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A B S T R A C T Objective: To characterize clinical communication about opioids through direct analysis of clinic visits and in-depth interviews with patients. Methods: This was a pilot study of 30 patients with chronic pain, who were audio-recorded in their primary care visits and interviewed after the visit about their pain care and relationship with their physicians. Emergent thematic analysis guided data interpretation. Results: Uncertainties about opioid treatment for chronic pain, particularly addiction and misuse, play an important role in communicating about pain treatment. Three patterns of responding to uncertainty emerged in conversations between patients and physicians: reassurance, avoiding opioids, and gathering additional information. Results are interpreted within the framework of Problematic Integration theory. Conclusion: Although it is well-established that opioid treatment for chronic pain poses numerous uncertainties, little is known about how patients and their physicians navigate these uncertainties. This study illuminates ways in which patients and physicians face uncertainty communicatively and collaboratively. Practice implications: Acknowledging and confronting the uncertainties inherent in chronic opioid treatment are critical communication skills for patients taking opioids and their physicians. Many of the communication behaviors documented in this study may serve as a model for training patients and physicians to communicate effectively about opioids.

Brief measures to assess and monitor pain in cancer patients are available, but few head-to-head psychometric comparisons of different measures have been reported. Baseline and 3-month data were analyzed from 274 patients enrolled in the Indiana Cancer Pain and Depression (INCPAD) trial. Participants completed the Brief Pain Inventory (BPI), the PEG (a 3-item abbreviated version of the BPI), the short form (SF)-36 pain scale, and a pain global rating of change measure. The global rating was used as the criterion for standardized response mean and receiver operating characteristic curve analyses. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm. All measures were responsive to global improvement, discriminated between participants with and without improvement, and detected a significant intervention treatment effect. Short and longer measures were similarly responsive. Also, composite measures that combined pain severity and interference into a single score (BPI total, PEG, SF-36 pain) performed comparably to separate measures of each domain (BPI severity and BPI interference). Perspective Pain measures as brief as 2 or 3 items that provide a single score are responsive in patients with cancer-related pain. Ultra-brief measures offer a valid and efficient means of assessing and monitoring pain for the clinical management as well as research of cancer-related pain.

Context Record numbers of Iraq and Afghanistan veterans survive their war injuries and yet continue to experience pain and mental health problems, particularly posttraumatic stress disorder (PTSD). Little is known about the association of mental health disorders and prescription opioid use. Objective To investigate the effect of mental health disorders, particularly PTSD, on risks and adverse clinical outcomes associated with prescription opioid use. Design Retrospective cohort study involving 141 029 Iraq and Afghanistan veterans who received at least 1 non–cancer-related pain diagnosis within 1 year of entering the Department of Veterans Affairs (VA) health care system from October 1, 2005, through December 31, 2010. Main Outcome Measures Independent association of mental health disorders and the prescription of opioids, higher risk opioid use, and adverse clinical outcomes (eg, accidents and overdose) within 1 year of receiving a pain-related diagnosis. Results A total of 15 676 veterans were prescribed opioids within 1 year of their initial pain diagnosis. Compared with 6.5% of veterans without mental health disorders, 17.8% (adjusted relative risk [RR], 2.58; 95% CI, 2.49-2.67) of veterans with PTSD and 11.7% (adjusted RR, 1.74; 95% CI, 1.67-1.82) with other mental health diagnoses but without PTSD were significantly more likely to receive opioids for pain diagnoses. Of those who were prescribed pain medication, veterans with PTSD were more likely than those without mental health disorders to receive higher-dose opioids (22.7% vs 15.9%, adjusted RR, 1.42; 95% CI, 1.31-1.54), receive 2 or more opioids concurrently (19.8% vs 10.7%, adjusted RR, 1.87; 95% CI, 1.70-2.06), receive sedative hypnotics concurrently (40.7% vs 7.6%, adjusted RR, 5.46; 95% CI, 4.91-6.07), or obtain early opioid refills (33.8% vs 20.4%; adjusted RR, 1.64; 95% CI, 1.53-1.75). Receiving prescription opioids (vs not) was associated with an increased risk of adverse clinical outcomes for all veterans (9.5% vs 4.1%; RR, 2.33; 95% CI, 2.20-2.46), which was most pronounced in veterans with PTSD. Conclusion Among US veterans of Iraq and Afghanistan, mental health diagnoses, especially PTSD, were associated with an increased risk of receiving opioids for pain, high-risk opioid use, and adverse clinical outcomes.

