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Pain Medicine 2016; 17: 1269–1281
doi: 10.1093/pm/pnv076
PSYCHOLOGY, PSYCHIATRY, IMAGING & BRAIN
NEUROSCIENCE SECTION
Original Research Article
Medical Judgments Across the Range of
Reported Pain Severity: Clinician and Lay
Perspectives
Raymond C. Tait, PhD, John T. Chibnall, PhD, Kylie
House, BA, and Joann Biehl, BS
Department of Neurology and Psychiatry, Saint Louis
University School of Medicine, St. Louis, Missouri,
USA
Correspondence to: Raymond C. Tait, Department of
Neurology and Psychiatry, Saint Louis University
School of Medicine, 1438 South Grand Boulevard,
Monteleone Hall 310, St. Louis, MO, 63104, USA.
Tel: þ1 (314) 977 4817; Fax: þ1 (314) 977 4901.
E-mail: [email protected].
Conflicts of interest: There are no conflicts of interest
to report.
Abstract
Background. While increasing evidence suggests
that observers discount high-severity chronic pain,
factors that occasion such discounting are poorly
understood, particularly regarding health provider
vs lay perspectives.
Objective. This study examined the effects of supporting medical evidence and comorbid psychological distress (pain behavior) on medical student and
lay clinical judgments of increasingly severe patient
pain reports.
Design. In a 2 3 2 3 2 3 (7) mixed between- and
within-subject design, participants (medical students vs lay) made clinical judgments after reading
vignettes describing a hypothetical patient that varied in levels of medical evidence and pain behavior
(low vs high) and pain severity (4/10–10/10).
Subjects. Fourth-year medical students (N 5 115)
and lay persons in the community (N 5 300) participated in this research.
Results. While both medical student and lay judgments plateaued at high levels of pain severity,
judgments regarding cause (medical vs psychological), treatment (opioid prescription), and disability
showed growing divergence as levels of reported
pain severity increased. Divergence relative to medical and psychological causes of pain was found irrespective of the level of supporting medical
evidence; divergence relative to opioid treatment
and support for a disability claim was found when
supporting medical evidence was low.
Conclusions. The results indicate differing expectations of chronic pain treatment for health care providers relative to the lay public that could impact
clinical care, especially at high pain severity levels,
where lay expectations diverge significantly from
those of health professionals.
Key Words. Chronic Pain; Clinical Judgment; Pain
Treatment; Pain Severity; Medical Evidence; Pain
Behavior
Introduction
Under-treatment of chronic pain is a longstanding health
care issue that remains problematic [1,2] secondary to
barriers involving the health care system [3], the patient
[4], and the provider [5]. Recent years have seen increased attention to provider factors, particularly factors
that can influence the patient-provider encounter and
provider judgments [6–8]. Substantial evidence shows
that provider judgments are influenced by multiple
clinical factors that can affect the credibility of a patient’s reported symptoms. Two of those factors have
considerable empirical support: the presence or absence of confirmatory medical evidence [9–12] and the
apparent contribution of psychological factors to a patient’s adjustment [13–16].
While abundant evidence supports the discounting effects of low levels of confirmatory medical evidence and
C 2015 American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: [email protected]
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high levels of psychological distress on clinical judgments, the effects do not operate evenly across the
spectrum of reported pain severity. Indeed, it appears
that pain reported at low-to-moderate levels of severity
is not subject to discounting. Instead, discounting
seems to operate at higher levels of pain severity
[9,11,17,18]. Several explanations have been proposed
to account for the severity phenomenon. One involves
cultural norms that value stoic responses to adversity:
patients who report pain of high severity are behaving in
a counter-normative manner, making them subject to
negative evaluations and symptom discounting [11].
Another explanation reflects mechanisms associated
with exchange theory [19–21]: pain reported at high severity represents an implicit demand for potentially burdensome caregiving, while pain of low severity makes
no such demand [22].
Of course, the former (counter-normative) and latter
(provider burden) explanations for pain discounting are
not mutually exclusive. Indeed, it is likely that both impact observer judgments, although the impact may be
mediated by the observer’s role vis-à-vis the patient.
For example, counter-normative factors, likely reflecting
broad societal values that favor stoic responses to illness [11], should be evident in the lay public (also representing the patient perspective), as well as among
health care providers. By comparison, secondary to
their role as health care providers, we expected medical
students to be more influenced than lay participants by
the implicit demands for potentially burdensome caregiving that they would face in treating patients who present with high-severity symptoms and substantial
psychosocial overlay. In fact, there is evidence that providers who treat patients with high-impact chronic pain
(i.e., pain with significant functional compromise) expect
that treatment will be complex, associated with a challenging psychosocial overlay and high patient demands
(e.g., for opioids), and have a low likelihood of symptom
alleviation [6,23–27]. Under such conditions, providers
would be expected to further discount reported pain
and/or attribute it to psychological factors, effectively reducing their need to provide aggressive medical care.
To date, however, research has yet to determine
whether the well-documented discounting effect differentially affects decisions of lay vs health care judges.
The current study examines the latter issue through a
comparison of clinical judgments regarding pain causes,
treatment, and pain-related disability made by lay subjects
and by fourth-year medical students, who already had
some exposure to the treatment of chronic pain patients
in their clinical rotations. Each group made a series of
clinical judgments regarding a hypothetical patient whose
reported levels of pain severity incremented from moderate (4/10) to very high (10/10). Patient presentations also
varied in their levels of supporting medical evidence (low
vs high) and in physical manifestations of psychological
distress (i.e., low vs high levels of pain behavior). The latter
approach was taken in order to make the manipulation of
psychological distress consistent with a clinical literature
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that suggests that, in order to minimize the likelihood of
providers attributing pain symptoms to psychological
causes, many chronic pain patients de-emphasize frank
symptoms of distress and emphasize their physical symptoms [28–30]. Participants then completed a set of semantic differential items to assess their impressions of the
hypothetical patient’s personality features.
