Date Published: May 1, 2019
Publisher: Public Library of Science
Author(s): Fiona Webster, Kathleen Rice, Joel Katz, Onil Bhattacharyya, Craig Dale, Ross Upshur, Steve Koester.
This study reports on physicians’ experiences with chronic pain management. For over a decade prescription opioids have been a primary treatment for chronic pain in North America. However, the current opioid epidemic has complicated long-standing practices for chronic pain management which historically involved prescribing pain medication. Caring for patients with chronic pain occurs within a context in which a growing proportion of patients suffer from chronic rather than acute conditions alongside rising social inequities.
Our team undertook an ethnographic approach known as institutional ethnography in the province of Ontario, Canada in order to explore the social organization of chronic pain management from the standpoint of primary care physicians. This paper reports on a subset of this study data, specifically interviews with 19 primary care clinicians and 8 nurses supplemented by 40 hours of observations. The clinicians in our sample were largely primary care physicians and nurses working in urban, rural and Northern settings.
In their reflections on providing care for patients with chronic pain, many providers describe being most challenged by the work involved in helping patients who also struggled with poverty, mental health and addiction. These frustrations were often complicated by concerns that they could lose their license for inappropriate prescribing, thus shifting their work from providing treatment and care to policing their patients for malingering and opioid abuse.
Our findings show that care providers find the treatment of patients with chronic pain–especially those patients also experiencing poverty–to be challenging at best, and at worst frustrating and overwhelming. In many instances, their narratives suggested experiences of depersonalization, loss of job satisfaction and emotional exhaustion in relation to providing care for these patients, key dimensions of burnout. In essence, the work that they performed in relation to their patients’ social rather than medical needs seems to contribute to these experiences. Their experiences were further exacerbated by the fact that restricting and reducing opioid dosing in patients with chronic pain has become a major focus of care provision.
Chronic pain is a significant health concern globally, affecting an estimated 20 percent of adults worldwide , and is among the most prevalent chronic conditions in Canada . In the province of Ontario–the site of this study–it is the most prevalent chronic condition , especially among those with multimorbidity . Chronic pain also disproportionately affects individuals with low SES . This means that clinicians regularly engage with the constraints and challenges experienced by patients who struggle to cope with pain and other chronic conditions in conditions of poverty and marginalization. These circumstances were impetus to ground our ethnographic study in the standpoint of clinicians in primary care, as little is known about the actual work that is involved in providing care for these patients. An empirical understanding of the materiality of physicians’ work is crucial for understanding–and ultimately addressing–these evidently socio-medical conditions.
This article draws on data from an ongoing institutional ethnography  of the coordination of care for chronic non-cancer pain in Canada. Developed by sociologist Dorothy Smith, institutional ethnography (IE) is an approach to research rather than a set of research methods. We have described this approach and how we have used it in our work previously . IE uses people’s everyday work problems as the starting point for an exploration of the often-invisible social relations that scaffold and orient experiences [23, 24]. Smith explains ruling relations as being “that extraordinary yet ordinary complex of relations that are textually mediated, that connect us across space and time and organize our everyday lives” .
Our findings are organized around physicians’ experiences providing care to chronic pain patient, and are presented in a narrative style that demonstrates care providers’ changing role vis a vis care provision, the frustrations they experience in trying to effectively provide care for patients that they find challenging, and their struggles to effectively respond to situations that they feel helpless to address. We have drawn on the many examples in which physicians describe having to manage issues of poverty and marginalization in their work rather than strictly patient’s health concerns. We also note in their stories many examples of loss of job satisfaction, emotional exhaustion and, at the extreme end of the continuum, depersonalization.
In keeping with IE’s emphasis on an expanded definition of work, our findings demonstrate the shifting nature of the work performed by care providers causes them frustration, exhaustion and compromised job satisfaction. These are key characteristics of what has been termed physician burnout . In the literature, burnout is often described as an individual phenomenon and one that is anecdotally on the rise due to stress although inconsistently defined. However, the empirical experiences underpinning this stress are rarely described. While we do not diagnose “burnout” in our physician participants, we take note of the many examples of experiences consistent with this term that they describe in their accounts.
Institutional ethnography is a particular qualitative approach that allows researchers to link the everyday experiences of participants working lives to the wider institutional factors influencing that experience through an examination of texts including discourse. In our study we were able to link physician accounts of stress, emotional exhaustion and even depersonalization with the many examples they provided of treating patients with low SES, within the context of changing legislation by their professional Colleges. We noted how much of the work that physicians described was about gatekeeping or policing patient access to chronic pain medication rather than the work of healing. This puts the provider in a conflicted position relative to their patients in need as the institutional priority is restricting or withholding therapies once widely prescribed and now recognized as risky.
We have drawn together discourses on health and social inequality and the rising literature on physician well-being. Indeed, the pervasiveness of poverty among chronic pain patients means that care providers are being asked to mediate across class lines, to help people whose problems they have not been trained to solve. This results in a lot of anguish and worry for them.