Ernesto A. Moralez Sofia Cobos -Sanchez Jared Van Netta Mary Alice Scott,

1. Adapted Integrative Health Coaching to Improve Pain Management for Hispanics Patients in Primary Care Ernesto A. Moralez Sofia Cobos-Sanchez Jared Van Netta Mary Alice Scott, Presented to the UNM Family Medicine Residency September 5, 2018

2. The problem… • There are significant racial/ethnic disparities in the treatment of individuals presenting with pain • This includes: • Increased risk of pain • Pain severity • Impact on daily activities • Additionally, disparities exist in the quality of pain management. • Hispanics and AA receive inadequate and/or ineffective care compared to non-Hispanic counterparts • Data from 13 US medical education programs reported more than 80% of residents having little to no confidence assessing pain and 30% reported using derogatory terms to describe patients with pain

3. The long-term goal of this research is to decrease the racial disparities reported in the treatment of individuals with pain by addressing the psychosocial factors that make pain care vulnerable to low prioritization (both by patient and provider) and mismanagement.

4. Specific Aims • SA1- To conduct a clinical-based communication training using an adapted form of IHC (AIHC) for medical residents to decrease provider-level psychosocial barriers that can contribute to disparities in the assessment • SA2- To compare AIHC to standard care alone in improving patient satisfaction with provider and patient knowledge about pain management strategies among Hispanic patients presenting with pain

5. AIHC • Includes strategies from IHC and Motivational Interviewing • Based on supporting the patient’s own motivations to initiate and maintain behavioral modifications • Assist the provider (and the patient) recognize and acknowledge the complex social and psychosocial factors contributing to pain management • Collaborative relationship (empathy, reflective listening) • Aligns with patient-centered care allowing behavior modification to be directed by the patient and not the provider (paternalism)

6. Approach • Eight medical residents (Y2 and 3) were randomly assigned to trained/not trained groups • 79 patients were recruited using provider lists (F/M; 18-75; reporting pain affecting daily activities) • Family Medicine Center at Memorial Medical Center (300,000 county residents) • Patient recruitment by telephone and in clinic

7. Data collected • Brief Pain Inventory (Short Form) • Level of pain currently and over the last 24 hours • Treatments • Relief from treatments (medications) • How pain interferes with general activity, mood, sleep, interactions with others, enjoyment of life • Pain Management Barriers Questionnaire • Good patients avoid talking about pain • Pain builds character • Pain medicine should be saved • Pain Stages of Change Questionnaire • Additionally, questions about perceived control, behavioral intention and attitude were asked

8. Preliminary Patient Data

9. Limitations • Sample size • Resistance to participate from patients • Subjective scoring of AIHC • Self-report • Not enough “dosage” of AIHC

10. For today’s talk… • Objective 1: Describe the value of organizing open forum discussions as part of the medical training/residency experience  • Objective 2: Identify common biases shared by medical residents towards patients presenting with pain 

11. So let’s talk about organizing open forum discussions as part of the medical training/residency experience. What do you think?

12. Resident Focus Group • The goal was to ascertain resident’s attitudes concerning and treating patients presenting with pain • Facilitated by Dr. Mary Alice Scott, Associate Professor in Anthropology and my mentor • 1.5 hours during regularly scheduled didactics

13. Focus group findings • Key themes • Addiction • Frustration • Low Expectations • Bias • Fear • Workload • Reasons for pain(pathology) • Referrals (Ambivalence about treating) • Time constraints • Negative responses

14. Sample Quotes • …sometimes the patients are on really high doses of narcotics…huge dose of narcotics, I want to cut it down. In the back of my mind, I’m like what if this patients pain is not well controlled after…(another resident) they will never come back to you (laughter). • I have a headache when I have a patient with chronic pain • The first thing I think when they have chronic pain is all the work that I’ll have to do for that patient • The first thing I think is schedule disruptor • I’m going to be honest, addiction, it’s the first thing that crosses my mind • I will try to address everything else that will help this patient, addressing the psychiatric issues, addressing the social/financial issues, besides PT, besides other non-pharmacological modalities for pain management.