Consistent with existing literature, we expected that
both lay and medical student participants would endorse more aggressive treatment for patients with higher
levels of supporting medical evidence and less aggressive treatment for patients presenting with higher levels
of pain behavior (psychological distress). Further, while
we expected that clinical judgments of lay participants
regarding pain causes, treatment, and associated disability would correlate with those of medical students
across levels of reported pain severity and would
plateau at higher levels (secondary to the counternormative effect), we expected greater divergence between lay and medical student judgments as pain levels
approached high levels of severity, consistent with the
tenets of exchange theory described above. Relative to
lay participants, at severe levels of pain we expected
medical students to endorse less aggressive
approaches to treatment, lower attributions of pain to
medical causes, higher attributions to psychological
causes, and lower levels of support for pain-related disability, a pattern reflecting a predisposition to reduce
burdensome demands for care associated with such
symptoms. Finally, we expected evaluative impressions
of the patient to vary in a pattern similar to that of clinical judgments.
Methods
The study was approved by the Saint Louis University
Institutional Review Board, and all participants gave
consent.
Sample Recruitment
Lay participants (N ¼ 300) were recruited through
Amazon’s Mechanical Turk (MTurk) service [31]. MTurk
is an open online portal for surveys and market research
that is used in the social sciences to recruit samples of
the general population to participate in research electronically. Members of the general community across
the United States and nearly 100 international countries
self-select opportunities to be MTurk “workers” (only the
U.S. community was included in the current research).
MTurk has been demonstrated to yield generalizable, reliable, and valid data from samples that are much more
diverse than convenience samples of community members, students, or patients [32].
Medical students at Saint Louis University who had just
completed their third (clinical) year of medical school
(N ¼ 160) were also asked to participate (with no financial or other forms of compensation). Participant recruitment and data collection occurred after a mandatory
Clinician and Lay Perspectives
informational meeting to start the fourth (final) year of
medical school.
Study Design
The study was a mixed between- and within-subjects
2 2 2 (7) design. Participants (lay public vs medical students) were randomly assigned to read one of
four vignettes that presented information about RJ, a
hypothetical patient with low back pain being seen for a
medical examination. Information that was kept constant
across vignettes included the patient’s presenting problem, past and present treatments, history, and current
functioning. Between-subjects information was varied in
a 2 2 fashion to create four experimental conditions:
medical evidence (low vs high) and pain behavior (low
vs high). While the clinical information was comparable
across participant groups, medical terms were defined
in less technical language in the lay sample materials
compared with the medical student materials. Figures 1
and 2 display the vignette information for the lay public
and medical students, respectively.
Levels of medical evidence were varied in the
“Diagnostics” section in the vignettes, and levels of pain
behavior were varied in the “Clinical Examination” section. For example, for medical students, high medical
evidence was represented by plain radiographs that indicated “grade II spondylolisthesis,” an L4–5 disc that
was described as “bulging” with “possible disc herniation,” a disc space that was described as “narrowing,”
and EMG results that suggested “possible nerve root
compression.” Low medical evidence was represented
by plain radiographs that were described as
“unremarkable,” an L4–5 disc that was described as
“bulging,” disc space that was described as showing
“no evidence of narrowing,” and EMG results that suggested “no nerve root compression.” With respect to
pain behavior, the vignette information was based on
the presence vs absence of Waddell signs [33]. In the
medical student vignette, high pain behavior was represented by patient agitation during the examination, “superficial” tenderness over the lumbar spine, a straight
leg raise that was negative with distraction, and a positive response to axial loading. Low pain behavior was
represented by an absence of agitation, removal of the
word “superficial” when describing lumbar tenderness, a
straight leg raise that was positive with distraction, and
a negative response to axial loading.
The within-subjects factor was the patient report of
usual pain severity. Usual pain levels varied from 4 to 10
on a 0–10 scale, where 0 meant “no pain,” 5 meant
“moderate pain,” and 10 meant “worst pain imaginable.”
Low levels of reported pain severity (0–3) were not included in the study and were described to participants
as being incompatible with the patient’s presenting condition and circumstances: “Since it is unrealistic that a
patient like RJ would report ‘no pain’ or extremely low
levels of pain, we have omitted pain levels of 0–3 from
this task.”
Measures
After reading a vignette, participants made clinical judgments regarding RJ under the assumption that they
were RJ’s treating physician. Before reading a vignette,
participants were familiarized with the study rating task
through a practice rating session in which they were
asked to rate the likelihood that they would do yard
work, using a 1–4 Likert-type scale (1 ¼ very unlikely,
2 ¼ unlikely, 3 ¼ likely, and 4 ¼ very likely), as a function of the outside temperature (temperature range was
40 Fahrenheit [F], 50 F, 60 F, 70 F, 80 F, 90 F, and
100 F). Participants later used this same approach to
clinical judgments made about the patient described in
the vignette, but the seven points on the temperature
scale were replaced with seven points on a pain scale.
After reading a vignette, participants, acting as the treating physician, made likelihood estimates (using the
same Likert-type scale as in the practice ratings) regarding six clinical judgments at each of seven progressive
levels of usual pain severity (4–10/10). Two likelihood
estimates concerned assessment of the patient: (a)
“What is the likelihood that you would consider this to
be primarily a medical problem,” and (b) “What is the
likelihood that you would consider this to be primarily a
psychological problem.” Three estimates concerned
treatment: (c) “What is the likelihood that you would prescribe an antidepressant,” (d) “What is the likelihood
that you would prescribe an opioid,”and (e) “What is the
likelihood that you would refer RJ to an orthopedist.”
