Problems of Quality and Equity in Pain Management: Exploring the Role of Biomedical Culture

Authors

  • Megan Crowley-Matoka PhD,

    Corresponding author
    1. Assistant Professor of Medicine and Anthropology, University of Pittsburgh and Research Scientist, Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania;
    Search for more papers by this author
  • Somnath Saha MD, MPH,

    1. Associate Professor of Medicine, Oregon Health and Science University and Staff Physician, Portland VA Medical Center, Portland, Oregon;
    Search for more papers by this author
  • Steven K. Dobscha MD,

    1. Associate Professor of Psychiatry, Oregon Health and Science University and Staff Psychiatrist, Portland VA Medical Center, Portland, Oregon;
    Search for more papers by this author
  • Diana J. Burgess PhD

    1. Assistant Professor of Medicine, University of Minnesota, and Research Scientist, Center for Chronic Disease Outcomes Research, Minneapolis Veterans Affairs Medical Center, Minneapolis, Minnesota, USA
    Search for more papers by this author

Megan Crowley-Matoka, PhD, Center Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System (646), 7180 Highland Drive (151C-H), Pittsburgh, PA 15206, USA. Tel: 412-365-4463; Fax: 412-954-5264; E-mail: Megan.Matoka@med.va.gov.

ABSTRACT

Objectives.  To explore how social scientific analyses of the culture of biomedicine may contribute to advancing our understanding of ongoing issues of quality and equity in pain management.

Design.  Drawing upon the rich body of social scientific literature on the culture of biomedicine, we identify key features of biomedical culture with particular salience for pain management. We then examine how these cultural features of biomedicine may shape key phases of the pain management process in ways that have implications not just for quality, but for equity in pain management as well.

Setting and Patients.  We bring together a range of literatures in developing our analysis, including literatures on the culture of biomedicine, pain management and health care disparities.

Measures.  We surveyed the relevant literatures to identify and inter-relate key features of biomedical culture, key phases of the pain management process, and key dimensions of identified problems with suboptimal and inequitable treatment of pain.

Results.  We identified three key features of biomedical culture with critical implications for pain management: 1) mind-body dualism; 2) a focus on disease vs illness; and 3) a bias toward cure vs care. Each of these cultural features play a role in the key phases of pain management, specifically pain-related communication, assessment and treatment decision-making, in ways that may hinder successful treatment of pain in general—and of pain patients from disadvantaged groups in particular.

Conclusions.  Deepening our understanding of the role of biomedical culture in pain management has implications for education, policy and research as part of ongoing efforts to ameliorate problems in both quality and equity in managing pain. In particular, we suggest that building upon the existing the cultural competence movement in medicine to include fostering a deeper understanding of biomedical culture and its impact on physicians may be useful. From a policy perspective, we identify pain management as an area where the need for a shift to a more biopsychosocial model of health care is particularly pressing, and suggest prioritization of inter-disciplinary, multimodal approaches to pain as one key strategy in realizing this shift. Finally, in terms of research, we identify the need for empirical research to assess aspects of biomedical culture that may influence physician's attitudes and behaviors related to pain management, as well as to explore how these cultural values and their effects may vary across different settings within the practice of medicine.

Introduction

Pain management is a persistent and pervasive problem in American medical practice. Myriad reports and guidelines published over the past two decades call for more aggressive and effective treatment of all pain types, yet inadequate treatment of pain continues to be reported across a wide variety of treatment settings and disease types [1–6]. Further compounding shortcomings in the overall quality of pain management is mounting evidence of problems with equity, with a growing body of research documenting disparities in pain management by race/ethnicity, gender, and age in multiple settings [7–16]. Indeed, recent key reviews have found that such problems with both suboptimal and inequitable pain management are evident not only across the general health care system, but within the Veteran's Affairs (VA) Health System as well [17–20].

