Hypotheses
Hi: Physicians
and their RA patients usually agree when evaluating the patients’ pain.
The analysis
disclosed that, consistent with the literature, there does exist a difference in pain perception by some RA patients. The
patients responded in three classifications:
1) Those evaluating their pain as attending physician ratings
2) Those evaluating their pain at as did the attending
physicians
3) Those evaluating their pain as attending physician ratings Consequently, this null hypothesis is rejected.
LESS than the the
SAME level WORSE than the
ff2: Physicians
base their perceptions of RA patient pain on the basis of clinical measures of disease severity, such as physical structural
damage.
The analysis
shows that the physician ratings between observed RA structural damage and their ratings of disease activity had a substantial
gamma of +.9l538. In asking the physicians the subjective question of the amount of pain the patient felt, based upon the
structural damage, Table 4 shows gamma of .73382, still a substantial rating. This suggests that physicians are likely to
rank the patients’ disease and pain as an objective measurement in their diagnosis, based largely upon measurements
of the actual RA structural damage.
Consequently,
this hypothesis is not rejected.
ff3: RA
patients include subjective information in evaluations of their own pain. The physician evaluations of patient pain, based upon structure damage, show a gamma of .73382. The
patients’ own pain evaluations, based upon structure damage, show a gamma of .30275. The disparity is substantial between
evaluations of the patients and the physicians. The new variable, evaluation groups, was created to find the link between
Hypothesis 3 and 4.
Consequently,
this hypothesis is not rejected at this level, though the exact nature of the subjectivity of the patient is not revealed.
ff4: When
physician and patient disagree on pain evaluations, psychosocial factors of depression will influence this differential evaluation.
Depression
(SDS Index) measurements found in this study are consistent with the hypothesis that higher depression scores result in differences
in patients’ pain evaluation, using the physician evaluations as a baseline. Both patient groups which did not agree
with the physician evaluation exhibited higher depression scores than did the group reporting agreement with the physician
evaluations.
Consequently,
since some variation was found among the evaluation groups based on depression, this hypothesis is not rejected at this level.
ff5: Increased
depression experienced by patients lessens their objectivity in evaluation of their own pain. This can be measured by an increased
disparity between physician ratings of pain and patient ratings of pain.
ANOVA
did not bear out the significance of this measure. However, the study findings disclosed that those patients who reported
having MORE pain than their physicians evaluated were more likely to be younger patients who have suffered the illness for
a shorter time and have had less damage to the affected joints with recent changes less likely to have occurred. They have
an elevated level of depression, when compared to the “agree” group, and are more represented by the male gender.
The study
findings further disclosed that patients reporting LESS pain than their attending physicians evaluated were more likely to
be older patients who have suffered the illness for a longer period of time. They have had more damage to the affected joints
with recent changes more likely to have occurred. They exhibit the highest level of depression of all three groups and are
more represented by the female gender.
Patients
reporting the SAME evaluation as their attending physicians were found to be in between the other two classifications with
regard to age, illness duration, gender, depression levels, and structural damage as well as recent changes in their RA condition.
Although these patients fall in between the two other classifications in the findings, they are closer in the measurements
to the classification of “feels LESS pain than doctor reports” group.
Consequently,
this hypothesis is rejected due to the failure of ANOVA findings of statistical significance.
The findings
of this study address each of the hypotheses. In testing each hypothesis, the conclusions from this study are:
ff1: Physicians
and their RA patients usually agree when evaluating the patients’ pain. This null hypothesis is rejected.
ff2: Physicians
base their perception of RA patient pain on
the basis of clinical measures of disease severity, such as physical structural damage. This hypothesis is not rejected.
ff3: RA
patients include subjective information into evaluations of their own pain. This hypothesis is not rej ected.
ff4: When
physician and patient disagree on pain evaluations, psychosocial factors of depression will influence this differential evaluation.
This hypothesis is not rejected.
ff5: Increased
depression experienced by patients lessens their objectivity in evaluation of their own pain. This can be measured by an increased
disparity between physician ratings of pain and patient ratings of pain. This hypothesis is rejected due to the insignificance
of the ANOVA test.
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page------------------------------
CHAPTER 5
DISCUSSION AND CONCLUSIONS
Introduction
This study
examined reports of attending physician estimations of patient pain contrasted with that of patient self-reports of pain.