Finally, one estimate concerned disability: (f) “What is
the likelihood that you would support a disability application for RJ.” Participants made likelihood ratings for a
judgment across each of the seven pain levels (usual
pain severity levels ¼ 4, 5, 6, 7, 8, 9, 10), then made
ratings for the next judgment, and so on.
Next, participants rated their impressions of the patient
on 10 semantic differential items. Each item was rated
on a 1–10 scale that was anchored on the ends
by descriptive antonyms: “industrious–lazy,” “stable–
unstable,”
“strong–weak,”
“dishonest–honest,”
“careless–careful,” “good–bad,” “complaining–stoic,”
“wise–foolish,” “healthy–sick,” “tense–relaxed.” For each
pair, the positive or negative word was assigned randomly to anchor the right side of the continuum.
Participants selected the number on the continuum that
best represented their impressions.
Procedure
Per standard MTurk procedures, the study materials
were made available to MTurk workers through a link to
Qualtrics, an online survey software platform. Inclusion
criteria were age 18 years or older and United States
residency. Workers who met the inclusion criteria selected one of four postings representing the four experimental conditions of the study, labeled only as Pain
Study A, B, C, or D. Once workers selected a posting,
they could not access other postings. Postings were
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Tait et al.
Clinical Information:
Presenting problem: Imagine that you are a physician in internal medicine who is seeing RJ,
a 43 year-old white male, who has just been referred to you for medical care. He initially
sustained a herniated disc in his low back in a work accident 3 years ago. A herniated disc
occurs when the “spacer” (disc) between two vertebrae tears, pinching nerves in the spine
and causing pain. After low back surgery to repair the herniated disc, he returned to work at
a large manufacturing plant in the maintenance department. Although flare-ups of low back pain
(LBP) caused intermittent absences, he continued to work at the plant. Approximately 6 months
ago, episodes of LBP increased in frequency and severity until 3 months ago, when RJ reported
experiencing constant LBP with radiation into his left leg. Since that time, he has been unable to
work. Pain is reported to increase with any sustained activity, with bending, and with lifting. It
also increases with weather changes. It decreases with rest, with application of heat, and with
medication. RJ currently takes 10 mg of cyclobenzaprine, a muscle relaxant, three times per
day, as well as 800 mg of ibuprofen, an anti-inflammatory, three times per day. When pain
is particularly severe, he takes extra doses, sometimes with several beers. He reports that the
medications have been of decreasing benefit.
History: RJ has a high school education and some subsequent training as an electrician. He has
worked primarily in industrial jobs. He has worked at his present job for approximately 6 years.
He describes his job satisfaction as “fair,” and he is annoyed that his employer is pressuring him
to return to work. He is married with children ages 12 and 15. While he describes his marriage as
stable, he is frustrated that his wife, who also works full time, is not more supportive.
Current function: Pain is reported to interfere with virtually all work, home, and social activities.
Most days are spent reclining. Sleep onset is delayed, and he reports frequent awakenings. His
wife is frustrated at his inactivity. Finances at this time are “OK,” although RJ acknowledges that
he worries about future expenses, especially if he can’t return to work.
Diagnostics: X-rays of RJ’s low back do not show any obvious problems. A recent MRI, a
diagnostic test that is more sensitive than x-rays, shows that one of the discs (spacers
between vertebrae) in RJ’s low back is bulging, but there is no evidence that the disc has
“herniated” (torn). The MRI also shows that the space between vertebrae in RJ’s low back
is relatively normal, although the vertebrae show some signs of wear. Electromyography
(EMG), a method for examining the electrical impulses that move along nerves in RJ’s low
back, shows no evidence that nerves in RJ’s spine are damaged. [Low Medical Evidence]
Vs.
Diagnostics: X-rays of RJ’s low back show that one of his vertebra has slipped forward over
another vertebra, a condition known as “spondylolisthesis.” This slippage may cause pain
if it pinches the nerves in the spine. On a scale of 1 (least) to 4 (worst), RJ’s
spondylolisthesis is a 2, which usually does not require surgery. A recent MRI, a diagnostic
test that is more sensitive than x-rays, shows that one of the discs (spacers between
vertebrae) in RJ’s low back is bulging and possibly has “herniated” (torn), although this
can’t be determined for sure. The MRI also shows that the space between vertebrae in RJ’s
low back is narrower than normal. Electromyography (EMG), a method for examining
how electrical impulses move along nerves in RJ’s low back, suggests that nerves in RJ’s
spine may be damaged. [High Medical Evidence]
Clinical examination: Your medical examination shows that RJ is moderately overweight at
5’10” and 210 pounds (Body Mass Index = 29.3). Vital signs (heart rate, breathing) are within
normal limits, except for mild high blood pressure. A physical examination of RJ shows no
obvious problems with his heart, lungs, stomach/digestive tract, or brain.
During the examination, RJ is calm. He puts his weight on his right side, and he walks
slowly and favors his left side. His ability to bend forward and backward is limited, and he
says that it hurts when he bends. His low back is tender when you press on it. When RJ’s
left leg is raised to 45 degrees while lying down, he reports that low back pain goes down
his left leg. He reports the same pattern when the left leg is raised while he is sitting down
and distracted in conversation. When you press down on the top of RJ’s head while he is
seated, he reports no increase in pain. [Low Pain Behavior]
Vs.