Patients with major depressive disorder (MDD) often suffer from accompanying symptoms that influence the choice of pharmacotherapy with second-generation antidepressants (SGAs). We conducted a systematic review to determine the comparative effectiveness of citalopram, escitalopram, fluoxetine, fluvoxamine, paroxetine, sertraline, desvenlafaxine, duloxetine, venlafaxine, bupropion, mirtazapine, nefazodone, and trazodone, for accompanying anxiety, insomnia, and pain in patients with MDD.We conducted searches in multiple databases including MEDLINE®, Embase, the Cochrane Library, International Pharmaceutical Abstracts, and PsycINFO, from 1980 through August 2011 and reviewed reference lists of pertinent articles. We dually reviewed abstracts, full-text articles, and abstracted data. We included randomized, head-to-head trials of SGAs of at least 6 weeks' duration. We grouped SGAs into three classes for the analysis: selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors, and others. We graded the strength of the evidence as high, moderate, low, or very low based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group (GRADE) approach.We located 19 head-to-head trials in total: 11 on anxiety, six on insomnia, and four on pain. For the majority of comparisons, the strength of the evidence was moderate or low: evidence is weakened by inconsistency and imprecision. For treating anxiety, insomnia, and pain moderate evidence suggests that the SSRIs do not differ.Evidence guiding the selection of an SGA based on accompanying symptoms of depression is limited. Very few trials were designed and adequately powered to answer questions about accompanying symptoms; analyses were generally of subgroups in larger MDD trials.

Post-traumatic stress disorder (PTSD) is prevalent and under-recognized in Veteran's Administration (VA) primary care and commonly co-occurs with chronic pain. Our primary aim was to analyze existing clinical and administrative data in Veterans Integrated Service Network (VISN) 11 to determine whether the presence of pain affects the diagnosis and treatment of PTSD among VA patients who have a positive PTSD screening test. We identified 4,244 patients who had a positive PTSD screen between January 1, 2001 and January 1, 2007. The mean patient age was 50.4 and 91.9% were male. Half of the cohort had a concurrent pain diagnosis (n=2,104). Those with pain were slightly younger (48.8 vs. 52.0 years, p0.001), more likely to have depression (33.4% vs. 29.4%, p=0.005), and less likely to have medical comorbidity (p0.001) than those without coexisting pain. In the year following their positive PTSD screen, 56.4% of patients received a mental health visit and 27.7% received a diagnosis of PTSD. After controlling for baseline characteristics, patients with coexisting pain were less likely to have a follow-up mental health visit (HR 0.889, 95% CI 0.821, 0.962) than those without pain. The groups did not differ in the rate of PTSD diagnosis (HR 0.968, 95% CI 0.866, 1.082).

Pain and depression are the most prevalent physical and psychological symptom-based disorders, respectively, and co-occur 30 to 50% of the time. However, their reciprocal relationship and potentially causative effects on one another have been inadequately studied. Longitudinal data analysis involving 500 primary care patients with persistent back, hip, or knee pain were enrolled in the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. Half of the participants had comorbid depression and were randomized to a stepped care intervention (n = 123) or treatment as usual (n = 127). Another 250 nondepressed patients with similar pain were followed in a parallel cohort. Outcomes were assessed at baseline, 3, 6, and 12 months. Mixed effects model repeated measures (MMRM) multivariable analyses were conducted to determine if change in pain severity predicted subsequent depression severity, and vice versa. Change in pain was a strong predictor of subsequent depression severity (t-value = 6.63, P.0001). Likewise, change in depression severity was an equally strong predictor of subsequent pain severity (t-value = 7.28, P.0001). Results from the full cohort were similar in the clinical trial subgroup. In summary, pain and depression have strong and similar effects on one another when assessed longitudinally over 12 months.This study strengthens the evidence for a bidirectional and potentially causative influence of pain and depression on one another. A change in severity of either symptom predicts subsequent severity of the other symptom. Thus, recognition and management of both conditions may be warranted, particularly when treatment focused on 1 condition is not leading to an optimal response.

