Table 3.

Contextual Factors Identified by Clinicians

Insurance, Inherited Patients, and the 15-Minute Visit: Contextual Factors
Theme: Reimbursement structures limit time for pain management in the safety-net
“I went to that [CME and] they [said], “You got to spend at least an hour [in] the first visit with each [CNCP] patient,” and all these internists were saying, “Okay, yeah, no problem.” And they're going to bill the patient for the time. I'm working in a Medi-Cal [Medicaid] clinic, I can't do that. So, I went, “Yeah, in an ideal world.” So, I heard all this stuff that I'm supposed to be doing, taking a complete history, complete addiction history… But I don't have time to do what I am supposed to do in terms of proper treatment, opioid treatment, so I cut corners a bit.”
Theme: Thorough initial assessment is difficult in brief visits, but essential for future care
“[Any] time I get a new patient who has pain it's like the first visit… as soon as I can get to the place where everything else feels stable enough for me to talk about the pain, that's all I'll do. Because I think that initial pain assessment is so important and often times lost to me when you inherit [another clinician's patient]… You need time to listen… it takes more than fifteen minutes often… I just see that as such an important initial step in coming up with good plans and setting up people for expectations.”
Theme: Visit duration and availability pose challenges to pain management
“[A] new patient for us should be a 30-minute visit but there's so many new patients sometimes that new patients will be put into a 15-minute visit. And even 30 minutes is not enough for a lot of complex issues… And, yes, we do often have a culture where we deal with one or two problems on one issue because we don't have the time and we'll bring them back [for a follow-up visit].”
“It's very hard to get an appointment in the clinic [when] you want one, and so one defense mechanism that almost all the doctors there use is to see people more frequently than they actually need to because everyone's afraid of their patients falling through the cracks and that just makes the problem [of clinical availability] worse.”
  • CNSP, chronic noncancer pain.