Professor Tamar Pincus, Royal Holloway University of London, UK, holds a PhD in psychology as well as master’s degrees in experimental research methods in psychology (University College London, UK) and epidemiology (Cambridge University, UK). She is a strong advocate for patients and health equity and her most recent research focuses on the components of an effective consultation.
Here, Tamar chats with Erin Macintyre, a PRF correspondent and PhD candidate at the University of South Australia, about her journey to pain research, experiences conducting research in the Global South, and how we can improve consultations. Below is an edited transcript of their conversation.
Can you tell me about your path to scientific research?
It was unusual. When I was a teenager, I rejected science completely. I was very creative – I had music, drawing, and literature. My first degree was in music, and when I finished my degree, I wanted to look at how music enhanced communication. The academic musicians had no idea how to include psychological methods in music research. So I had to change and catch up with my master’s in experimental methods and statistics.
What led you to pain as an area of interest?
It was complete serendipity. I was just looking for an area to do my thesis research in, and I knocked on the right door. There was a very inspiring young lecturer there, Dame Shirley Pearce. I had absolutely no interest in pain when it happened. I’m just so grateful that I knocked on the right door. There is no great story there. She was amazing, and I followed.
What kept you going down that path?
In those early years, I was blown away by the research in cognitive biases. It was well developed in depression and anxiety, but in pain we knew very little. The idea that you have all these messages, stimuli coming at you, and your brain does this clever filtering thing where it looks at them and goes, “How threatening is this? How salient is this? How is this tied to my immediate goals? How is this tied to my memories of what happened with this kind of thing before….” All before it produces an experience in your consciousness.
I thoroughly enjoyed those early years doing experimental work looking at memory, attention, and interpretation biases in people living with pain. I don’t think that’s going to be the breakthrough – the “silver bullet” – for chronic pain, but it’s incredibly interesting.
Speaking of “silver bullets,” do you have any idea what, if any, the “silver bullet” will be for pain?
I really like that you asked me this. Obviously, I don’t have an answer. So where do I think the big changes are? I think that there are a couple of places that offer hope.
The one thing that we haven’t really considered adequately is the societal level. We have such inequality and poverty around the world. Until we deal with that, we can’t improve health in any meaningful way. Let’s start with a global attempt to understand how different people are living.
The next step is starting to understand how humans live within their environment. If you don’t understand what we breathe, where we walk, and what we eat, you can’t understand health.
The third layer is around culture, which we have been so poor at understanding. It’s only my recent introduction to collaborating on research in the Global South where I’m starting to understand this at all. I think we need the humility to understand that we have very little idea how culture affects behavior and health.
Finally, the more multidisciplinary we are, the better we are. We’re going to have to get rid of a hierarchy in medicine and medical research. We are going to have to throw out the idea that surgeons are “more important” than physiotherapists, or that psychological research that relies on qualitative approaches is “less scientific” than neuroscience. You can’t do one without the other if you aim to understand complexity. I would also say that we have a lot to learn from the humanities and social science. They have methodologies which we have not incorporated yet. If we can triangulate, we will do better.
Your research combines many disciplines and types of research methods. Can you talk to me about that?
Let me give you an example: This week we published a qualitative paper looking at how surgeons struggle in consultations with people with debilitating chronic low back pain that is not suitable for surgery. They told us they look at the MRI and they go, “There is nothing I can do for you. Out you go.” We already knew from our research that the patients find this discharge devastating, but the surgeons, it turns out, are also quite distressed about these consultations.
Then, we moved on to a longitudinal study. We measured a lot of factors – things that patients told us were important, things that practitioners told us were important, what happened in the consultation, especially in reference to communication – and then we followed patients up three months later. We found that the way the practitioners talked to the patients – the quality of their communication skills – was not only associated with further healthcare seeking, but also levels of low mood, even when no treatment was given.
Now that we know that the quality of communication matters, the question is, “Can we improve it?” If we do, will we improve well-being in patients? The next stage is doing an intervention. We’ve just published our intervention development, which is based not only on our findings from these studies, but also on discussions with stakeholders. We talked to the patients, surgeons, the physiotherapists, and other team members working with the surgeons, and the referring general practitioners.
The next stage for us, of course, is the full RCT, which will hopefully be funded. That’s how you put it together, but none of this could happen without the initial qualitative research.