Comparative responsiveness data are needed to inform choices about pain outcome measures.To compare responsiveness of pain intensity, pain-related function, and composite measures, using data from a randomized trial and observational study.Analysis of responsiveness.A total of 427 adults with persistent back, hip, or knee pain were recruited from primary care.Participants completed Brief Pain Inventory, Chronic Pain Grade (CPG), Roland disability, SF-36 bodily pain, and pain global rating of change measures. We used the global rating as the anchor for standardized response mean and receiver operating characteristic curve analyses. We used the distribution-based standard error of measurement to estimate minimally important change. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm.All measures were responsive to global improvement and all had fair-to-good accuracy in discriminating between participants with and without improvement. SF bodily pain was less responsive than other measures in several analyses. The 3-item PEG was similarly responsive to full Brief Pain Inventory scales. CPG and SF bodily pain were less responsive to the trial intervention and did not perform well among participants with hip/knee pain. Agreement between anchor and distribution-based methods was modest.If a brief measure is desired, the 3-item PEG is more responsive than the SF bodily pain scale. CPG and SF bodily pain scales may be relatively poor choices for trial outcome assessment. Both anchor and distribution-based methods should be considered when determining clinically important change.

We appreciate the interest in our work and commend the letter’s author for raising the important and complex issue of depression assessment in patients with pain. It is critical to consider the appropriateness of our assessment measures to address the validity of our study findings. The overlap between chronic pain symptoms and depression symptoms, as highlighted by the author, is significant. There is an integral relationship between depression and pain that is clinically meaningful and therapeutically essential to recognize. For many patients, depression involves a physical experience, and chronic pain involves an emotional experience. Disentangling these symptoms becomes extremely challenging and perhaps impractical for clinicians. The existing evidence generally supports using standardized depression measures without modification for patients with chronic pain. There are several studies supporting the suitability of the Beck Depression Inventory (BDI) for patients with chronic pain,1,2 one of the most commonly used measures of depression. Most recently, Harris and D’Eon3 conducted a careful examination of the factorial validity, internal consistency, and gender invariance of the BDI among 481 patients with chronic pain. The factor structure showed that somatic items covaried with the cognitive and affective items, and correlated as highly as other items with the total score (with the exception of sleep). The investigators concluded there is evidence to support the construct validity and internal consistency of the intact BDI for identifying depressive symptoms in patients with pain. In contrast to the findings of Blalock et al.4 referenced by the letter’s author, there is also support for the use of the Centers for Epidemiological Studies Depression Scale (CES-D) for patients with chronic pain. In 132 patients with chronic pain, Geisser, Roth and Robinson1 found the CES-D was able to discriminate significantly between individuals with and without depression. Additionally, they determined that removing somatic items did not improve accuracy. In 2005, the Initiative on Methods, Measurements, and Pain Assessment in Clinical Trials (IMMPACT), composed of 35 leaders in the pain field, developed consensus guidelines for specific measures of core pain treatment outcomes including emotional functioning.5 The IMMPACT recommendations state, “the evidence indicates that measures of emotional functioning are adequately reliable, valid, and responsive when used with the medically ill.” They recommend the use of the Profile for Mood States (POMS) and the BDI, however, and do not specifically consider the Patient Health Questionnaire – 9 (PHQ-9), 6 one of the depression measures used in our study. The CES-D, POMS, and BDI are all well-validated, robust self-report measures of depressive symptoms. Unfortunately, in busy primary care settings each is relatively long, time-consuming to score, and impractical. The PHQ-9 was developed as a research and clinical screening tool for busy primary care practices, and is valuable for its demonstrated accuracy, clinical utility and brevity. Nease and Malouin7 concluded the PHQ-9 is the best available screening tool for depression for use by primary care clinicians. Several other research teams have used the PHQ-9 for measurement of depression in patients with chronic pain. Three recent examples include a cluster randomized trial for veterans with musculoskeletal pain in primary care,8 a case control study of depression in urology patients with interstitial cystitis, chronic prostatitis, and chronic pelvic pain,9 and predictors of depression in primary care patients with osteoarthritis.10 These studies suggest an acceptance by the pain community of the PHQ-9 as a measure of depression among patients with chronic pain. For our study, the PHQ-9 was used to determine eligibility at study entry. Another measure, the 20-item Symptom Check List (SCL-20), was used to assess depression severity. The SCL-20 is a modified subscale of the Hopkins Symptom Checklist and has been used extensively to assess depression outcomes in primary care trials. SCL-20 scores were significantly higher in patients identified with clinically significant depressive symptoms by the PHQ-9. These findings confirm the significant convergent validity of the PHQ-9 and SCL-20 and argue against the over-estimation of depression prevalence in our study. Unfortunately, we do not know of any studies to date that examined the psychometric properties of the PHQ-9 for patients with pain. In a future study, we plan to assess its reliability and validity, evaluate the appropriateness of retaining the somatic symptoms, and calculate optimal threshold scores for clinically significant depression specifically for primary care patients with musculoskeletal pain. Finally, we contend there is another, potentially more harmful risk than overestimation of depression among patients with pain: underestimation. Physical symptoms, especially pain, negatively affect the recognition of depression. As a result, depression is often missed in patients with pain. By misattributing patients’ symptoms to their pain, we may fail to recognize and treat a significant depression. Standardized measures like the PHQ-9 are particularly valuable because they can facilitate our ability to detect and subsequently treat depression. In sum, the assessment of depression among patients with chronic pain is an important task for clinicians and researchers alike. We believe the PHQ-9 provides an acceptable choice for screening depressive symptoms, and its use is unlikely to lead to an overestimation of depression prevalence among patients with chronic pain in primary care. Yet we acknowledge further research and discussion is needed to evaluate its use further.

