiences of managing patients with chronic pain from a South Asian community in Leicester. At the last census, 25.7% of residents of the city of Leicester described themselves as Asian or Asian British Indian,1 making this the largest Indian population of any local authority area in England and Wales. We used a qualitative approach to explore the challenges GPs report in consulting with and managing this patient population. Ethical approval for this study was granted by the Leicestershire, Northamptonshire and Rutland Research Ethics Committee.
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Methods |
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Participants
The study was conducted in two primary care trusts in Leicester. Using purposive sampling, we recruited White British and South Asians, those who speak South Asian languages and those who do not and male and female GPs. We also recruited GPs from large group practices and single-handed practices. This enabled us to explore a broad range of GP experiences. As the study progressed, we used theoretical sampling to test theories, which emerged from earlier interviews. Theoretical sampling is used in grounded theory because it allows the researcher to collect data for the purpose of generating theory. Data are collected, coded and analysed before deciding what data to collect next and where to find those data in order to develop the emerging theory.
GPs included in this study were practitioners in Leicester city, had been in practice in Leicester for at least 12 months and had experience of providing treatment for pain to English-speaking and non-English-speaking South Asian patients. GPs were excluded if they had been practicing as a GP for less than 12 months in Leicester or felt they had insufficient experience to draw upon. A total of 56 letters of invitation were sent out to GPs identified from the theoretical sampling frame although GPs were also recruited by word of mouth.
Interviews
A topic guide containing open-ended questions and prompts was developed by the research team as a guide for conducting semi-structured interviews. Topics for discussion included GPs' personal experience of treating South Asian patients with pain, any challenges faced, implications for the consultation process and views on the appropriateness of existing services.
Letters of invitation were sent to GPs, which were followed up 1 week later, with a telephone call from the researcher to discuss participation. One-to-one interviews were conducted with GPs either over the telephone or at their practice. The interviews lasted between 30 and 60 minutes and, with consent, were tape-recorded for later transcription. All interviews were conducted by SP, a South Asian research health psychologist with experience of qualitative research in the field of chronic pain.
Data analysis
The recorded interviews were transcribed verbatim. The data were analysed using the constant comparative method of grounded theory,12 a process involving repeatedly comparing, contrasting and reviewing information across the interviews. By means of axial coding, codes were refined to categories and then to core categories. A ‘field diary’ was kept by the researcher to note additional information on theoretical explanation and thoughts on themes and operational issues. To help manage the data systematically NVivo (QSR International Pty Ltd, Victoria, Australia), a qualitative data software package was used to help code each transcript, a process whereby a theme or themes were assigned to segments of text.
The themes and possible meaning and interactions were discussed with the multidisciplinary research team. A research team from different backgrounds has the advantage of providing insight into the data challenging assumptions arising from the respective experiences and disciplinary affiliations of individuals.
The purpose of this study had not been to compare the experiences of GPs on the basis of their ethnicity, gender or practice size but rather to gain a broad understanding of their experiences. For this reason, sampling continued until theoretical saturation of each category was reached,12 that is, until there was no new conceptual information which indicates new codes (at any level) or expands existing codes.
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Results |
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A total of 19 GPs participated and gave informed consent. One GP was excluded as they had not practised as a GP within Leicester for at least 12 months (Table 1).
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Fifteen GPs interviewed came from group practices, while only three came from single-handed practices. All the South Asian GPs spoke at least two South Asian languages. Between them, they spoke all the major South Asian languages including Gujarati, Hindi, Punjabi, Urdu and Bengali.
The main themes emerging from the GP interviews which we have presented in this paper focus around the consultation process. Additional emerging themes not presented here include clinical management of pain, patient expectations, acculturation and service/educational requirements.