Measurements were employed to find the difference, if any, that resulted from alterations in patient subjectivity. Those alterations
were hypothesized to be the result of patient psychosocial factors, specifically depression, even when severity of the disease
was controlled for.
A sample
of 108 patients being treated at the University of Utah Medical Center Out-patient Arthritis Clinic in 1970 form the case
group used in this study. The case sample demographically form a fairly representative group of the sample community, Salt
Lake City, Utah. Questionnaires completed by attending physicians were also used to contrast pain evaluations and establish
the PA disease severity base for each patient.
Hypotheses
ff1: Physicians
and their RA patients usually agree when evaluating the patients’ pain. This null hypothesis is rejected.
The results
of this study indicate patients responded in three
classifications:
1) Those evaluating their pain as LESS than
the attending physician ratings (40.7% of the sample).
2)
Those evaluating their pain at the SAME level as did attending physicians (20.3% of the sample).
3)
Those evaluating their pain as WORSE than the attending physician ratings (38.9% of the sample).
ff2: Physicians base their perception of RA patient pain on the basis of clinical measures
of disease severity, such as physical structural damage. This hypothesis is not rejected.
Physician
evaluations of the pain the patients felt, based upon the structural damage, showed a very strong gamma of .73382. This suggests
that physicians are likely to rank the patient pain largely as an objective measurement of their diagnosis of RA structural
damage.
ff3: RA
patients include subjective information in evaluations of their own pain. This hypothesis is not rejected.
The patients’
own pain evaluations, based upon structure damage, show a gamma of .30275. The disparity between the evaluations of the patients
and the physicians is substantial. The subjectivity of pain is suggested in the literature review and shown in the later hypotheses.
ff4: When
physician and patient disagree on pain evaluations, psychosocial factors of depression will influence this differential evaluation. This hypothesis is not rejected.
Depression
(SDS Index) measurements found in this study are consistent with the hypothesis that higher depression scores result in differences
in patient pain evaluation, using the physician evaluations as a baseline. Both patient groups who did not agree with the
physician evaluations exhibited higher depression scores than did the group reporting agreement with the physicians’
evaluations.
ff5: Increased
depression experienced by patients lessens their objectivity in evaluation of their own pain. This can be measured by an increased
disparity between physician ratings of pain and patient ratings of pain. This hypothesis is rejected.
The ANOVA
did not show this to be of significance. However, the study findings disclosed that those patients who reported having MORE
pain than the physicians evaluated have an elevated level of depression, when compared to the group who agreed with the physician
evaluations.
The study
findings further disclosed that patients reporting LESS pain than the physicians evaluated exhibited the highest level of
depression of all groups.
These
findings show that depression did alter the patient pain evaluations, but not to the degree of statistical significance. The alterations were manifest in both directions from the baseline
of the physician evaluations; some felt LESS pain than the doctors estimated they would, and others felt MORE pain.
Limitations
Data used
in this study were already existent and, as such, are subject to misinterpretation at this later date. Generalizations to
other groups of RA sufferers should not be made, as members of this group were all enrolled at a specific clinic for treatment
of their RA. Confounds may exist due to the nature of the specific clinic, including its geographical location or proximity
to the RA population as a whole.
This study
also does not address any differences that may exist between case and control groups. The use of self-reports of patients
concerning their health status has been involved in controversy as to its validity (Rutler, Burkhauser, Mitchell & Pincus,
1987; Starker, 1986; Wan, 1976; Ware, 1976)
Research Recommended
The study
findings also document the need for further empirical studies of this important problem. Examples of the kinds of studies
which may be conducted to add to the theoretical and clinical insights obtained in this study are:
1) What
do these differences mean with respect to important medical outcomes, such as:
a) patient compliance to physician orders
b) progressive disease activity
c) patient satisfaction with the physician
2) To
test the influence of psychosocial factors on the disease course of RA, a longitudinal study with biological measurements
(such as the testing of immune efficiency) would be required.
3) Other
variables should be employed to study the psychosocial effects on patients with RA. These may include other control variables
(such as the age in which a person becomes symptomatic) or variables used to measure personality traits which may affect patient
health evaluations.
4) Since
this study was done at a specific clinic, it is recommended that other locations be studied and community controls considered.
