As one of his faculty colleagues put it, Adam Swenson feels your pain, philosophically speaking.
A professor of philosophy at California State University, Northridge, Swenson has devoted more than a decade of research, and a doctoral dissertation, to philosophical and ethical issues surrounding pain and its treatment. In 2013, he formed an interdisciplinary collaboration with researchers at the University of Southern California (USC) Pain Center to explore those issues.
Swenson and his colleagues studied how the physician’s impressions of their pain patients can affect decisions to prescribe powerful opioid medications — or not. They have submitted their findings to a leading scientific journal.
“There are no fully objective measures [for pain],” said Swenson. “With a heart condition, you can take an EKG reading, but there’s not much like that with pain conditions. At some point, the clinician has to make an assessment about how much pain a patient is in. And that’s going to depend largely on what they tell you.
“While [the field of] pain medicine is increasingly interdisciplinary, treatments for people with extreme pain will often involve powerful narcotics or certification for disability,” he said of chronic pain conditions such as severe migraines, post-traumatic injury pain and neuropathic diseases. “So, at the end of the day, the clinician has to decide whether to write a prescription for oxycodone or fentanyl based largely on whether they trust the patient, a stranger, to be telling the truth.
“On top of that, [patients have] an incentive to malinger or lie, in order to get powerful narcotics or disability certification,” Swenson continued. “But when we looked into the research on this, there was a lot about what affects the patient’s trust in their physician — but very little about the physician trusting [his or her] patients.”
Swenson collaborated with Dr. Steven Richeimer, director of the USC Pain Center; Faye Weinstein, director of pain management psychology for the center; and Doerte Junghaenel, a behavioral scientist at the USC Dornsife Center for Economic and Social Research. The group used as their foundation a survey conducted for the National Academies Institute of Medicine’s groundbreaking 2011 report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research.”
They obtained a copy of about 5,000 responses to the survey, which included long narratives from Americans living with chronic pain conditions. With Swenson’s computer programming skills, the team organized and processed the narratives to identify those they could use to explore responses to the ways pain patients present their own stories. They then built their own online survey and advertised it among pain patient groups and physicians in 2015. They received nearly 1,000 responses.
Their survey asked respondents to assess the trustworthiness of selected narratives’ authors, as well as their perceptions of the author’s personality and whether they seemed, for example, likable, histrionic, appreciative (of the doctor), depressed or stoic.
“I built a web app, which let us randomize the order of the questions and narratives so that we could probe how perceptions of personality relate to judgments of medically relevant trustworthiness,” he said. “For example, one of our hypotheses was that whether someone comes across as stoic or histrionic would affect whether they were trusted to follow the physician’s instructions.”
They found that patients who came across as dramatic correlated very strongly with not seeming trustworthy, he said.
“If you seem stoic, you seem more trustworthy about pain,” Swenson said. “We also asked about likability, and we found that [a patient’s likability] also correlates really strongly with trustworthiness.”
In the study, patients who seemed depressed also were deemed more untrustworthy by clinicians and non-medical personnel. It’s a Catch-22 for some patients in pain: “The more upbeat a pain patient seems, and not complaining, the more likely [the physician is] to trust them,” Swenson said.
He noted that patient advocate groups provide tips on how to be a “good patient,” such as bringing health records, asking questions and not treating the doctor as the enemy.
Physicians must be more aware of biases in their own treatment decisions, Swenson said.
“Our results suggest that clinicians should be cognizant of, for example, the role the patient’s tendency to be dramatic may be playing in their decision-making,” he said. “They may need to slow down and ask themselves: ‘This person strikes me as a complainer. Am I sure that’s not making me discount what they’re telling me?’
“We all rightly have a lot of respect for doctors — we see them as practical scientists,” he continued. “We trust them with our lives, quite literally. When I talk about this with people sometimes, they’re just [shocked] by the idea that your doctor might not trust you. But doctors are human beings, too.”
The team’s findings emerged under the cloud of the country’s pervasive opioid epidemic. When Swenson first started studying pain in 2003 as a doctoral student, he said, years of under-treatment of pain had finally given way to doctors being told, “Trust your patient and prescribe accordingly.” Now, the opioid epidemic is killing so many Americans that it’s pervasive across age groups.
“We need to figure out how to help doctors strike the right balance [in prescribing],” Swenson said. “[Learning] what affects trust in patients will help.”
“There’s something about pain that makes it particularly inscrutable,” he said. “Elaine Scarry, who wrote the book, ‘The Body in Pain,’ has this great line: ‘To feel pain is to know, but to hear of pain is to doubt.’ At some level, we just don’t want to believe that it could suck that much. We’re naturally skeptical, because you can’t see inside anyone else’s head. But in the case of pain, you don’t want to.”