I think that perfectly triangulates your background in terms of your research expertise and your background in the arts. It’s a richer story than just the numbers.
And even using all the methods I described is still limited. When we went to Southern Africa to look at chronic pain in Zambia and South Africa, there I was with all my questionnaires, trying to think of how I would look at the impact of pain on people living in enormous poverty. What I didn’t realize is how many languages were spoken in Zambia. My questionnaires were useless. My colleague, a medical sociologist, could use drawings to try and understand the impact. That was a methodology I have never used. It was so inspiring to think outside the box.
We briefly touched on how a lot of your recent research is looking at effective reassurance. Can you tell me how to provide effective reassurance to people in pain?
I’ve come to think of it more as effective communication in consultations, although reassurance is a cornerstone. There are broad “do’s-and-don’ts,” but I wouldn’t want anyone to think of these as communication rules. Our evidence suggests some practices are less helpful. There is a body of work about practitioners inspiring patients towards optimistic thinking through statements emphasizing their own qualifications, experience, and ability to solve the problem. This includes statements such as, "This pain is nothing serious; trust me, I have seen it all before. I can cure you." We have labeled this “generic reassurance,” because it offers no information specific to the patient or their problem.
For people who have been living with pain for a very long time – and feel they’ve tried everything – these generic optimistic statements are not credible, and are even perceived as patronizing. Our evidence suggests this behavior is perceived as false reassurance. If patients do believe these statements – and many of them are desperate enough to believe anything offering a cure – then a problem emerges down the line when the pain is not resolved. If [the pain] comes back, and you aren’t there to solve it in your “magical way,” you’ve broken their trust. What’s important here is that patients are not empowered to manage their own pain.
What is a good consultation? It starts with effective listening. Listening skills are still really poor in many clinicians. We interrupt, we’re obsessed with time keeping, we’re obsessed with following our own hypotheses – much of the time in consultations we’re not actually listening. Another important thing is building relationships, and giving empathy and validation. Validation is a really important message. The last is cognitive reassurance, which is really an interaction of useful information about possible causes, prognosis, and management options between the patient and the practitioner. It is evidence based, but it’s not a truth, and it’s not prescriptive.
A good consultation is one which is bidirectional, and it has a lot of avenues which you might walk down because the usability of any given technique is different from patient to patient. That is effective reassurance.
You have talked about how stress and depression that are related to pain seem to be different from clinical depression. Can you expand on this?
This stream of inquiry has been an interest to me throughout my career. We have evidence in cognitive bias which shows that when we compare people who have chronic pain and so-called depression to people who have clinical depression, they have different content biases. Most questionnaire measures will make these groups look the same, but people with pain-related distress don’t have the same common features of self-loathing or cognitions about the future being really threatening. Their distress is focused around their pain. There is, of course, a small group of people with chronic pain who have a psychological comorbidity. The majority of the people living with chronic pain, however, have pain which is impacting their life in a nasty way, and this impacts on their mood and well-being.
What happens when we turn to these people and psychiatrically label them, or we prescribe them antidepressants at high doses because we want to change their mood? I think we’re mistreating them in many ways, and the evidence suggests they agree and find this approach unacceptable.
This brings me to my current research. We are discussing low mood in chronic pain with patients and general practitioners to try and pull out the items you can ask to differentiate between clinical depression and pain-related distress. This might allow practitioners to differentiate between people who should be referred to mental health clinicians and those who would benefit more from a referral to multidisciplinary pain teams.
We are also looking at antidepressant use for chronic pain. This is a big study because there are many types of antidepressants, and they’re prescribed at many different doses. Here, the story gets complicated because at low doses they’re prescribed as analgesics. We’re trying to come up with suggestions about, “What works, for whom, in what dose, and what does it change?” We are also examining the adverse effects of these drugs to try to balance any positive outcomes with harmful effects.
A lot of your work also focuses on the interactions and relationships between health care providers and patients. What about this inspires your work?
I think the interpersonal aspects of patient-clinician consultations might offer a missing puzzle piece about the transition from acute pain to persistent pain. Acute pain is part of living – you’re going to have it sooner or later. What we need to know is what factors predict this move to persistent pain – with higher use of clinical time – and considerable distress, disability, and suffering.
