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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] V 1269 Tait et al. 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 1270 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 1271 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. 1272 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. 1273 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), 1274 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. 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