Consulting behaviour
GPs considered consultation rates for chronic pain to be higher among South Asian patients compared to the indigenous population. They report that it was not uncommon for South Asian patients to consult frequently with the same symptoms but present these as new, possibly in the hope of obtaining alternative medication:
Often patients keep on coming. You keep on changing their tablets, reassure them but that doesn't stop them. South Asian male (GP13)I think, South Asians, the only difference is South Asian will often come back and present the whole problem as a new problem and it's been going on for months or years and you've already dealt with it, then they come back and they present it as if it's again a new problem. South Asian male (GP4)
Er, well, it's a large part of the, erm, one's daily life. Erm, chronic pain, particularly things like back pain and leg pain and other, erm, joint pains really form, I would say, probably about 20 to 30% of consultations .... It's, erm, not necessarily the only part of a consultation. There are often other things as well which, erm, are part and parcel of chronic pain like depression and, sort of, social problems. White British female (GP9)
Participants reported that patients who choose to consult different GPs within a practice for the same symptoms make it harder to identify the problem, pursue a line of treatment and form a relationship with the patient:
I think if she had stuck to one, [GP] then I think probably we would have been able to form a better a relationship there and then, ... we would have been able to find out a bit more about her but each time she came to a new GP, it's like someone seeing her for the first time really. South Asian female (GP8)... often these patients have seen loads of different people within the practice as well and it's trying to get a clear picture of exactly what has and hasn't been done and is there anything that we've overlooked in the process. White British female (GP5)
Other GPs felt that patients did not do the rounds in a practice. On occasion, patients may make a choice as to who they feel is the best person to consult for a certain problem:
On the whole, they didn't do the rounds, no. We didn't find that. But certain sorts of people might have taken certain kinds of things to people who speak their own languages and it maybe that chronic pain went to doctors who could relate to it in a different way through language. British White male (GP16)I think, interestingly, that I would say they're much more likely to choose their doctor and stick with them. They're much more likely to want to see the same doctor, is my impression, so, I've got whole families that really will only consult with me, they've decided I'm their doctor. British White female (GP18)
Due to cultural barriers, GPs feel that South Asian patients use pain, a non-visible condition, as a way of consulting with psychosocial problems:
A lot of it is related to being depressed or unhappy, which is expressed in that way rather than saying I'm depressed. South Asian female (GP11)
Presentation of pain
The manner in which South Asian patients present and express their pain was perceived to be influential during the consultation process. Many GPs reported that South Asian patients present more frequently with widespread pain making it difficult to localize, diagnose and clinically manage the condition in primary care. In such circumstances, where presentation is rather florid, it can be both challenging and frustrating for the GP to treat and manage such patients:
Erm, I think it's harder to get a clear history of exactly what's going on, with defining the pain down, because often you'll get more, er, a situation with the South Asian group rather than the white group, of trying to actually identify exactly where the pain is. You do tend to find that you get this sort of, er, I'm generalising, obviously, I don't think it's true of everybody but, er, you do get a sort of much more of a sort of a pain everywhere syndrome, rather than being able to isolate it down to one or two key areas. White British male (GP2)... there's a small sub-group of patients who, no matter how hard you try to pinpoint where the pain is coming from, find it incredibly difficult, so you get the whole body pain or a group of pains down one side of the body or something that just doesn't anatomically fit with anything that we know about in conventional medicine, and it can be quite frustrating to try and pin it down to be able to work out what investigations to do. White British male (GP5)
The GPs found second and third generation South Asians presented differently from non-acculturated South Asians and were similar to White British patients:
The younger ones, they tend to have, if you like, be much more like the Caucasians in their presentation. I find the groups that this fits into are really the older ones, the ones that don't speak English, but also, interestingly, the younger ones who have recently come over from India, Pakistan and so on. South Asian male (GP3)
The difficulties associated with making formal diagnoses have led GPs to adopt a number of key management techniques once all medical avenues have been exhausted. A popular means of managing these patients is to provide ongoing reassurance and support:
I think our role is to support someone through whatever symptoms they have and to be non-judgmental, not judging that they're, you know, depressed, not worthy people, and so to be non-judgmental is important and to be unconditional, despite you're continuing having pain, despite whatever investigations and tests and treatments you do, you still have the pain and to be there to be supportive. I think being non-judgmental and being non-conditional and continuing to be supportive. South Asian female (GP19)
GPs personal challenges
The difficulties associated with managing South Asian patients with chronic pain pose personal challenges for GPs including feelings of ‘heart sink’. The inability to clinically treat and manage patients became progressively more frustrating, causing some GPs to question their medical training and value to the community:
... to me, somebody comes in with body pain, it's a real heart sink because you think, I'm never going to work out where this is coming from and you know it's going to be a tough consultation trying to pin it down, whereas if we understood a bit more about where that comes from and what people mean by that, then that would help us to understand them a lot more. White British female (GP5)Your own response, as a doctor, you know frustration, you become a doctor not to tell people I can't do anything, I can't find anything, you have this perception of yourself as well that you're going to sort it out and if you can't sort it out, it's frustrating. What's the point of you being there. So, I think all of those things are part of the picture and I think, er, when you're confronted with somebody who, when you're trying to get a point across in different cultural terms as well, it becomes a bit more difficult, you become even more frustrated. South Asian male (GP7)