Such findings are particularly striking in light of numerous recent national initiatives intended to improve pain management, including treatment guidelines issued by the American Pain Society and the American Academy of Pain Medicine, and the implementation of the VA National Pain Management Strategy [21–25]. Progress related to such initiatives has been mixed—for example, although understanding of the differences between tolerance, dependence, and addiction in opioid usage seems to have improved [26], many physicians remain reluctant to prescribe opioids, or to prescribe them in adequate doses [16,26–28]. Similarly, despite widespread adoption, first by the VA and later by the Joint Commission on Accreditation of Healthcare Organizations, of the clinical standard that pain be routinely assessed as the “5th vital sign”[29–31], recent research suggests that such assessments may not necessarily improve the actual quality of pain management [32,33].

Poor outcomes in pain management are clearly shaped by the complex interaction of multiple factors at the patient, health care provider, and systems levels. For example, a patient who is reluctant to seem like a “whiner,” who goes to see a physician whose discomfort with opioids stems from fears about their addictive potential, as well as from a prohibitively onerous set of administrative requirements for prescribing them, may face multiple barriers to successful pain treatment. While recognizing the importance of these complex interactions in pain management, in this article, we focus on enriching the current framework for understanding the role of allopathic physicians in particular. Physician knowledge, attitudes, and beliefs, such as lack of knowledge about chronic pain treatment and fear of using opioid analgesics (“opiophobia”), have been widely identified as key contributors to ongoing problems in pain management [32–41]. While such specific attitudes or beliefs likely play an important role in pain management outcomes, we suggest that these individual physician-level factors may be shaped by and reflect a more general underlying issue: the culture of biomedicine itself.

In this article, we direct our attention to this culture in which all allopathic physicians in the United States are immersed. In doing so, we focus on several key features of this cultural system that have critical implications for how physicians interact with, assess, and manage patients with pain. Drawing on an understanding of culture as inherently dynamic and amenable to change over time, we suggest that a deeper examination of the culture of biomedicine may help to identify and ameliorate barriers to quality and equity in pain management. Initiating such change, however, first requires identifying the dimensions of biomedical culture that may play role in the current problems in pain management. Once identified, such cultural dimensions may thus become open to further study, debate, and intervention.

We begin by outlining the general concept of culture, seeking to expand beyond the relatively narrow uses to which this concept is most often put in American medicine today. We then develop a framework for understanding the role of biomedical culture in suboptimal pain management at a conceptual level, highlighting three key features of this cultural system with particular salience for pain management. Next, we move to ground this conceptual framework in specific areas of clinical practice, examining how these cultural features of biomedicine may shape pain-related communication, assessment, and treatment decision-making in ways that have implications for not just quality, but equity in pain management as well.

The Concept of Culture

Culture can be generally understood as a set of shared meanings, norms, and values that underlie and shape the way members of a social group understand and act in the world around them [42–46]. Operating as a taken-for-granted lens through which we interpret our experiences, these meanings, norms, and values are often tacit and largely invisible. That is, while the unfamiliar beliefs and habits of those from a different social group may stand out as part of their culture, one's own culture often remains difficult to see because it seems so “common sense” and natural. Social groups of all sorts—not only those based on nationality or ethnicity, but also on professional training and identity, for example—develop cultural systems with identifiable habits, practices, forms of language, and styles of social relationship. Understanding such features of a particular cultural system can provide critical insight into the behavior of members of that social group.

Importantly, however, culture must not be misinterpreted as a determining force in any sort of straightforward way. For one, different facets of individual identity and experience, such as gender, religion, age and sexual orientation, all shape how someone responds to the norms and values of a given culture [44–47]. Moreover, individuals typically belong to multiple social groups and so are accustomed to navigating between different cultural systems [47–50]. A Filipino-American, Catholic, gay male physician, for instance, may belong simultaneously to cultures related to each of his ethnic, religious, sexual, gendered, and professional identities, and may privilege the meanings, values, and practices relevant to each of them at different times and in different situations. Not only may any individual's relationship to a particular culture shift, but cultures themselves change over time and through interaction with other cultural systems as well [47–49]. The past several decades in American culture have seen enormous changes, for example, in a wide range of social habits and norms regarding matters as varied as the acceptability of divorce, the role of women in the workplace, and even the rights of patients to be involved in medical decision-making.