Researchers and quality improvement advocates sometimes use review of chart-documented pain care processes to assess the quality of pain management. Studies have found that primary care providers frequently fail to document pain assessment and management.To assess documentation of pain care processes in an academic primary care clinic and evaluate the validity of this documentation as a measure of pain care delivered.Prospective observational study.237 adult patients at a university-affiliated internal medicine clinic who reported any pain in the last week.Immediately after a visit, we asked patients to report the pain treatment they received. Patients completed the Brief Pain Inventory (BPI) to assess pain severity at baseline and 1 month later. We extracted documentation of pain care processes from the medical record and used kappa statistics to assess agreement between documentation and patient report of pain treatment. Using multivariable linear regression, we modeled whether documented or patient-reported pain care predicted change in pain at 1 month.Participants' mean age was 53.7 years, 66% were female, and 74% had chronic pain. Physicians documented pain assessment for 83% of visits. Patients reported receiving pain treatment more often (67%) than was documented by physicians (54%). Agreement between documentation and patient report was moderate for receiving a new pain medication (k = 0.50) and slight for receiving pain management advice (k = 0.13). In multivariable models, documentation of new pain treatment was not associated with change in pain (p = 0.134). In contrast, patient-reported receipt of new pain treatment predicted pain improvement (p = 0.005).Chart documentation underestimated pain care delivered, compared with patient report. Documented pain care processes had no relationship with pain outcomes at 1 month, but patient report of receiving care predicted clinically significant improvement. Chart review measures may not accurately reflect the pain management patients receive in primary care.

Our objective was to assess predictors of self-reported opioid use among patients with back pain due to lumbar disc herniation or spinal stenosis. Data were from the Spine Patient Out- comes Research Trial (SPORT), a multi-site observational study and randomized trial. We examined characteristics shown or hypothesized to be associated with opioid use. Using generalized estimating equations, we modeled associations of each potential predictor with opioid use at 12 and 24 months. At baseline, 42% of participants reported opioid use. Of these participants, 25% reported continued use at 12 months and 21% reported use at 24 months. In adjusted models, smoking (RR = 1.9, P < .001 at 12 months; RR = 1.5, P = .043 at 24 months) and nonsurgical treatment (RR = 1.7, P < .001 at 12 months; RR = 1.8, P = .003 at 24 months) predicted long-term opioid continuation. Among participants not using opioids at baseline, incident use was reported by 8% at 12 months and 7% at 24 months. We found no significant predictors of incident use at 12 or 24 months in the main models. In conclu- sion, nonsurgical treatment and smoking independently predicted long-term continued opioid use. To our knowledge, this is the first longitudinal study to assess predictors of long-term and incident opioid use among patients with lumbar spine conditions. Perspective: This longitudinal study of patients with disc herniation or spinal stenosis found that nonsurgical treatment and smoking predicted long-term self-reported opioid use. The greater risk of opioid continuation with nonsurgical therapy may be helpful in decision-making about treatment. The relationship between opioid use, smoking, and other substance use deserves further study.