Adherence to medication is also difficult to determine. GPs reported feelings of frustration when patients repeatedly consulted with the same symptoms yet had failed to adhere to previously prescribed medication:
The patients that are most frustrating are the ones that are supposed to be on regular medication, go to India for three months and stop taking everything while they're away and then come back and pretend they haven't stopped taking them, or they might have not stopped it, they may have just got something else while they were there, but, you've no idea what that was. White British female (GP18)
When GPs referred to patients they found difficult to manage, reference was frequently made to an elderly female, South Asian patient with chronic pain:
The sort of stereotype of the chronic pain patient is the largely overweight, er, aged about 60 Asian woman, often who is socially isolated, by virtue of coming to a country where she's not familiar with the language, which there is a whole palette of family relationships and dynamics that I don't understand. White British male (GP16)... the difficult thing is that there's this perception that South Asians complain of pain more, it's easy for you to get into the framework of thinking that this pain isn't as severe, therefore they don't need referring, so you have to be quite careful not to let any of those prejudices influence who you're referring. White British female (GP5)
GPs have reported that building a strong doctor–patient relationship is important. However, this is perceived to take a long time with South Asian patients:
I think what I learned, talking to people with chronic pain from a South Asian background is that you have to move very slowly in some areas, you are feeling your way in the conversation all the time, checking out presumptions, whether cultural or language or experience of the pain. So, I guess it just turned on my alert buttons in a different kind of way. White British male (GP16)
Psychosomatic interpretations
Chronic pain was frequently perceived by GPs as somatization particularly amongst the non-acculturated South Asians. GPs have acknowledged that by labelling patients as psychosomatic or depressed, there is a perceived risk of missing a serious physical condition:
So a white person who's unhappy would come here and say I cry all the time, whatever else, the Asian patient would say I hurt, you know, heart's hurting, something's hurting, head's hurting, something that is much more physical and I don't know why that it is. It may be difficult for them to explain it so when they go to the doctor's, it's easier to say I've got pain or maybe they convert the mental thing into physical symptoms. They seem to come with physical symptoms a lot more. South Asian male (GP7)... when somebody comes with total body pain, it's not specific pain and you mistake it for a cultural interpretation or think they're depressed and therefore, the pain's due to depression then you may miss something underlying and I think that's definitely one of the problems with people whose cultural background is different (from the host nation for White British patients) like South Asians. So yes, you have to be very careful; sooner or later all of us do some physical investigations to make sure we're not missing something. South Asian male (GP7)
GPs felt that their ability to discuss psychosomatic issues with patients was often determined by time and required a trusting doctor–patient relationship to be established. They found this particularly difficult with South Asian patients because such an approach was perceived to be culturally inappropriate:
Because I think it takes quite a long time, you know, sort of, managing the pain before then you can start talking to the patient that, hang on, maybe it's not physical pain, maybe it might be, erm, something else or it might be depression. I've got a few, mainly Asian women actually. South Asian female (GP8)
Communication
Communication difficulties, primarily the language barrier, add to the challenges and complexities of managing patients from this community with pain. Most patients bring a friend or family member as an interpreter which can be beneficial. However, at times, the three-way conversation with uncertainty over accuracy can be difficult:
I've seen patients who come in and maybe they think I don't speak their language and so I'll talk to them and they'll say something to the person who's supposed to be interpreting, which I understand completely and then their interpreter will tell me in English and I'll think, well, that's not what she just said. South Asian female (GP8)
GPs feel language plays a key role in the expression of pain. They feel South Asian patients use language differently to White British patients and, as a result, patients find it difficult to express what they are feeling, thus making it harder to identify and diagnose the problem:
Erm, I think they express themselves in a different way and I can't think of an example they, erm, they don't seem to use the language in exactly the same way as I would use it. The nuances of what we talk about, our facial expressions and things like that, that betray what we're feeling, seem to be different. White British male (GP6)
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Discussion |
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Our study used a qualitative approach to help explore the challenges faced by GPs in consulting and managing patients with chronic pain from a South Asian community. Many challenges stem from the consultation process where South Asian patients are reported to consult and present with non-specific pain symptoms. Their pain presentations and use of language make it difficult for GPs to clarify, diagnose and manage their pain. For some GPs, this has been personally challenging, particularly in cases where an underlying medical explanation is not clear. In such cases, GPs seem to conceptualize the pain as somatization or psychosomatic and therefore management focuses around reassurance and support for the patient. GPs find discussing a psychological basis for pain with this population difficult and, as a result, avoid doing so for fear of disturbing the doctor–patient relationship. How this can be appropriately addressed in clinical practice remains unclear to some GPs.
The strengths of this study are that our purposive sampling strategy has ensured that we have sampled the accounts of a broad spectrum of GPs and their experiences of being consulted by South Asian patients with chronic pain and an exploration of their beliefs, perceptions and views. Our analysis was rigorous in incorporating transcription of interviews, careful reading and rereading of the text with generation of codes from the data and active search for negative cases. Rigour was maintained at every stage of the analysis to minimize any potential investigator bias by the first author (SP) regularly consulting co-authors for clarification over interpretation throughout the analysis process. We actively sought and achieved saturation of the data with no new themes emerging from the final cases. This helps to ensure that the results are generalizable. Nevertheless, caution must be taken against over-generalizing these data.