The Culture of Biomedicine

Although the general understanding of culture outlined previously is common in the social sciences, within the field of medicine, the concept of culture is most often used in a more restricted sense, primarily as a characteristic of patients that affects health behavior, adherence to treatment regimens, and acceptance of health care services. Most evident in the growing movement to promote “cultural competence” in medical practice, culture in this arena is typically regarded as something held in particular by patients from ethnic or racial minority groups, whose “cultural beliefs” providers need to understand—and often, to overcome—in order to deliver effective care [50–52]. Frequently missing from this picture is the fact that physicians are themselves far from “culture-free”[52–54].

In fact, American biomedicine as itself a cultural system has been the object of extensive study, much of which has focused on the socialization process inherent in medical training, as well as the powerful norms which underlie and shape clinical practice and medical decision-making [55–62]. Collectively, this body of research has elucidated a number of core features characteristic of the culture of American biomedicine, several which have particular relevance for pain management at a conceptual level:

  • 1) Mind–body dualism: American biomedicine tends to view the body and the mind as separate entities [57–60,63,64]. This is a separation with roots in the scientific tendency to categorize and compartmentalize, as well as to privilege that which is available to direct observation and hence “objective” over that which is unobservable and hence “subjective.” Reflecting this hierarchical division, in American biomedicine, the physical and mental domains of health are thus not only separated in clinical training, practice and research, but are prioritized differently as well. The derogatory nature of the phrase “It's all in your head,” or the ongoing struggle for “mental health parity” in American health policy serve as just two examples of this simultaneous dichotomization and prioritization of the physical over the mental. The result is that observably physical ailments tend to be regarded within biomedicine as more “real,” while problems without a convincing physical correlate are often treated as either suspicious or simply irrelevant by biomedical practitioners. Related to this preference for the objectively observable is a further tendency to treat information that can be quantified as also more “real,” and thus more important than other kinds of information.Importantly, this mind/body separation and prioritization of the observable, objectifiable, and quantifiable are highly problematic in the context of pain—particularly chronic pain [65–67]. Pain by its very nature fundamentally defies the mind–body distinction; it is simultaneously and interactively both physical and mental. Moreover, pain itself cannot be observed or measured “objectively,” and even when pain syndromes are accompanied by a physical correlate (e.g., abnormality on an imaging study), there is often poor congruence between the magnitude of the observed phenomenon and the subjective experience of pain. Hence, the inherent subjectivity of pain, coupled with its lack of adherence to mental–physical boundaries, put patients with pain at a distinct disadvantage within the rigidly anatomized framework of American biomedicine.
  • 2) Disease vs illness: The American biomedical model centers around “diseases,” manifest phenomena with discrete causes that are visible or otherwise detectable through examination of the body using physical, imaging, or laboratory methods [57–59]. Clearly related to the previously noted privileging of the observable, this notion of disease is far more limited in scope than the “illnesses” experienced by patients [66,68–71]. Patients' illnesses, in contrast, encompass not only the physical causes and manifestations of disease but also the psychosocial context in which they occur and the impact they have on patients' lives and relationships. The biomedical focus on disease tends to limit consideration of a wide range of social determinants of illness and suffering, thus decontextualizing and oversimplifying what patients actually experience. The resulting tunnel vision narrows the physician's focus to physical causes and manifestations, resulting in a strong bias favoring patients whose syndromes fit the biomedical disease model. Patients presenting with “classic” physical manifestations of disease are characterized as “great cases,” while those whose illnesses have strong psychosocial influences are thought of as “frustrating.” This decontextualization of the illness experience and emphasis on physical manifestations can also cause a disconnect between what the patient and the physician consider important and “real,” leading to dismissal of patients' concerns, conflict between physician and patient, and further frustration.Within this framework, it is not surprising, therefore, that pain—particularly chronic pain—with its often ambiguous relationship to physiological damage and well-documented relationship to life circumstances, is often regarded as “frustrating,” while pain patients are frequently characterized as “difficult”[65,72–75]. This thus becomes another way in which the biomedical model, with its focus on diseases as observable phenomena independent of psychological and social context, disadvantages the patient with pain, whose experience is integrally biopsychosocial.
  • 3) Bias toward cure vs care: With the advent of antimicrobials and technological advances in imaging and surgery, American medicine in the 20th century transformed from a discipline concerned primarily with “caring” for patients to one concerned more with “curing” diseases [76,77]. This shift has resulted in a bias favoring conditions and patients with a clinical story for which a parsimonious diagnosis can be made and for which efficacious treatments exist [58,59,78,79]. This preference for patients and illnesses that “fit” into available diagnostic and treatment options has only intensified with the increasing emphasis on classification schemes, clinical pathways and evidence-based practice in American biomedicine in recent years [79,80]. Reflected in this trend is a prioritization of not only efficacy, but efficiency as well. Physicians are under increasingly severe pressures to address the often complex and multiple care needs of their patients in brief periods of time. “Competing demands” require physicians (and their patients) to continuously prioritize their work together; making it less likely issues will be addressed that are perceived as unproductive in terms of clinical outcomes, or that require additional effort to learn about or address, or that are more uncomfortable [81].In a system that prioritizes both efficacy and efficiency, pain patients—for whom neither diagnosis nor treatment decisions may be clear cut—are all too often a poor “fit.” Chronic pain, in particular, is the source of much conflict between physicians and patients precisely because it so often defies biomedical efforts to “fix” it, while consuming considerable time, effort, and resources in the process [72–75,82,83]. Immersed in an increasingly evidence-based medical culture, physicians often feel at a loss, uncomfortable, or perhaps even vulnerable in the face of the considerable clinical uncertainty often surrounding pain management. This uncertainty derives not only from the failure of many pain syndromes to fit neatly into a clear diagnostic category, but from the ongoing doubts many physicians continue to feel regarding existing pain treatment options, despite existing clinical guideline criteria [16,26–28,84,85].