During the examination, RJ is agitated. … … … … … … … … … … … … … … … …
…………………………………………………………………………………
… … … … … … … … … … … .. His low back is tender, even when touched lightly. When
RJ’s left leg is raised to 45° while lying down, he reports that low back pain goes down his
left leg. He reports no changes in pain, however, when the left leg is raised while he is
sitting down and distracted in conversation. When you press down on the top of RJ’s head
while he is seated, he reports an increase in both low back and leg pain. [High Pain
Behavior]
Figure 1 Vignette read by lay participants. Bold indicates that the text was worded differently in the lay vignette
compared with the medical student vignette (see Figure 2). Boxed information was varied to create the two levels
(low vs high) of medical evidence (under “Diagnostics”) and pain behavior (under “Clinical Examination); relevant text
is labeled as low vs high medical evidence and low vs high pain behavior.
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Clinician and Lay Perspectives
Clinical Information:
Presenting problem: RJ is a 43 year-old white male referred to you for medical care. He
initially sustained a herniated disc at L4-L5 in a work accident 3 years ago. After a discectomy,
he returned to work at a large manufacturing plant in the maintenance department. Although
flare-ups of low back pain (LBP) caused intermittent absences, he continued to work at the plant.
Approximately 6 months ago, episodes of LBP increased in frequency and severity until 3
months ago, when RJ reported experiencing unremitting LBP with radiation into his left leg.
Since that time, he has been unable to work. Pain is reported to increase with any sustained
activity, with bending, and with lifting. It also increases with weather changes. It decreases with
rest, with application of heat, and with medication. RJ currently takes cyclobenzaprine (10
mg, TID) and ibuprofen (800 mg, TID). When pain is particularly severe, he takes extra doses,
sometimes with several beers. He reports that the medications have been of decreasing benefit.
History: RJ has a high school education and some subsequent training as an electrician. He has
worked primarily in industrial jobs. He has worked at his present job for approximately 6 years.
He describes his job satisfaction as “fair,” and he is annoyed that his employer is pressuring him
to return to work. He is married with children ages 12 and 15. While he describes his marriage as
stable, he is frustrated that his wife, who also works full time, is not more supportive.
Current function: Pain is reported to interfere with virtually all work, home, and social activities.
Most days are spent reclining. Sleep onset is delayed, and he reports frequent awakenings. His
wife is frustrated at his inactivity. Finances at this time are “OK,” although RJ acknowledges that
he worries about future expenses, especially if he can’t return to work.
Diagnostics: Plain radiographs are largely unremarkable. Recent MRI of the lumbar spine
shows disc bulging at L4-5. There is some degenerative change at L4-5 and L5-S1 with no
evidence of narrowing of disc space at L4-5 or L5-S1. EMG findings suggest no nerve root
compression. [Low Medical Evidence]
Vs.
Diagnostics: Plain radiographs show a grade II spondylolisthesis at L5-S1. Recent MRI of
the lumbar spine shows disc bulging and possible disc herniation at L4-5. There is
degenerative change at L4-5 and L5-S1 with narrowing of disc space at L4-5 and L5-S1.
EMG findings suggest possible nerve root compression. [High Medical Evidence]
Clinical Examination: RJ is moderately overweight at 5’10” and 210 pounds (BMI = 29.3). Vital
signs are within normal limits, except for mild hypertension. Review of systems
(cardiovascular, respiratory, GI, genitourinary, and neurologic) is unremarkable.
No patient agitation was observed during the examination. Weight bearing was
primarily on the right side, and the patient’s gait was slow and antalgic on the left. Range
of motion was limited in lumbar extension and flexion, with increased pain on movement.
Physical examination was noteworthy for tenderness over the L4-5 spinous processes.
Straight leg raise testing was positive at 45° with increased pain and radiation into the left
lower extremity when supine and also positive when the patient was sitting and distracted.
Axial loading was negative, with the patient reporting no increase in low back or radicular
pain with the application of pressure to the head. [Low Pain Behavior]
Vs.
Patient agitation was apparent during the examination. … … … … … … … … … … …
…………………………………………………………………………………
………………………………………………………………………………
Physical examination was noteworthy for superficial tenderness over the lumbar spine.
Straight leg raise testing was positive at 45° with increased pain and radiation into the left
lower extremity when supine, but negative when the patient was sitting and distracted.
Axial loading was positive, with the patient reporting increased low back and radicular
pain with the application of pressure to the head. [High Pain Behavior]
Figure 2 Vignette read by medical students. Bold indicates that the text was worded differently in the medical student vignette compared with the lay vignette (see Figure 1). Boxed information was varied to create the two levels
(low vs high) of medical evidence (under “Diagnostics”) and pain behavior (under “Clinical Examination”); relevant text
is labeled as low vs high medical evidence and low vs high pain behavior.
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Tait et al.
restricted to the first 300 workers who completed the
materials (75 per experimental condition). Workers were
paid $1.00, which was automatically and anonymously
transferred into the worker’s account from a studyrelated MTurk account.
Unlike the MTurk participants, who completed the study
online, medical students completed paper-and-pencil
versions of the study materials. Each medical student
was randomly assigned a packet of research materials
(40 per experimental condition). Medical students who
agreed to participate completed the study materials after the informational meeting.
Statistical Analyses
Mixed-model analysis of variance (ANOVA) was used to
analyze the data. There were three between-subjects variables (participant type, medical evidence, and pain behavior), each with two levels (lay vs medical student or
low vs high) and one within-subjects variable (seven usual
pain severity levels). The main effects and interaction effects for the usual pain variables were assessed for violations of sphericity. In cases where sphericity was
significantly violated, Greenhouse-Geisser adjusted degrees of freedom were used when evaluating statistical
significance (p < 0.05). Effect sizes were estimated using
partial eta-squared (g2) (variance accounted for by independent variable/[variance accounted for by independent
variable þ variance unaccounted for by the model as a
whole]). For interaction effects, 95% confidence intervals
(95% CI) were calculated for the mean values. Prior to
analysis of the 10 semantic differential items, principal
components analysis with orthogonal (Varimax) rotation
was used to identify the fewest number of uncorrelated
components for characterizing these ratings. Factor extraction was guided by the scree plot and factor eigenvalues. A minimum factor loading was set at j0.35j, and
rotated loadings were examined for magnitude, crossloading, and failure to load. Factor scores were generated from the final principal components solution.
