Difficult Encounters in Chronic Pain Patients: A Cohort Study

To determine variables associated with difficult clinical encounters.

This was a cross-sectional study of 428 new patients evaluated from 2022 to 2023. Demographic, clinical, social (eg, missed appointments, prior felony conviction, prior pain physicians, medical assistance) and visit-related (eg, visit took longer than expected, difficulty communicating) information was recorded, supplemented by in-person history gathered by the trainee and attending whose demographic data were also recorded. Physicians independently rated the "difficulty" of the encounter on a 6-point Likert scale from 1 = very easy/pleasant, 2 = easy/pleasant, 3 = neutral/average, 4 = difficult, 5 = very difficult, to 6 = extremely difficult. A difficult encounter was a combined trainee and attending rating of one IQR above the median of 2.0±1.75.

Among 428 participants, mean ± SD age was 54.2±15.8 years and 261 (61.0%) were female. Attending gender, gender concordance, race and racial concordance, and years of physician experience were not associated with difficulty. In multivariable analysis, requesting opioids (P=.001), lengthier than expected visit (P<.001), hostile/demanding behavior (P=.003), refusal to try recommended treatment (P=.002), unrealistic expectations (P<0.001), and difficulty communicating (P=.02) were associated with difficult encounters.

Most variables associated with physician impressions of difficult encounters were visit-related, suggesting some patient-related factors (eg, prior substance abuse, translator requirement) may be less relevant in pain patients. Future research should evaluate interventions designed to decrease the difficulty of encounters and determine their effect on patients and physicians.