Taken together, the key pain-relevant dimensions of American biomedical culture delineated here help to move beyond the level of individual physician attitudes and beliefs by identifying some of the larger cultural forces that may underlie the pervasive problem of inadequate pain management. In the following section, we extend this general conceptual framework to examine more specifically how such cultural features of biomedicine may influence critical dimensions of clinical practice, and in so doing, may contribute not just to problems of quality in pain management, but of equity as well.

Clinical Practice, Biomedical Culture and Inequities in Pain Management

In this section, we explore how the cultural features of American biomedicine outlined previously may shape the clinical processes of communication, assessment, and management in the context of pain, and in the process, may contribute to disparities in pain management.

  • 1) Clinical communication regarding pain: The frequent failure of pain to fit with biomedicine's prioritization of mind over body, disease over illness, and cure over care, places particular pressure on communication between physician and patient. Because pain cannot be objectively tested, and is so often both psychosocially complex and resistant to a “quick fix,” successful treatment is particularly reliant on good communication. Yet for precisely these same reasons, physicians may find communicating about pain frustratingly time-consuming and difficult. Such difficulties in clinical communication regarding pain may be exacerbated for pain patients from vulnerable groups [81,86]. In clinical interactions with non-white and low-income patients, physicians have been shown to engage in communication patterns that are both less participatory and more narrowly biomedical, as well as to spend less time in the encounter [87–90]. In keeping with this, ethnographic observations of clinical encounters in the VA suggest that some physicians may “steel” themselves for conflict before a patient interaction they anticipate will be difficult, setting an initial tone for the encounter that encourages limiting both time spent and opportunities for the patient to exercise control over the interaction [36]. Notably, both patient characteristics such as race/ethnicity and the presence of a pain complaint on the patient's chart were observed to trigger this anticipation of difficulty for some physicians.To some degree, these problematic communication patterns may reflect greater social discomfort related to the social distance common between many physicians and patients from disadvantaged groups. Yet also reflected in these problematic communication patterns may be the effect of perceptions of minority patients as more likely to have complex psychosocial problems. That is, in a biomedical culture that prioritizes discrete diseases amenable to efficacious and efficient treatment, these patients may be disadvantaged from the start by disproportionate expectations that they will have precisely the kinds of problems physicians often regard with suspicion and/or impatience. Recent qualitative research with medical students, residents and attendings illustrates these kinds of expectations that minority patients are more likely to present psychosocially complex—and thus frustrating—problems. One resident, for example, observed a stereotype of African American patients as being “dreadfully sick and their social life is so disorganized that they are ‘non-compliant’ and living in a state of chaos, with a disorganized household, or that they are socially isolated. And incredibly sick and incredibly difficult to manage” (78, p. 564). When these more generalized expectations are coupled with a pain complaint, the situation may be even further complicated, given the previously discussed clinical ambiguity regarding both diagnosis and treatment of pain syndromes—as well as the physician discomfort often caused by that ambiguity. At a double disadvantage, pain patients from vulnerable groups may thus be perceived in advance as “difficult” within the culture of American biomedicine as a result of both their social characteristics and their health problems. Importantly, these are perceptions that may work to limit precisely the time and collaborative communication often required for successful pain management.