Furthermore, in qualitative research, reflexivity is important as it encourages the researcher to introspect on their own experiences, values and feelings and how these may interact with their engagement in the research process. In a grounded theory approach, it is particularly important that emerging categories are truly grounded in participants’ accounts. Reflexivity helps to guard against the personal ‘agenda’ of the researcher biasing the interpretation data. Given the interpretative nature of the analysis, who the researcher is will always have an influence on the process, but provision of a reflexive account of relevant information helps to make this more transparent to the audience. Interviews in this study were carried out by a South Asian female Health Psychology researcher with an interest in ethnicity and pain. While it is possible that the cultural background of the researcher as well as their professional status may have influenced interviewer–interviewee relationship and the responses obtained, the combination of this reflexivity and the multi-ethnic and multi-professional composition of the research team who all contributed to the analysis and interpretation of the data decrease this risk.
Throughout this paper, we have referred to South Asian patients as a group. It is important to note that when we talk about South Asian patients, we are grouping a large number of faiths and cultures together as one and within this large group there are significant language and cultural variations which may impact upon pain behaviour.
There is support from previous studies that South Asian patients are more likely to consult and present with non-specific pain symptoms.13 Specifically, in the case of acute back pain management, GPs report experiencing personal challenges in dealing with this patient population.14 When GPs referred to patients they found difficult to manage, reference was frequently made to elderly female, South Asian patients with chronic pain. This is particularly problematic if these patients are perceived to be difficult. To avoid stereotypes, prejudice and discrimination, self-awareness of one's clinical practice is crucial. It is important to appreciate that some of the personal challenges may not be specific to a South Asian patient population. The idea of heart sink can be applicable to all cultures and chronic conditions. Therefore, care needs to be taken over the conclusions drawn from this study.
GPs report that second and third generation South Asian patients born or educated in UK present similarly to White British patients and are consequently easier to manage and treat. These results can be interpreted from two perspectives: firstly, a patient-driven phenomenon whereby the degree of acculturation displayed by the patient has an influence on GPs perceptions of ease/difficulty. Secondly, it could be considered as a phenomenon driven by ‘cultural difference’ whereby the cultural background of the GP and the degree to which this is similar or different to the patient could be influential. Research has suggested that as people become more ‘Westernized’, their presenting symptoms increasingly resemble that seen in the West.15 Greater acculturation has been associated with lower prevalence of pain16 compared to non-acculturated South Asian patients and acculturation has been associated with reductions in health risks in some other conditions through improved management.17
Our findings suggested that GPs do interpret pain among South Asians as somatization. Although there is no evidence that South Asian people are more likely to present mental distress as pain than White British patients, research has shown that the expression of psychological distress through somatization is more frequently reported among South Asian and other immigrants from non-Western cultures.18 This cultural variation makes it difficult for GPs to diagnose and treat.19 One study has shown that South Asian patients fail to distinguish between pain in a specific part of the body and broader social and personal issues and as a result fail to recognize the latter as depression or psychological distress.20 Other studies have reported that South Asian women are clearly able to distinguish between mental and physical illness as well as identify the interaction between physical and mental health21; yet Asian patients who scored above a cut-off point for psychiatric caseness were more likely to consult for physical health problems which also matched the GPs' beliefs about their reasons for consulting.22 However, discussing a psychological basis for pain has been reported to be challenging for GPs particularly because there is a strong desire to preserve the doctor–patient relationship.23 This demonstrates the complexity of the presentation of chronic pain by South Asian people and the need for further research in this field.
This study provides a broad overview of the practitioners' perspective. Elicitation of the views of south Asian patients to capture their experience and perspective and to what extent their views are congruent with those of GPs would be informative and may help to determine whether GPs are misinterpreting pain in South Asian patients as somatization. Research also needs to determine whether mental health problems are presented as pain in GP consultations or if depression is an important key feature of pain presentation in South Asian patients.
It is clear that practitioners find these consultations difficult and novel approaches to help both practitioners and their patients are required. These approaches will need to address both consultation skills and the establishment of culturally sensitive primary and secondary care services which may require counsellors, cognitive behaviour therapy and pain management programmes to manage these patients effectively. While quick and easy access to interpretation services alone is essential, it is not sufficient.
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Declaration |
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Funding: MediSearch.
Ethical approval: Approval for this study was granted by the Leicestershire, Northamptonshire and Rutland Research Ethics Committee.
Conflicts of interest: None
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Acknowledgments |
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We would like to thank all the GPs for their time in participating in this study.
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Notes |
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Patel S, Peacock SM, McKinley RK, Clark Carter D and Watson PJ. GPs’ experience of managing chronic pain in a South Asian community—a qualitative study of the consultation process. Family Practice 2008; Pages 1–7 of 7.
The author's addresses have been corrected.
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References |
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