Background. Although previous research suggests women report more severe pain than men, evidence for sex-related differences in pain-related disability is conflicting. Also, the impact of psychological factors on sex differences in disability is uncertain. Objective. The purpose of this study is to assess sex differences in pain-related disability and evaluate whether they are accounted for by psychological factors. Methods. Analysis of baseline data from the Stepped Care for Affective disorders and Musculoskeletal Pain study. Participants included 241 male and 249 female primary care patients with moderately severe persistent pain of the back, hip, or knee. Multivariable log-linear models were used to determine the association between sex and pain-related disability and whether sex differences persisted after adjustment for psychiatric comorbidity and potential psychological mediators. Results. Compared with men, women reported worse pain intensity, greater pain-related interference with function, and more disability days due to pain. They also had worse depression, anxiety, and self-efficacy. Sex differences in pain interference with function and pain disability days remained significant in multivariable models. Depression, poor self-efficacy, and fear of reinjury were independently associated with disability in both men and women. Conclusions. Women report greater pain-related disability than do men, even after controlling for depression, anxiety, and other psychological factors. Pain management strategies that target functional disability may be particularly important in the treatment of women with pain.

we sought to describe gender differences in medical and mental health conditions and health care utilization among veterans who used Veterans Health Administration (VA) services in the first year after combat in Iraq and Afghanistan.this is an observational study, using VA administrative and clinical data bases, of 163,812 Operation Enduring Freedom/Operation Iraqi Freedom veterans who had enrolled in VA and who had at least one visit within 1 year of last deployment.female veterans were slightly younger (mean age, 30 years vs. 32 for men; p.0001), twice as likely to be African American (30% vs. 15%; p.0001), and less likely to be married (32% vs. 49%; p.0001). Women had more visits to primary care (2.6 vs. 2.0; p.001) and mental health (4.0 vs. 3.6; p.001) clinics and higher use of community care outside the VA (14% vs. 10%; p.001). After adjustment for significant demographic differences, women were more likely to have musculoskeletal and skin disorders, mild depression, major depression, and adjustment disorders, whereas men were more likely to have ear disorders and posttraumatic stress disorder. Thirteen percent of women sought care for gynecologic examination, 10% for contraceptive counseling, and 7% for menstrual disorders.female veterans had similar rates of physical conditions, but higher rates of some mental health disorders and additionally, used the VA for reproductive health needs. They also had slightly greater rates of health care service use. These findings highlight the complexity of female Veteran health care and support the development of enhanced comprehensive women's health services within the VA.

BACKGROUND Inadequate pain assessment is a barrier to appropriate pain management, but single-item “pain screening” provides limited information about chronic pain. Multidimensional pain measures such as the Brief Pain Inventory (BPI) are widely used in pain specialty and research settings, but are impractical for primary care. A brief and straightforward multidimensional pain measure could potentially improve initial assessment and follow-up of chronic pain in primary care. OBJECTIVES To develop an ultra-brief pain measure derived from the BPI. DESIGN Development of a shortened three-item pain measure and initial assessment of its reliability, validity, and responsiveness. PARTICIPANTS We used data from 1) a longitudinal study of 500 primary care patients with chronic pain and 2) a cross-sectional study of 646 veterans recruited from ambulatory care. RESULTS Selected items assess average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G). Reliability of the three-item scale (PEG) was α = 0.73 and 0.89 in the two study samples. Overall, construct validity of the PEG was good for various pain-specific measures ( = 0.60–0.89 in Study 1 and = 0.77–0.95 in Study 2), and comparable to that of the BPI. The PEG was sensitive to change and differentiated between patients with and without pain improvement at 6 months. DISCUSSION We provide strong initial evidence for reliability, construct validity, and responsiveness of the PEG among primary care and other ambulatory clinic patients. The PEG may be a practical and useful tool to improve assessment and monitoring of chronic pain in primary care.

Objective The objective of this study was to determine if psychosocial stress and anxiety were associated with depression severity in primary care patients with chronic musculoskeletal pain. Methods A cross-sectional sample of 500 primary care patients with musculoskeletal pain (250 with depression and 250 without depression) was assessed for anxiety, psychosocial stress, depression severity and demographics. The depressed and nondepressed participants were compared using t test and χ2 analyses. Multiple linear regression analyses were used to evaluate the respective associations of psychosocial stressors and anxiety with depression severity based on the 20-item Symptoms Check List across all 500 participants. Results Compared with nondepressed patients, the depressed patients reported significantly more psychosocial stressors and more severe anxiety. Depressed patients reported a higher frequency of difficulties with every psychosocial stressor assessed. After controlling for covariates, both anxiety and psychosocial stressors were found to be associated with depression severity. Conclusions Both anxiety and psychosocial stress should be considered in the assessment and treatment of patients with musculoskeletal pain and depression. Psychosocial stressors among patients with pain may have an impact on depression beyond that of anxiety. Tailored, integrated treatments that target the psychosocial needs of patients with pain and depression are needed. In addition to pharmacotherapy, psychotherapy and other behavioral treatments may be especially important for depression complicated by anxiety or psychosocial stress.