  • 2) Clinical assessment of pain: Combined with the potential effects on communication outlined previously, the culture of American biomedicine may also work to hinder successful pain assessment—and to do so particularly for patients from vulnerable groups. As described previously, the biomedical cultural value of de-emphasizing psychosocial context poses particular problems for fully understanding and addressing patients' pain experiences. Moreover, it is plausible that this preference for focusing on the strictly biological hurts members of disadvantaged groups who experience disproportionately higher levels of social stressors the most (e.g., poverty, unemployment, racism, and discrimination). Although these social stressors have been associated with greater physical and mental health burdens among disadvantaged populations [91–95], these are issues with which a biomedical model heavily focused on discrete disease, efficiency, and efficacy is ill-equipped to deal. Ultimately, when patients' illnesses are viewed as separate from their social context, physicians are more likely to mislabel problems that originate in the social and economic sphere as negative characteristics of the patients themselves. Notably, this effect is particularly critical in the context of pain, in which psychosocial factors are well known to be integrally important.In addition, there is some evidence that non-white patients are more likely to hold beliefs that are less similar to physicians' beliefs relative to white, U.S.-born patients [86,96,97]. This lack of cultural overlap, in addition to affecting patient satisfaction, has been shown to lead to lower levels of concordance between patients' and physicians' perceptions of the patient's health. In one such study, for example, health care providers were more likely to rate Native American patients as healthier than the patients rated themselves [98]. Even more strikingly, another recent study found that physicians were twice as likely to underestimate pain intensity in black patients than in all other ethnicities combined [99]. These data suggest that physicians may underestimate the pain and suffering of patients' whose cultural views differ from their own, perhaps because cultural similarity facilitates communication and mutual understanding. Thus, pain assessment in patients from disadvantaged groups may be compromised by both greater cultural distance between patients and physicians, and by the biomedical tendency to segregate psychosocial issues in the interests of both clarity and efficiency.
  • 3) Clinical management of pain: It is not surprising that the previously described conjunction of reduced encounter time, less open communication, higher levels of frustration, and poorer assessment make developing an appropriate treatment plan even more difficult in the case of pain patients from disadvantaged groups. Added to the potential “double-disadvantage” of being perceived as frustrating and “difficult” in terms of both their social characteristics and their health problems is the frequent perception among physicians that management options for pain are themselves frustrating, because of the high degree of uncertainty which continues to surround them. Although numerous clinical guidelines exist, large gaps in the evidence base remain [84,85], and many physicians are still uncomfortable with using opioid medications in particular [16,26–28,65]. Moreover, much of the evidence we do have points to multimodal treatment approaches as the most likely to succeed in managing chronic pain [100,101]. Such multimodal—and often multi-disciplinary—approaches are, as noted previously, clearly at odds with the biomedical bias toward efficiency and efficacy. They are also highly dependent on effective communication and partnering between physicians and patients, requirements that only become more challenging as gaps in understanding and identification widen between physician and patient across social and cultural distance.Further heightening the problems of uncertainty in pain management are the risks perceived to accompany many treatment options, particularly opioid medications. These include risks to the patient (dependence and/or addiction), to the physician (regulatory oversight and sanction), and to society (misdirection for illicit use) [34,39,41,102–105]. Thus physicians are often left feeling not only that it is all too easy to err in treating pain, but that the potential costs of such errors are unacceptably high. As many, including the Institute of Medicine, have noted, clinical situations in which physicians feel both uncertain and uncomfortable are particularly vulnerable to the influence of sociocultural factors such as largely unconscious biases about race/ethnicity [35,36,38,106]. And in the context of pain management, the particular fears surrounding opioids intersect powerfully with existing biases toward non-white patients, which may range from the blatant (as more likely to be drug-addicted, more likely to be involved in criminal activity, etc.) to the more subtle (as simply less easily understood, and thus less easily trusted). Hence minority pain patients once again may find themselves at double disadvantage, as suggested by current evidence regarding disparities in prescribing and availability of opioid medications to non-white patients [107–110].