Results
Sample Description
Three hundred lay participants accessed the study postings in a 43-hour period. Data were examined for invariance in responding (i.e., selecting the same rating for
every question), apparent random response patterns,
time to completion (based on an estimate of the minimum time required to actually read the study materials
and make ratings), and incompleteness. No cases were
eliminated. The sample was 53% men (n ¼ 159) and
47% women (n ¼ 141). Mean age was 35.2 years
(SD ¼ 12.3). Race/ethnicity was self-reported as White
Non-Hispanic (78%, n ¼ 234), Asian (6%, n ¼ 19), White
Hispanic (6%, n ¼ 18), and African American (5%,
n ¼ 14); all other racial-ethnic categories accounted for
5% of the sample (n ¼ 15). Highest level of education included high school or GED equivalent (32%, n ¼ 95),
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college associate’s degree (17%, n ¼ 51), college bachelor’s degree (39%, n ¼ 116), post-graduate degree
(12%, n ¼ 35), and trade or professional school (1%,
n ¼ 3). Chronic pain was reported by 38% of lay participants (n ¼ 113); a first-degree relative with chronic pain
was reported by 51% (n ¼ 153).
The medical student response rate was 72% (115/160
students agreed to participate). This sample was 55%
men (n ¼ 62) and 45% women (n ¼ 51), with two students declining to indicate their gender. Based on the
108 students who provided their age, mean age was
26.0 years (SD ¼ 1.7). While racial/ethnic data were not
solicited from the medical students, the typical breakdown for this school of medicine is approximately 60%
White Non-Hispanic, 25% Asian, 4% African American,
2% White Hispanic, and 3% mixed race (with the remainder unspecified). At the end of their study participation, medical students were asked to rate their clinical
experience with patients like the one depicted in the vignette (1 ¼ very little; 2 ¼ some; 3 ¼ moderate; 4 ¼
substantial). The mean rating was 2.7 (SD ¼ 0.7).
Random assignment of materials to students resulted in
different numbers of students in each of the four experimental conditions: 23 students (20%) in the high medical evidence/high pain behavior condition; 25 (22%) in
the low medical evidence/high pain behavior condition;
31 (27%) in the low medical evidence/low pain behavior
condition; and 36 (31%) in the high medical evidence/
low pain behavior condition. A one-sample chi-squared
test comparing the observed cell percentages with
expected cell percentages (25%) was not significant,
v2(3) ¼ 3.6, p ¼ 0.30, indicating that students did not
participate differentially as a function of the vignette to
which they were assigned.
Relative to sociodemographic characteristics of study
participants, gender distribution did not differ significantly between the lay and medical student samples,
v2(1) ¼ 0.1, p ¼ 0.73. Of course, all medical students
had at least a bachelor’s degree. Not surprisingly, medical students were significantly younger than the lay
sample, t(406) ¼ 7.8, p < 0.001. Age correlated significantly but weakly with participant ratings of the
likelihood of an opioid prescription (r ¼ 0.19) and with
likely support for a disability application (r ¼ 0.17). In order to assess the potential role of age and education as
possible moderators of between-group differences in
judgments, they were entered as covariates into the analytic models. Because neither variable impacted results
significantly, the covariates were not included in subsequent analyses.
Practice Ratings
Practice ratings were recorded by 286 (95%) lay participants and 100 (87%) medical students. Inspection of
the data showed the expected bell curve, where the
likelihood of outside work was lower in cold and hot
Clinician and Lay Perspectives
compared with more moderate temperatures, indicating
that subjects understood the rating methodology.
Primary Analyses
Assessment Judgments
Assessments of the likely medical and psychological
components of the pain condition both demonstrated
magnitude effects for levels of pain severity. For the
medical component, this was reflected in a main effect
for pain level (p < 0.001) and in significant interactions
of pain level with participant type (p < 0.001, partial
g2 ¼ 0.059) and medical evidence (p ¼ 0.008, partial
g2 ¼ 0.014). Relative to participant type, Figure 3A
shows that, at lower pain levels (4/10 or 5/10), the likelihood of a primary medical component was judged to
be lower by lay participants than by medical students;
at moderate pain levels (6/10 or 7/10), lay and medical
For likelihood estimates that psychological components
contributed to the pain condition, main effects emerged
for pain level (p ¼ 0.004), participant type (p < 0.001),
and medical evidence (p ¼ 0.024). In addition, a
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
Mean (95% CI) Psychological Problem Likelihood Rating
A
A 4.0
Mean (95% CI) Medical Problem Likelihood Rating
student judgments were comparable; and at severe levels of pain (>7/10), lay participants were more likely
than medical students to judge the medical component
to be a primary factor in the pain condition . Relative
to medical evidence, Figure 3B shows that, for lowto-moderate pain levels (<7/10), medical factors were
more likely to be judged a primary component when
medical evidence was high than when it was low; this
difference was not found for severe pain levels (>7/10).
No magnitude effect was found for pain behavior: for
both participant groups, the likelihood of a significant
medical component was lower when pain behavior was
high than low (p ¼ 0.049, partial g2 ¼ 0.010) across all
levels of pain severity.