Objectives Chronic pain is one of the most prevalent, costly and disabling conditions in both clinical practice and the workplace, yet often remains inadequately treated. Moreover, chronic pain commonly co-occurs with depression, anxiety and somatoform disorders, and adversely affects response of these conditions to psychiatric treatments. This article provides an evidence-based approach to the pharmacotherapy of chronic pain. Methods This narrative review is derived largely from meta-analyses and systematic reviews published since 2005. For a few medications, findings from multiple recent trials are synthesized if a systematic review had not yet been published. Classes of medications are first reviewed, followed by an overview of four common pain disorders: neuropathic pain, low back pain, fibromyalgia and osteoarthritis. Results A stepped care approach based upon existing evidence includes (1) simple analgesics (acetaminophen or nonsteroidal anti-inflammatory drugs); (2) tricyclic antidepressants (if neuropathic, back or fibromyalgia pain) or tramadol; (3) gabapentin, duloxetine or pregabalin if neuropathic pain; (4) cyclobenzaprine, pregabalin, duloxetine, or milnacipran for fibromyalgia; (5) topical analgesics (capsaicin, lidocaine, salicylates) if localized neuropathic or arthritic pain; and (6) opioids. Disease-specific recommendations for neuropathic, low back, fibromyalgia and osteoarthritis pain are reviewed. Conclusions A number of medications have proven effective in chronic pain disorders and their use individually or in combination should improve the management of chronic pain.

Background Approximately two-thirds of patients with depression experience physical pain symptoms. Coexisting pain complicates the treatment of depression and is associated with worse depression outcomes. Objective The authors reviewed the effect of newer antidepressants on pain in patients with depression. Method The authors searched systematically for trials of second-generation antidepressants that enrolled depression patients and reported pain outcomes, pooling changes on the pain visual-analog scale (VAS), using random-effects models. Results Eight trials were eligible. Pooled analysis of head-to-head trials showed no difference in VAS between duloxetine and paroxetine. Both drugs were superior to placebo. Conclusion The authors found insufficient evidence to support the choice of one second-generation antidepressant over another in patients with pain accompanying depression.

In den letzten 20 Jahren hat die Verschreibung von Opioidanalgetika bei chronischen Schmerzen in den USA fast exponentiell zugenommen. In diesem Zusammenhang werden immer haufiger Bedenken laut, dass diese Praxis Abhangigkeitserkrankungen und akzidentelle Uberdosierungen fordert. Dabei gibt es durchaus Leitlinien zur Opioidverschreibung – nur werden sie in der Primarversorgung selten angewendet. Warum das so ist, haben Erin Krebs et al. untersucht.

Background Literature on difficult doctor-patient relationships has focused on the "difficult patient." Our objective was to determine physician and practice characteristics associated with greater physician-reported frustration with patients. Methods We conducted a secondary analysis of the Physicians Worklife Survey, which surveyed a random national sample of physicians. Participants were 1391 family medicine, general internal medicine, and medicine subspecialty physicians. The survey assessed physician and practice characteristics, including stress, depression and anxiety symptoms, practice setting, work hours, case-mix, and control over administrative and clinical practice. Physicians estimated the percentage of their patients who were "generally frustrating to deal with." We categorized physicians by quartile of reported frustrating patients and compared characteristics of physicians in the top quartile to those in the other three quartiles. We used logistic regression to model physician characteristics associated with greater frustration. Results In unadjusted analyses, physicians who reported high frustration with patients were younger (p < 0.001); worked more hours per week (p = 0.041); and had more symptoms of depression, stress, and anxiety (p < 0.004 for all). In the final model, factors independently associated with high frustration included age < 40 years, work hours > 55 per week, higher stress, practice in a medicine subspeciality, and greater number of patients with psychosocial problems or substance abuse. Conclusion Personal and practice characteristics of physicians who report high frustration with patients differ from those of other physicians. Understanding factors contributing to physician frustration with patients may allow us to improve the quality of patient-physician relationships.