Ultimately, the key features of biomedical culture outlined here can be seen to play a role throughout the clinical process surrounding pain, from communication, to assessment to management. Examining the impact of biomedical culture at each of these clinical stages not only provides insight into the general problem of quality in pain management, but also reveals a confluence of phenomena that synergistically converge to disadvantage minority and low-income patients with pain. Before the clinical encounter even begins, physicians may consciously or unconsciously anticipate a difficult or uncomfortable interaction, because of the patient's complaint (pain) and possibly because of the patient's sociocultural background (typically different from the physician's own). Physicians may gird themselves for the anticipated difficulty of the interaction by exerting more control over the agenda and looking for ways to keep the visit short. Minority and low-income patients enter the encounter with, on average, a larger burden of psychosocial stressors. Physicians, steeped in the culture of biomedicine, tend to view those stressors as characteristics of the patient that magnify complaints about the “actual” disease, rather than important aspects of the “illness” itself. They minimize the importance of social context and limit time spent discussing it. Additionally, physicians may not only be less willing to spend the time necessary to develop an effective treatment plan with patients from disadvantaged groups, but also less willing to prescribe some classes of pain medications to them (i.e., opioids). Overlying all of this is the fact that, because of sociocultural differences, physicians may relate less well to minority and low-income patients and invite less patient participation. It should not be difficult to see how these factors together form a recipe for frustration, conflict, and poor outcomes.

Implications and Future Directions

This exploration of the role of biomedical culture in problems of both quality and equity in pain management is meant to contribute to ongoing efforts to identify and ameliorate barriers to treating pain. We have focused here on the impact of biomedical culture on allopathic physicians in particular, highlighting how the key features of mind-body dualism, a focus on disease vs illness, and a bias toward cure vs care play out in how physicians communicate about, assess, and manage pain. This focus reflects the crucial role played by physicians in the pain management process, as well as the fact that it is physicians who are most deeply and directly steeped in the biomedical culture outlined here. Having spent years of their lives training and practicing within the system of biomedicine, the cultural values and norms associated with it are necessarily and deeply ingrained in most physicians.

However, physicians are clearly neither solely responsible for outcomes in pain management nor are they the only members of society influenced by the culture of biomedicine. Indeed, the scientific worldview and cultural values of biomedicine are strongly influential throughout American society, and the cultural features outlined here surely influence the pain-related experiences and expectations of non-physicians as well. Patients who adamantly reject any psychological or behavioral approaches to pain treatment out of a belief that such approaches imply that their pain is not “real,” for instance, are also operating with the hierarchical mind–body distinction characteristic of biomedical culture. Similarly, health care reimbursement policies that provide payment for nerve blocks and opioid prescriptions—but not for the additional clinic visit time that might be required to address the complex psychosocial aspects of a patient's pain syndrome—are sending a message about priorities in which the orientation toward disease rather than illness, and cure rather than care seem all too evident. Ultimately, although this article addresses the role of physicians in pain management most directly, we believe that promoting a deeper understanding of the culture of biomedicine has implications for improving pain management at the patient and systems levels as well. Below we detail some of the future directions this exploration of biomedical culture points to in terms of education and training, policy, and research.