4.0
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
1.0
6
7
8
Patient Usual Pain Level
9
4
10
B 4.0
B
Mean (95% CI) Psychological Problem Likelihood Rating
5
Mean (95% CI) Medical Problem Likelihood Rating
4
3.5
3.0
Low
Medical
Evidence
2.5
High
Medical
Evidence
2.0
1.5
5
6
7
8
Patient Usual Pain Level
9
10
4.0
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
1.0
4
5
6
7
8
Patient Usual Pain Level
9
10
Figure 3 (A) Interaction of pain level and participant
type on likelihood that the pain condition is primarily a
medical problem. Lay vs medical student means differ
(p 0.002) for pain levels of 4, 5, 8, 9, and 10. (B)
Interaction of pain level and medical evidence on likelihood that the pain condition is primarily a medical problem. Low vs high medical evidence means differ
(p 0.007) for pain levels of 4, 5, and 6.
L ow
High
Medical Evidence
Figure 4 (A) Interaction of pain level and participant
type on likelihood that the pain condition is primarily a
psychological problem. Lay vs medical student means
differ (p 0.032) for pain levels of 4, 7, 8, 9, and 10. (B)
Interaction of participant type and medical evidence on
likelihood that the pain condition is primarily a psychological problem. Lay vs medical student means differ
(p < 0.001) for high medical evidence.
1275
Tait et al.
magnitude effect again emerged in an interaction of
pain level and participant type (p < 0.001, partial
g2 ¼ 0.059). Figure 4A shows that, at low levels of pain
(4/10), medical students were less likely to judge psychological factors to be an important component than
lay participants; at moderate levels of pain (5–6/10),
such judgments were comparable between groups; and
at high levels of pain (7/10), they were higher for medical students than lay participants. Participant type also
interacted with medical evidence (p ¼ 0.003, partial
g2 ¼ 0.021). At low levels of medical evidence, lay participants and medical students judged the psychological
component of the pain condition similarly; when medical
evidence was high, however, lay participants weighted
Lay
Medical
Student
3.5
3.0
2.5
2.0
1.5
1.0
L ow
High
Pain Behavior
Figure 5 Interaction of participant type and pain behavior on likelihood of prescribing an antidepressant.
Lay vs medical student means differ (p ¼ 0.001) for high
pain behavior.
Magnitude effects for levels of pain severity also were
evident in treatment judgments. A main effect for pain
level emerged (p < 0.001, g2 ¼ 0.108), with no interactions, for the likelihood of prescribing an antidepressant:
this reflected a linear increase in the likelihood of an
antidepressant prescription with increasing levels of reported pain. A main effect for participant type also was
found (p ¼ 0.018), but this variable interacted significantly with pain behavior (p ¼ 0.005, g2 ¼ 0.019). As
shown in Figure 5, the likelihood of an antidepressant
prescription was comparable for lay and medical student participants at low levels of pain behavior, while
the likelihood was greater for medical students than lay
participants when pain behavior was high.
Regarding opioid analgesic prescriptions, main effects
were found for pain level (p < 0.001) and participant
type (p < 0.001), as well as their interaction (p < 0.001,
g2 ¼ 0.020). In addition, they each interacted with medical evidence in a significant three-way interaction
(p ¼ 0.017, g2 ¼ 0.010). Figure 6 displays the three-way
interaction. When medical evidence was high, medical
students were less likely than lay participants to prescribe an opioid at all pain levels except 7/10. When
medical evidence was low, medical students were less
likely to prescribe an opioid than lay participants at high
pain levels (7/10). While these data are consistent with
the main effect for participant type, the difference between groups was particularly evident when low
medical evidence was paired with high levels of pain
(>7/10): under those conditions, the magnitude of the
difference between medical students and lay participants was significantly greater than when medical evidence was high.
Low Medical Evidence
4.0
Mean (95% CI) Opioid Likelihood Rating
Treatment Judgments
High Medical Evidence
4.0
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
Mean (95% CI) Opioid Likelihood Rating
Mean (95% CI) Antidepressant Likelihood Rating
4.0
the psychological component less than medical students (see Figure 4B).
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
4
5
6
7
8
Patient Usual Pain Level
9
10
4
5
6
7
8
Patient Usual Pain Level
9
10
Figure 6 Interaction of pain level, participant type, and medical evidence on likelihood of prescribing an opioid. For
low medical evidence, lay vs medical student means differ (p 0.031) for pain levels of 7, 8, 9, and 10. For high
medical evidence, lay vs medical student means differ (p 0.037) for pain levels of 4, 5, 6, 8, 9, and 10.
1276
Clinician and Lay Perspectives
High Medical Evidence
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
4
5
6
7
8
Patient Usual Pain Level
9
10
Mean (95% CI) Disability Support Likelihood Rating
Mean (95% CI) Disability Support Likelihood Rating
Low Medical Evidence
4.0
4.0
3.5
3.0
Lay
2.5
Medical
Student
2.0
1.5
1.0
4
5
6
7
8
Patient Usual Pain Level
9
10
Figure 7 Interaction of pain level, participant type, and medical evidence on likelihood of supporting a disability application for the patient. For low medical evidence, lay vs medical student means differ (p 0.040) for pain levels of
7, 8, 9, and 10. For high medical evidence, lay vs medical student means differ (p 0.017) for pain levels of 6, 7, 8,
9, and 10.
In regard to orthopedic referrals, a main effect for pain
level again emerged (p < 0.001). As above, a three-way
interaction among pain level, participant type, and medical evidence also emerged (p ¼ 0.035, g2 ¼ 0.010), although the interaction was associated only with the
most severe pain level (10/10). When medical evidence
was low and the reported pain level was 10, medical
students (mean ¼ 3.4, 95% CI ¼ 3.2–3.6) were less
likely than lay participants (mean ¼ 3.7, 95% CI ¼ 3.6–
3.8) to refer to an orthopedist (p ¼ 0.007). When medical evidence was high, the likelihood of a referral did
not vary across pain levels as a function of participant
type.