In the first instance, research focused on physiology and anatomy. We measured everything under the sun, and we could only predict a small variance of the transition to chronic pain. Next, we studied individual differences, often with pejorative labeling. We were able to add a tiny bit to our ability to predict prognosis. Then, we thought, it’s going to be social – it’s going to be the workplace. If you add all of that together, you can predict about 50% of the variance, which is where we’re at.
But we don’t work like this as human beings. We’re constantly playing ping-pong with the world around us. Some of the other players we play with are much more important than others in terms of our health behaviors, our health perception. Very few are more important than the clinicians that we interact with.
In the study I told you about earlier on, where the surgeon’s interaction with patients predicts subsequent [general practitioner] visits, we controlled for everything. We controlled for pain intensity, pain duration, whether or not they wanted surgery, how old they were, male or female, how many practitioners they saw beforehand, how many interventions they had tried, which hospital they came from, who they saw, and even the gender of the person they saw. We controlled for all of that, and we still found a very small effect of the interaction itself predicting whether they went to see their [general practitioner] afterwards for low back pain.
What’s amazing about this is that the surgeons in this study were not trained in communication skills. The variability in the behavior was much smaller than there would be if we also included clinicians who had been trained, so the small effects we observed in outcomes might be greater. There is potential there.
You have produced some videos on YouTube. What was the inspiration or the reason behind creating them?
The Pain and Me [YouTube video] has been one of the most rewarding things I have ever done. I thought of the metaphor [used in the video] as an attempt to get to grips with acceptance and commitment ideas and cut through the jargon. I put [the video] together in an hour – just me and a photographer. There was no script, and it was completely improvised. The level of success that it has had – the amount of people who are still contacting me from around the world, practitioners and patients saying, “I found this so helpful,” and, “Can I translate this?” It’s just been gorgeous. I am so, so happy that the video has been helpful.
The Why Psychology Matters [YouTube video] was influenced by a surgeon who said to me, “Look, I completely recognize that psychology matters. People have anxiety, they have depression. What you need to do is somehow take off their head and give it to a psychologist so that the psychologist can deal with all that depression and anxiety. Then give me the spine and I’ll fix it.” I thought, we have a problem here.
Another reason was that patients have such a hard time with stigma when it comes to psychological problems. They have such a hard time opening up and saying, “I’m devastated.” They’re afraid of the psychiatric labels. They’re afraid of being judged. They’re feeling guilt. They’re feeling shame.
If we can just realize that all experience, interaction, and behavior is “psychology,” then perhaps discussing mood, beliefs, and thoughts in pain consultations will no longer be taboo. I can’t think of a single intervention that doesn’t include psychology, including surgery. People’s expectations, people’s behavior, people’s motivation, and even the surgeon’s mood at the time all influence outcomes.
So we might as well make it part of the package. Study it, measure it well, figure out what is going on, and just stop this Cartesian thinking. The body is here, the mind is here, give me the head, take the body…. It’s not helping anybody.
Given that your research focuses on the interactions between clinicians and patients, do you think that there should be stronger links between these two groups of people? If so, how could we best achieve that?
In my research, we always work with patients from the conception of the idea. We have networks of patients and we bounce [our ideas] off of them. We learn so much in terms of the measurements we use, what to measure, and how to measure. I think strong patient partners in research are fundamental. We need to invest in them, and we need to find money to pay people for their time.
The question now is where the boundaries lie. Recently, some patient partners told us that they felt they should be doing the interviewing in a qualitative study, because patients are more likely to talk to them than to researchers. This got my head buzzing about my own biases. I thought about training and being a professional interviewer. What about guarding and protecting these expert-patients doing the interviewing from possible triggers?
Then, I have to just go, “You know what, Tamar? You’re being such an idiot. You have chronic pain. When are you wearing your hat as a researcher, and when are you wearing your hat as somebody who suffers from pain? You don’t even know.” We need to be flexible and open-minded. There probably is a line where I am the researcher and I am the experienced expert, but I don’t know where it is. The beauty of working together is that over time, as we academics age, we have had to learn to live with pain, and over time, as they supported our research, the people in our patient network have picked up a huge amount of knowledge and skills. I guess that makes for a great partnership.
Erin Macintyre is a physiotherapist and PhD candidate at the University of South Australia in Adelaide.