One central implication of our analysis relates to the push for greater cultural competence among physicians. Deficiencies and disparities in pain management are often viewed as emanating, at least in part, from cultural differences between patients and physicians. The solution to this cross-cultural conflict has usually been framed in terms of physicians learning to better understand and adapt to the cultural viewpoints of patients from diverse racial, ethnic, and socioeconomic backgrounds. Clearly, this aspect of “cultural competence” is an important step toward improving patient care in general, and pain management specifically. However, our exploration of the role of biomedical culture in pain management problems suggests the need for another form of cultural competence as well; that is, for physicians to become more self-reflectively aware of the culture of biomedicine in which they themselves are immersed. To reduce the cultural distance between physicians and patients—and thereby enhance clinical communication, assessment, and management—physicians must unpack their own cultural baggage and examine its contents and the ways in which it affects their responses to and care of patients in pain.

One promising strategy for fostering this new form of competence in the culture of biomedicine could come from emerging approaches in narrative medicine and ethics [111–113]. Indeed, narrative approaches have been specifically identified as potentially useful in untangling the ambiguity of pain more generally [113], as well as in facilitating pedagogical discussions about the culture of medicine [54]. In general, narrative approaches in medicine harness the organizing logic and intuitive appeal of story-telling to produce insight about complex, often emotionally-laden experiences. Patients, for example, might be asked to write the story of their chronic illness, or medical students might be asked to tell a story about a clinical situation in which they felt ethically compromised. In either case, the process of constructing a narrative can be used to generate new understandings of the values, emotions, and power dynamics at work in those experiences. In pain management, precisely because this is so often an area of clinical practice fraught with frustration and uncertainty for many physicians, narrative approaches may be similarly useful in fostering self-reflection on how the cultural values of biomedicine may shape their responses to pain. Such strategies could be incorporated into formal medical education, and could also contribute to ongoing intervention efforts aimed at improving practicing physicians' skills and confidence in managing pain. Moreover, similar narrative strategies could potentially be adapted for use in patient education and activation efforts as well, in order to arm patients with a better understanding of how biomedical culture may influence both their own pain experiences and their pain-related interactions with physicians.

Another key implication of our analysis is the need for a cultural shift in biomedicine: a movement from the biomedical to the biopsychosocial and the accommodation of sociocultural diversity. Although calls for a biopsychosocial approach to health care more generally are not new, the negative impact of the biomedical model (as outlined here) on quality and equity in pain management, as well as the high cost and burden of pain, suggest that efforts should be made to accelerate this cultural shift in the context of pain management. Beginning steps toward such a shift have been initiated on several fronts. The shift to a biopsychosocial model is already starting to occur within the context of medical education, for example, as the tenets of patient-centered care are beginning to permeate the curriculum. This step is particularly important in light of evidence suggesting that the process of medical training reinforces negative attitudes toward chronic pain patients [114]. Given such findings, efforts to explicitly link the trend toward increased attention to pain in medical education with this growing focus on the tenets of patient-centered care and the biopsychosocial model may offer powerful synergies for strengthening pain management curricula.