Disability Judgment
Regarding support for a disability application, not only
were there magnitude effects for levels of pain severity
(p < 0.001), but main effects emerged for all four independent variables: participant type (p < 0.001), medical
evidence (p ¼ 0.001), and pain behavior (p ¼ 0.034,
g2 ¼ 0.011). For pain behavior, participants were less
likely to support a disability application when pain behavior was high (mean ¼ 2.5, 95% CI ¼ 2.4–2.6) than low
(2.6, 2.5–2.7). Analyses of the other variables (pain level,
participant type, and medical evidence) demonstrated a
significant three-way interaction (p ¼ 0.033, g2 ¼ 0.010),
as displayed in Figure 7. When pain levels were high
(7/10) and medical evidence was low, medical students
were less likely than lay participants to support a disability application. When pain levels were high (6/10) and
medical evidence was high, medical students again were
less likely to support a disability application, but the difference in the likely support for a disability application
was substantially greater at high levels of pain (8/10)
when the level of medical evidence was low.
Impressions of the Patient
Separate principal components analyses of the 10 semantic differential items were first done by participant
type. These analyses yielded two-factor solutions that explained 58% of the variance in the lay participant ratings
and 48% of the variance in the medical student ratings.
A principal components analysis of all 415 participants
yielded the same two-factor solution that explained 56%
of the variance. For all analyses, factor 1 included items
related to the patient’s character: industrious–lazy, stable–unstable, strong–weak, dishonest–honest, careless–
careful, good–bad, complaining–stoic, and wise–foolish.
Factor 2 included two items related to the patient’s physical and mental status: healthy–sick, tense–relaxed.
Factor scores generated from this solution yielded no
significant main or interaction effects associated with
pain level, participant type, medical evidence, or pain
behavior.
Discussion
As expected, both medical student and lay participants
associated higher levels of pain severity with an increasing likelihood of an opioid prescription, an orthopedic referral, and support for a disability application. More
impressive than the consistencies, however, were differences between participant groups, especially those associated with changes in the magnitude of reported
pain severity. Lay judgments of the medical component
of the pain condition increased over the pain severity
continuum, plateauing at pain ratings of 8/10. Medical
student judgments, however, peaked at and then declined somewhat beyond a pain level of 7/10. At moderate pain levels (4–6/10), medical students judged the
medical component of pain to be greater than lay participants; at high levels (>7/10), however, those views
reversed. Assessments of the psychological component
were a mirror image of the latter pattern: lay judgments
1277
Tait et al.
of the psychological component declined and then plateaued as pain increased from moderate (4–6/10) to severe (7/10) levels, while medical student judgments
were lower than lay judgments at moderate pain levels,
but higher for severe levels.
The tendency among study participants to cap the perceived contribution of a medical component to highseverity pain is consistent with other studies involving
both lay and medical participants [8,9,11,12,17,18], possibly because reports of very severe pain contravene social norms of stoicism [11]. While lay assessments of
medical and psychological factors plateaued at high levels of pain severity, medical student assessments of the
likely medical component actually declined for pain levels
above 7/10, while judgments of the likely psychological
component increased. The latter pattern suggests that
more doubt existed among medical students regarding
self-reported symptoms of pain than in the lay sample. It
also is possible that the medical students, relative to lay
participants, simply understood the importance of the
psychological component of a pain condition, especially
at severe levels. Other differences in judgments of the
psychological component also emerged. For lay participants, confirmatory medical evidence offset the psychological component: the psychological component was
judged more important when supporting evidence was
low than when it was high. Medical students, possibly
sensitized to the frequent association of chronic pain
with psychological distress [34,35], judged the psychological component to be unaffected by the presence or
absence of supporting medical evidence.
The latter data suggest that providers may consider attention to psychological components as routine in the
management of a severe pain condition, an attitude that
may be anathema to patients who are sensitive to having their symptoms dismissed as psychological [28,30].
This divergence in views can occasion differing expectations for treatment between patient and provider and,
potentially, undermine clinical outcomes, given the importance of shared expectations in successful treatments for chronic pain [36,37]. Divergent patient and
provider expectations may be particularly problematic
for severe pain syndromes, where an effective patientprovider collaboration is typically necessary for successful pain management [6,7].
Aside from psychological issues, differences in approach to other aspects of treatment can also have implications for an effective patient-provider relationship.
For example, medical students exhibited greater willingness than lay participants to prescribe antidepressant
medications at high levels of pain behavior. This finding
may reflect predictable differences in medical education
available to the participant groups: medical student
training regarding the mood and analgesic benefits associated with many antidepressants [38] may have increased their willingness to prescribe for patients
exhibiting behavioral signs of distress. On the other
hand, patients without such knowledge may view a
1278
prescription for an antidepressant as further evidence
that the validity of their symptoms is being questioned.
A different pattern emerged for opioid prescriptions. With
weak medical evidence and moderate levels of pain, lay
and medical student participants did not differ in their
recommended use of opioids. With weak medical evidence and high levels of pain (7/10), lay participants
were significantly more likely than medical students to
recommend an opioid. With strong medical evidence,
however, lay participants were more willing than medical
students to prescribe opioids across almost all levels of
pain severity, but especially at higher levels.
The relative reluctance of medical students to prescribe
opioids is consistent with current medical practice, in
which providers often view opioids with caution. This
caution likely reflects both opiophobia [39] and increasingly justified concerns regarding opioid abuse potential
and its consequences [40]. Recent changes in regulations regarding opioids may occasion even more caution
in medical practice. Risk Evaluation and Mitigation
Strategies (REMS) require more active physician engagement, including evaluation of abuse potential and
use of medication contracts [41]. Even if attitudes toward opioids do not stiffen in the face of such regulations, the differing patient and provider perspectives
evident in this study reflect potential conflict, especially
for patients with severe pain who may have the greatest
desire for such treatment.
