Shared decision making in medical encounters has been advocated in order to respect patient values and improve patient outcomes.⁵ We conducted a pilot study to test a 2 session primary care physician-training program focused on shared decision making with patients with chronic pain. The study had 3 primary aims: (1) to test the feasibility of teaching a shared decision-making model concerning opioid treatment of chronic pain in primary care, (2) to test whether shared decision making enhances physicians' sense of collaboration and satisfaction in treating these patients, and (3) to obtain preliminary physician self-report data on whether the shared decision-making model might improve the quality of care for patients with chronic pain.

Physician satisfaction was assessed with a modified version of the Physician Satisfaction Questionnaire,⁶ adapted to assess satisfaction with recent encounters with chronic pain patients. This 20-item scale contains 4 subscales: relationship quality, adequacy of data collection, appropriate use of time, and patient's cooperative nature. Physician patient centeredness was assessed with a 20-item measure⁷, which has been validated for use with primary care physicians. The scale contains 4 subscales: doctor receptiveness, patient involvement, affective content of the relationship, and information giving. Three additional measures were developed by the authors: (1) frequency of opioids prescribed and patient treatment agreement completion, (2) changes in prescription practices and attitudes concerning caring for patients with chronic pain, and (3) the overall usefulness and effectiveness of the shared decision-making training.

In November 2004, intervention and control physicians were given an educational packet on the use of chronic opioids that included the following (1) an opioid conversion table, (2) an educational resource list, (3) a review article on opioid therapy for chronic pain,⁸ and (4) GIMC policy on the use of opiates for chronic pain (including recommendations concerning patient care agreements, depression assessment, and methadone use but no strategies or guidance). Intervention physicians attended 2-hour long shared decision-making training sessions held at GIMC.

Each session utilized a videotape of an office visit where the “patient” presented with low back pain of 1 year's duration and requested continuation of Percocet prescribed by her previous physician. The first training was divided into three 5-minute video segments with the following learning objectives: (1) to introduce the shared decision-making model, including negotiation and documentation of shared treatment goals with the patient; (2) to negotiate nonmedication treatments; and (3) to negotiate the prescription of methadone (as the long-acting opioid least prone to abuse).

The second training hour followed the patient into her next visit when she asks for more pain medication because of worsening pain. The learning objectives were as follows: (1) to review goals established in her previous visit, (2) to screen for depression while exploring declining health status, and (3) to negotiate from the patient's initial request for more pain medication to a prescription for antidepressant medication. Hypothetical third visit scenarios were then presented for discussion, portraying improving, stable, or deteriorating health status. Learning objectives for the training are listed in Table S1.

To explore the training's generalizability, it was repeated for resident and attending physicians (n=20) at the Seattle Providence Family Medicine Program. Assessments were administered immediately before and after training. There was no control group or 3-month posttraining assessment for this sample.

The overall physician patient-centeredness score and 3 subscale scores (doctor receptiveness, patient involvement, and affective content of the relationship) were not significantly different between groups at 3 months postintervention. The fourth subscale (information giving) was significantly higher in the intervention group (F=4.88, P <.05), indicating a greater propensity to give patients more information to assist them in making decisions.

At 3 months postintervention, intervention physicians reported they were more likely to complete patient-care agreements and to report “making overall changes in their management of” and “attitude toward” chronic pain patients (see Fig. 1). At 3 months postintervention, physicians were more likely to prescribe methadone (F=4.42, P <.05) and more likely to set functional goals (F=11.65, P <.01).

Eighty-two percent of intervention physicians rated the training as useful at the end of the training, and 67% did so at a 3-month follow-up. After the training, 73% of physicians also reported feeling more competent to care for patients with chronic pain. Four of 22 intervention physicians attended a focus group after the 3 months posttraining assessments. Although self-selected, these 4 were typical of the intervention group in terms of pre-intervention assessment scores. They reported that the training was helpful in 3 specific areas: (1) in producing a less antagonistic relationship between the physician and chronic pain patient, (2) in promoting regular use of patient treatment agreements, and (3) in promoting a shift of focus from level of pain to patient function.

Our pilot study has a number of important limitations. First, assessments were limited to self-reports of physician attitudes and behaviors. Second, this was a small sample of physicians at a single institution. We did partially replicate our findings at an additional site, but the generalizability of the intervention effects still needs to be shown. Third, 4 physicians randomized to the intervention were excluded from the study because scheduling precluded completion of both training and baseline assessment, but they were similar to the participants who were included. Fourth, the intervention group had more contact time with the investigators, a bias, that may have partially accounted for the observed effect.

Previous-randomized trials of training in shared decision making have had mixed results. Most report success at changing physician behaviors and attitudes, but fail to improve patient outcomes.^10,11 A single trial of shared decision making in fibromyalgia showed improved patient receptiveness to a chronic pain treatment plan.¹² Opioid contracts have been a common accompaniment to opioid prescription in the specialty pain management setting.¹³ They have been recently been adapted to include collaboration with the primary care physician.¹⁴ However, these contracts are generally used to put limits on patients, rather than to empower or collaborate with them. In a recent review, the goals of care were among the least common elements of pain contracts, found in only 38%.¹⁵ Truly collaborative treatment agreements focusing on negotiated goals for chronic pain care could be a powerful tool for increasing patient participation and satisfaction with care. This remains to be shown in a subsequent trial.