Although this study sample seemed to be representative of the national statistics (Arthritis Foundation, 1982), much of the
prior research found on this subject in the literature most often was conducted in the same geographic area (Smith, Peck,
Milano, & Ward, 1988).
Implications
In conclusion,
this study disclosed that patient definitions of their pain experience often differ from that of their attending physician. These patients exhibit increased levels of depression.
Even though these findings are not statistically significant, they suggest the need for more research on this topic and the
need for medical providers to assess the impact of these differential evaluations.
All patient
health evaluation should be considered by the physician in treatment. Understanding such factors “...may lead to effective
behavioral interventions as adjuncts to the traditional medical care of RA patients” (Smith, Peck, Milano, & Ward,
1988).
The information
considered in this study can enable RA attending physicians to enhance their practices through recognition of the possible
effects of depression on patient pain perceptions.
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page---------------------------------
APPENDIX
THE PATIENT QUESTIONNAIRE (1970)
I.
Descriptive Information
1. Sex:
Male Female
2. Race: White
Negro
Other (specify) ______
3.
How old were you on your last birthday?
4. Circle the last grade of school that you have finished. Also rank for spouse.
Spouse
No schooling
________
Grades
12345678
High
School
1 2 3 4
College
1 2 3 4
Other Schooling
(number of years)
Business
_________ (years)
College, Post graduate
________ (years)
Trade
________ (years)
Other
________ (years)
5. What was the last grade of school completed by your father?______________. Your mother?__________________
6. Where more of life was spent: rural area____
towns under 5,000
larger towns______
7. Where born: rural area larger town
town under 5,000
8. To which of the following groups can you trace you identity as an American citizen? (Check one or more)
Spanish _____
Indian _____
Negro
_____
Jewish _____
Irish
____
Oriental_____
English _____
Scottish _____
Finnish _____
French ______
German ______
Scandinavian______
Greek
Polish
Puss ian
Italian
Hungarian
Other
A. Deprivation Scale
2. What is your annual income?
A. Your Family
9. Which
of the following applies to you?
Married and living with husband or wife
_____
Married but separated
_____
Divorced
______
Widow or widower
_____
How many years ago were you widowed2
______
Single
_____
10.
With whom are you living?
With husband or wife
With children alone.
With parents . .
With relatives .
With friends . .
Others
(who?). .
Alone
B. Employment History
18.
Are you working now?
Yes _____ (full-time) Yes _____
(part’—time)
No_____
C. Your Religion
20. What is your religion?
Roman
Catholic
_____
Greek Orthodox
_____
Jewish
_____
Protestant (Denomination)
Latter-day
Saint
_____
Other (specify)
_____
SELF-RATING DEPRESSION SCALE
1. I feel downhearted and blue: *
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
2. Morning is when I feel the best:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the
time
3. I have crying spells or feel like it: *
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
4. I have trouble sleeping at night: *
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
5. I eat as much
as I used to:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the
time
6. I still enjoy sex:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the
time
7. I notice that I am losing weight:
1. A little of the time
2. Some of the time
3. Good part of the time
4. Most of the time
8. I have trouble with constipation:
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
9. My heart beats faster than usual:
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
10. I get tired for no reason:
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4.
Most of the time
11. My mind is
as clear as it used to be:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the time
12. I find it easy to do the things
I used to: *
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the time
13. I am restless and can’t keep still:
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4.
Most of the time
14. I feel hopeful about the future:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the time
15. I am more
irritable than usual: *
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
16. I find it easy to make decisions:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
___
4.
A little of the time
17. I feel that I am useful and needed:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the time
18. My life is
pretty full:
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the time
19. I feel that others would be better off if I were dead:
____
1.
A little of the time
____
2.
Some of the time
____
3.
Good part of the time
____
4. Most of the time
20. I still enjoy
the things I used to do: *
____
1.
Most of the time
____
2.
Good part of the time
____
3.
Some of the time
____
4. A little of the
time
XVI. Questions concerning
your arthritis:
D. Duration of disease
1. How long have
you had arthritis?
XIX. Arthritis Data
2. How much pain do you experience in the treatment of
your arthritis?
____
1. Very much ___
2. Much ___ 3.
Some ____ 4. Little ____ 5. Very little
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page------------------
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