Attitudes toward disability applications also were substantially more generous for lay participants. Regardless
of the presence or absence of supporting medical evidence, at high levels of pain severity (7/10), lay participants were more supportive of a disability application
than were medical students. This difference, however,
was particularly pronounced when medical evidence
was low. In fact, medical student support for a disability
application was evident only for patients exhibiting both
high levels of pain severity and high levels of supporting
medical evidence.
It is interesting to consider the latter differences in light
of the recent report from the Institute of Medicine [2], in
which the costs of chronic pain associated with treatment, lost work productivity, and disability payments
were estimated at up to $635 million annually. These
and other reports [42] describe a “disability epidemic”
that demands attention at patient, provider, and societal
levels. Indeed, the disability trends are among the factors that impelled the development of a National Pain
Strategy [43] aimed at improving the treatment and reducing the impact of chronic pain. The findings in this
study suggest that an improved patient-level understanding of disability-related issues may be a critical
piece of any successful strategy.
The general pattern evident in the above findings reflects increasing divergence in clinical judgments between medical student and lay participants as levels of
Clinician and Lay Perspectives
pain severity increase, a pattern not readily accounted
for by counter-normative explanations of symptom
judgments and, instead, consistent with responsibilityreducing attributions, such as those suggested in an
exchange-based interpretation of judgment. In the
absence of an accepted heuristic to guide clinical decision-making [44,45], such attributions may shield health
care providers from responsibility for unsatisfactory
treatment outcomes. Indeed, previous research has
found such a pattern among surgeons asked to assess
treatment outcomes for low back pain [16]: favorable
outcomes were attributed to provider skill, while poor
outcomes were attributed, perhaps defensively, to the
patient’s psychological state.
Symptom discounting and defensive attributions may be
mediated by demands (i.e., for opioids and/or aggressive pain care) implicit in reports of high pain severity,
demands that are not present when reported pain severity is low or moderate [22,46]. When faced with highimpact chronic pain, health care professionals may be
motivated to discount pain reports in order to reduce
their responsibility for managing such conditions. While
such behavior may be psychologically and behaviorally
protective for the provider, it also may increase the risk
of inadequate care for a patient population that needs
attention to both the medical and psychological elements of their condition.
Interestingly, analyses of the patient’s personality profile
(personality structure, health status) showed that lay and
medical student participants held similar impressions of
the patient. These impressions did not vary as a function of the patient’s self-reported pain level, pain behavior, or available medical evidence. Thus, participants did
not appear to disparage the patient’s personality, a potential rationale for more restricted treatment decisions
or weaker support for a disability application. This result
is inconsistent with the literature suggesting that pain
discounting and under-treatment for patients with ambiguous medical evidence are occasioned by negative
perceptions of the patient’s legitimacy [11]. Rather, the
current results suggest that patients with high pain severity, a strong psychosocial overlay, and ambiguous
medical data represent a major treatment challenge for
a medical provider. This is consistent with a recent
study demonstrating that medical students who understood they would be responsible for ongoing medical
care of a patient with severe chronic pain rated the psychosocial contribution to the condition significantly
higher than those who understood that they were acting
only in a consultative role [47].
Several study limitations should be noted. Foremost is
the hypothetical nature of the study: such studies differ in
obvious ways from the demands and the richer information that characterize actual clinical practice. That said,
such studies can and often do yield results relevant to
practice [48,49]. In addition, the study involved self-reported data that differed in many ways from data drawn
from actual clinical practice. Further, the study
methodology required that participants make clinical decisions at progressive levels of pain severity. While it is
likely that study participants “guessed” that a purpose of
the study was to gauge stepwise changes in clinical
judgments, it is also likely that such guessing affected
both experimental groups similarly. A methodological
consideration that may have affected study groups differentially, however, involved the reference to a “bulging
disc” in both the high and low medical evidence scenarios. While medical students are likely to have viewed that
finding as ambiguous, the lay participants may have
viewed it as more definitive evidence of a medical component. A final methodological consideration concerns
the use of pain behavior and Waddell’s signs as the
manner in which psychological distress was operationalized. This approach was taken because of its consistency with clinical literature on how chronic pain patients
often present for treatment. Nonetheless, the use of such
indirect behaviors, coupled with the lack of additional descriptors consistent with psychological distress in the vignettes, made it possible that neither the lay nor the
medical student participants viewed these constructs as
synonymous with psychological distress.
Finally, the level of clinical exposure of medical students
to chronic pain patients should be considered. While
the medical students certainly differed from practicing
physicians in their levels of experience, they had completed their third (clinical) year, considered themselves
reasonably familiar with such patients, and were asked
to make judgments consistent with those that they
would have confronted in their clinical training. Relative
to the lay sample, there is evidence that subjects who
participate in MTurk-assisted research are more representative of the community population than convenience
samples of students, local community members, or patients. Indeed, it is noteworthy that 38% of the MTurk
sample reported some level of chronic pain themselves,
a figure that is reasonably consistent with recent reports
regarding the prevalence of pain in the United States.
[2]. Unfortunately, we did not collect data on the personal experience with pain of medical students, either
pain that they experienced themselves or pain experienced by others with whom they were familiar. This
meant that we could not compare the medical student
and lay samples on that dimension.
While these methodological considerations should be
kept in mind, the results of this study demonstrate a
tendency for observers to adjust clinical judgments
as pain severity increases. The lay vs medical student differences may interfere with assessment and
treatment, in that they may raise the risk of a disconnect between patient and provider expectations,
especially among patients reporting high levels of
pain. Finally, the data suggest that decision-making
paradigms for patients and clinicians may shift across
the pain severity range, a shift that may predispose
the provider to under-treatment of the most vulnerable patients, those experiencing severe, high-impact
chronic pain.
1279
Tait et al.
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