We report the impact of a monthly educational exercise for residents that emphasized practical skills and equipment usage rather than knowledge of advanced cardiac life support (ACLS) protocols. Residents were divided into groups of approximately four that rotated through three stations. Each station included several objectives, most of which related to specific types of equipment. The exercise was held six times from July 2003 to June of 2004. Sixty-seven residents participated and completed a questionnaire prior to and following the exercise. The questionnaire elicited comfort level with basic tasks including using an automated external defibrillator (AED), attaching leads and paddles to read a cardiac rhythm, delivering unsynchronized shocks with monophasic and biphasic defibrillators and imple- menting the pacing function on a defibrillator. There were significant differences in the pre- and post-answers to each question. The largest difference was found in the question asking how comfortable participants were delivering unsynchronized shocks with a defibrillator. Importantly, responses for the question 'How comfortable are you being a code leader?' showed significant improvement. Simple skills such as attaching tubing to the oxygen tank, turning on the defibrillator and entering appropriate charge, or positioning paddles and monitor leads properly often caused significant difficulty. Cardiopulmonary arrests tend to generate anxiety among house staff, despite certification in ACLS and adequate knowledge of protocols. Exercises, such as the one presented here, will reduce anxiety by specifically addressing this skill. We conclude that residents benefit from additional teaching and practice in actual performance of basic skills used during cardiac arrests. Furthermore, our data demonstrate that comfort levels among house officers increase when they are given the opportunity to practice these skills.

OBJECTIVE: To assess the efficacy and tolerability of phytoestrogens for treatment of menopausal symptoms. DATA SOURCES: We searched the Cochrane Library and MEDLINE from 1966 to March 2004, using a detailed list of terms related to phytoestrogens and menopausal symptoms and also hand-searched abstracts from relevant meetings. METHODS OF STUDY SELECTION: Randomized trials were eligible if they involved symptomatic perimenopausal or postmenopausal women, compared phytoestrogen with placebo or control, reported hot flush frequency or menopausal symptom scores, and were at least 4 weeks in duration. TABULATION, INTEGRATION, AND RESULTS: Data were extracted onto standardized forms using a prospectively developed protocol. Twenty-five trials involving 2,348 participants met criteria. At baseline, the mean age was 53.1 years, mean duration of menopause was 4.3 years, and mean daily hot flush frequency was 7.1. Mean study duration was 17 weeks. Trials were grouped into categories according to type of phytoestrogen: soy foods, beverages, or powders (n = 11); soy extracts (n = 9); and red clover extracts (n = 5). Of the 8 soy food trials reporting hot flush frequency outcomes, 7 were negative. Five trials of soy foods provided information to calculate effect sizes; these were in the small-to-medium range, favoring placebo in 3 trials and soy in 2. Of the 5 soy extract trials reporting hot flush frequency, 3 (including the 2 largest trials) were negative. Effect sizes were calculated for 2 soy extract trials: one favored placebo with small effect size and the other favored soy with moderate effect size. Red clover trials showed no improvement in hot flush frequency (weighted mean difference -0.60, 95% confidence interval -1.71 to 0.51). Adverse effects were primarily gastrointestinal and taste intolerance in the soy food and beverage trials. CONCLUSION: The available evidence suggests that phytoestrogens available as soy foods, soy extracts, and red clover extracts do not improve hot flushes or other menopausal symptoms.

Explicit cross-cultural learning experiences in medical education are provided within the context of implicit experiences provided by a greater "hidden curriculum." The authors conducted a content analysis of 983 cases presented in the 1996-1998 year one and year two curriculum at the University of Minnesota Medical School to determine in what ways they might embody elements of the hidden curriculum, i.e., how they either supported or undermined explicit messages about diverse patient populations. Cases were coded for demographic variables, potential risk factors, and diagnoses or presenting problems. The findings revealed that cases featuring males out-numbered those featuring females; this ratio differed across courses, and appeared to differ from the actual epidemiology of the conditions. Sexual orientation was specified infrequently. When sexual orientation and behavior were specified, these appeared in the context of a risk assessment for particular diseases (e.g., HIV infection). Most cases did not provide racial or ethnic descriptions. For many of the ethnic descriptors, links to genetic, cultural, or socioeconomic factors were apparent; no such link was apparent when the racial terms "white" or "Caucasian" were used. Analysis of the 983 cases shows that the pattern of demographics and associations of particular groups with diseases or risk factors in cases conveys messages, as does the lack of mention of sexual orientation and race or ethnicity. These messages are inconsistent with and may undermine the formal multicultural medical curriculum. The results suggest a need for formal deliberation of this aspect of the curriculum by curriculum planners.