15. Fear (e.g., addiction, patient attitude) • (it) starts before the visit. I look through my patients the night before. I look to see if they have a narcotics contract because most of them don’t…I look through their last PNP to see if there are any concerns…it starts the night before • I take the PNP report with me…say this is something that the state makes us check out, you’ve gotten narcotics from four different providers in the last two months, part of the contract we have you sign is that you only get them from us, can you explain what is going on, or why you feel like you need to go to these other providers. Sometimes they hit the roof because they feel judged • I like spy on them…how they walk down the hall as they are going to the room…I ask the nurse what their mobility level is like…kind of like a crap detector…it isn’t to judge.. It is to help me sort out what is legitimate, what’s not, which is okay

16. Communication Style • I usually try not to start with the pain issue, I’ve found that if you start with something else, they kind don't exaggerate about. Okay. So, I tried to start with a different issue that they have, like diabetes or hypertension and then after address that I never say, how is your pain? • …if they say I was fine with Naproxen, then why are you taking you know, a hundred pills with opiates? • Every time I see a patient with chronic pain I say let's see, how are you, how are you doing today? Do you have any concerns? How can I help you? I never ask like how is your pain, like they're coming for something else. So, I say, how can help you, and they say they are here for their pain medication, and I say okay. • telling them they can overdose and die, most of them when they hear that, they are like okay, maybe we should reduce • I don’t have strategies.***

17. Pathology • We want to see if there is organic reason for the pain…Then you think about how to address it, if it is organic, referral and PT, if it is not, then another referral with a behavioral psychologist. This is the most important thing for me to see if it is real, actual pain. You can differentiate if they are on opioid, if you want to continue that with a new patient, is it the right way to continue that • It kind of depends on where they are, if this is their first couple of visits to the clinic, I’ll take a history of the pain. I’ll start investigating the cause of the pain, if it is later in the visit and they’ve been on narcotics for a long time, or a regiment I’ll see what's been done recently to see what can be done more to. But I think a lot of work for me for quite a few years, why are we having the pain and what could be done to alleviate that. Whatever modality it may be, PT, or non-pharmacological therapies. I have to take a look at the patient and see what they are willing to do to treat the pain. • Sometimes patients come in and before you can even start it they say I’m in 10/10 pain today [laughter]. And so, what does that mean? I'm really hurting. So, does that mean your passing out from the pain? Oh no. I'm not passing up a you curled up in a fetal position and screaming all night? Oh no, no, I'm not doing that. Okay. So maybe your pain isn’t 10/10. Let's try to get a better idea of where your pain is really at. So, we know how effective your medicine is being

18. I need your help…

19. For myself. It depends on the patient and how the mood of the interview is going. So inherently I’ll start with the facts. What is causing the pain? If you know what it is. We understand you have pain whether or not we know what is causing it, we know you are having pain. I just talk about what is your goal for the pain. I let them voice their concerns, and expectations and how I can navigate within that. If they started getting upset or unhappy with the plan I’ll let them voice their concerns. I’ll try and be more empathetic and apologize for their pain, be more empathetic and not focus so much on the facts, but more on their emotions. Really just depends on the patient and how the interview flows and that will affect how I address their chronic pain

20. I had a patient that I was surprised he was on opioid, I couldn’t address it immediately, I tried and he got crazy mad. He said, what do you know about me to lower the dose. Then I told myself, I really don’t know anything, other than he’s been on the medication for like seven years, and he is up walking, talking, doing great things, and on his bike like 24/7. So, where is the pain? Then I went back on his chart and I saw that he had lost 150lbs and his diabetes, and hypertension improved. I said this is probably was on pain medication that helped him. You try to be unbiased, but you cannot sometimes, when you see the facts in front of you. From this experience, I would not address it in the beginning, but wait until I have developed trust. I always also say, because patient needs to feel that you are caring for them, and not only providing prescriptions. I always say that you only come every month for a refill, that make us as providers forget about the rest of your health, the heart, the kidney, I would prefer if you come in a week or two, to do an annual physical or something else, so we can focus on you as a whole, and not only on your pain. They will like it, and feel like they are a real human, and not only a real human. They are hard patients.

21. Challenges • Getting four residents in the same room for 8 hours • Language and cultural differences among residents • How pain is interpreted by Hispanics in the region • Hispanics are considered a “difficult to reach” population for research recruitment (language, distrust) • Implementing a strategy that can be time consuming in an already time-constrained environment • Mentor issues