At a policy level, the VHA National Pain Management Strategy offers another example of efforts to shift toward a more biopsychosocial approach to pain, through its emphasis on the provision of an interdisciplinary, multi-modal approach to pain management as one of its central goals [23,115]. Despite this important commitment to broadening approaches to pain beyond the strictly biomedical, however, progress on this goal has lagged somewhat behind achievements realized for other VA goals more easily assimilated into the culture of biomedicine. For instance, as part of the same national strategy, the implementation of the “pain as the 5th vital sign” initiative has been extraordinarily successful in terms of achieving routine pain screening across the VA system. Indeed, a recent record review showed pain screening in 97% of clinical encounters in the VA [115]—although it is important to note that it is not yet clear that successful screening translates into improved pain management outcomes [32,33]. This initiative is clearly an important step forward in making pain assessment and management a clinical priority for which healthcare providers are held responsible. It is also an initiative which fits relatively comfortably within the current culture of biomedicine: it converts the subjectivity of pain into a numerical score which can be collected, recorded and tracked with great efficiency. In contrast, the goal of promoting truly multidisciplinary, multimodal pain treatment services is clearly more at odds with the prioritization in biomedical culture of body over mind, disease over illness, and cure over care. Perhaps reflecting this greater cultural dissonance, progress on this VA goal appears to be more halting, with the availability of multidisciplinary pain services growing, but still not reaching the majority of facilities throughout the VA system [115]. Slower progress does not mean no progress, however, and as other strategic pain goals are achieved—and as evidence accumulates that problems in pain management persist despite those achievements—efforts may shift toward the harder-to-achieve task of truly broadening pain management beyond the biomedical model. In doing so, administrators and policy makers armed with a more robust understanding of the cultural values of biomedicine may be more adept at identifying—and challenging—the expression of those values in institutional barriers such as the lack of funding for integrative pain care teams, or reimbursement structures that favor performing procedures over time spent talking.

Finally, this exploration of the uneasy intersection between biomedical culture and pain has numerous implications for future research. One obvious implication is the need for empirical research to assess aspects of biomedical culture that may influence physicians' attitudes and behaviors related to pain management, as well as to assess how other factors may mediate that influence. Recent measures such as scales assessing “intolerance of clinical uncertainty,”“reliance on high technology,” and “orientation toward patients' psychological problems”[102,116] may help researchers pinpoint the aspects of biomedicine that are associated with problems in pain quality and equity and the types of settings in which these cultural values are most prevalent. In addition to seeking ways to measure the effects of biomedical culture on pain management outcomes, research into the effects on physicians themselves of this frequent clash between biomedical culture and pain also seems warranted. Physician frustration, anger and burn-out in relation to pain patients should be taken as a serious problem both for patients and for the physicians themselves, one which invites empirical research rather than simple blaming. Qualitative research methods are likely to be especially useful here, and narrative approaches in particular may offer opportunities not only for education and intervention, but for this kind of research into physician experiences with managing pain as well. Moving beyond the level of individual providers, a third key area of potential research suggested by our analysis would examine the variation in local clinical cultures around pain. Although the culture of biomedicine outlined here provides a useful general framework, there is of course considerable variation across different settings in the degree to which those cultural values are expressed, as well as in the force with which they come into conflict with managing pain. Comparative ethnographic study, for instance, of settings with very different institutional approaches to and resources for pain management might have much to teach us about potential strategies for beginning to shift the biomedical culture of pain—as well as about the implications of such shifts for the pain-related experiences of both patients and physicians in the process.

Ultimately, this exploration of the culture of biomedicine and problems of quality and equity in pain management is meant to serve as a first step toward developing more culturally attuned approaches to ongoing educational, policy and research efforts to improve the treatment of pain. Although we have focused here on the impact of biomedical culture on allopathic physicians in particular, the cultural dominance of biomedicine throughout American society suggests that this analytic approach has relevance for pain patients and pain policy makers as well. Cultures can and do change over time, in part through a deliberate ongoing, collective process of discussion, debate, and trial-and-error with new ways of doing things. As such, this article forms part of the current collective efforts, by those inside and outside the VA, to improve pain management. As they continue to steadily gain force in American medicine and society, such efforts may yet succeed in changing the biomedical culture of pain outlined here.

Disclosures

The authors have no relevant financial relationships to declare. Dr. Crowley-Matoka's work on this manuscript was supported by a VA HSR&D Merit Review award (VA IIR 05-210-01).

Ancillary