Importance Chronic musculoskeletal pain is among the most prevalent, costly, and disabling medical disorders. However, few clinical trials have examined interventions to improve chronic pain in primary care. Objective To determine the effectiveness of a telecare intervention for chronic pain. Design, Setting, and Participants The Stepped Care to Optimize Pain Care Effectiveness (SCOPE) study was a randomized trial comparing a telephone-delivered collaborative care management intervention vs usual care in 250 patients with chronic (≥3 months) musculoskeletal pain of at least moderate intensity (Brief Pain Inventory [BPI] score ≥5). Patients were enrolled from 5 primary care clinics in a single Veterans Affairs medical center from June 2010 through May 2012, with 12-month follow-up completed by June 2013. Interventions Patients were randomized either to an intervention group (n = 124) or to a usual care group whose members received all pain care as usual from their primary care physicians (n = 126). The intervention group received 12 months of telecare management that coupled automated symptom monitoring with an algorithm-guided stepped care approach to optimizing analgesics. Main Outcomes and Measures Primary outcome was the BPI total score, which ranges from 0 (“no pain”) to 10 (“pain as bad as you can imagine”) and for which a 1-point change is considered clinically important. Secondary pain outcomes included BPI interference and severity, global pain improvement, treatment satisfaction, and use of opioids and other analgesics. Results Overall, mean (SD) baseline BPI scores in the intervention and control groups were 5.31 (1.81) and 5.12 (1.80), respectively. Compared with usual care, the intervention group had a 1.02-point lower (95% CI, −1.58 to −0.47) BPI score at 12 months (3.57 vs 4.59). Patients in the intervention group were nearly twice as likely to report at least a 30% improvement in their pain score by 12 months (51.7% vs 27.1%; relative risk, 1.9 [95% CI, 1.4 to 2.7]), with a number needed to treat of 4.1 (95% CI, 3.0 to 6.4) for a 30% improvement. Secondary pain outcomes also improved. Few patients in either group required opioid initiation or dose escalation. Conclusions and Relevance Telecare collaborative management increased the proportion of primary care patients with improved chronic musculoskeletal pain. This was accomplished by optimizing nonopioid analgesic medications using a stepped care algorithm and monitoring. Trial Registration clinicaltrials.gov Identifier:NCT00926588

Sense of Coherence (SOC) is a measure of an individual’s capacity to use various coping mechanisms and resources when faced with a stressor. Chronic pain is one of the most prevalent and disabling conditions in clinical practice. This study examines the extent to which a strong SOC is associated with less pain and better health related quality of life (HRQoL) among patients with chronic pain. We analyzed data from the Stepped Care to Optimize Pain care Effectiveness (SCOPE) trial which enrolled 250 patients with persistent (3 months or longer) musculoskeletal pain who were receiving care in an United States Department of Veterans Affairs (VA) primary care clinic. The abbreviated three-item SOC scale was used to measure personal coping capability. Participants were categorized into Strong SOC (score 0–1) and Weak SOC (score 2–6). The Brief Pain Inventory (BPI) was used to assess the severity and disability associated with pain. Additionally, pain self-efficacy (ASES) and catastrophizing (CSQ) were assessed. HRQoL was assessed with the 36-item Short-Form Health Survey (SF-36) social functioning, vitality, and general health subscales. Multiple linear regression models were performed to examine whether SOC was independently associated with pain-specific and HRQoL outcomes, after adjusting for sociodemographic and socioeconomic characteristics, medical comorbidities and major depression. Of the 250 study patients, 61% had a strong SOC whereas 39% had a weak SOC. Multivariable linear regression analysis showed that a strong SOC was significantly associated with better general health, vitality, social functioning and pain self-efficacy as well as less pain catastrophizing. These significant findings were partially attenuated, but remained statistically significant, after controlling for major depression. SOC was not significantly associated with pain severity or pain disability. A strong SOC is associated with better HRQoL and self-efficacy as well as less catastrophizing in patients with chronic pain. SOC may be an important coping mechanism (strategy) for patients with chronic musculoskeletal pain. Clinicaltrials.gov Identifier: NCT00926588 .

[This corrects the article DOI: 10.1017/cts.2024.351.]., (© The Author(s) 2024.)