International Journal of Clinical Medicine, 2012, 3, 411-418 http://dx.doi.org/10.4236/ijcm.2012.35077 Published Online September 2012 (http://www.SciRP.org/journal/ijcm) 1 Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis Paula P. Souza1, Adriana P. M. S. Romão1, Ana Márcia S. Nakano2, Julio C. Rosa-e-Silva3, Francisco J. Candido-dos-Reis3, Antonio A. Nogueira3, Omero B. Poli-Neto3* 1Department of Gynaecology and Obstetrics, School of Medicine University Hospital, University of São Paulo at Ribeirão Preto, Ribeirão Preto, Brazil; 2Department of Public Health, School of Nursing, University of São Paulo at Ribeirão Preto, Ribeirão Preto, Brazil; 3School of Medicine University Hospital, University of São Paulo at Ribeirão Preto, Ribeirão Preto, Brazil. Email: paulaps@usp.br, adrianapeterson@usp.br, nakano@eerp.usp.br, juliocrs@convex.com.br, fjcreis@fmrp.usp.br, aanoguei@fmrp.usp.br, *polineto@fmrp.usp.br Received June 18th, 2012; revised July 19th, 2012; accepted July 28th, 2012 ABSTRACT Because the aetiology of chronic pelvic pain is complex, studies of the condition involve extensive investigation but provide few conclusions. Numerous studies have addressed the experiences of women with chronic pelvic pain, as well as the interaction between those women and their health care providers. Our objective was to investigate how physi- cians at a specialized clinic perceive the medical care prov ided to such women. This was a qua litative study employing semi-structured interviews and conten t analysis. We interv iewed seven physicians at the Chron ic Pelvic Pain Outpatient Clinic of the University Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil. Medical training and practice constituted the central theme of the study, which was subdivided into categories addressing the influence that the current medical training has on the type of medical care provided to women with chronic pelvic pain. Medical practice has been characterized by a reductionist appro ach to health and illness, as well as by the fragmentation of health care. These characteristics are, to a certain extent, the result of the biomedical model of education, which has been predominant, ignoring social, cultural, psychological and emotional aspects. There is a need to shift the medical paradigms toward a humanistic model of health care. We hope that we have provided a critical view of current medical training and practice, as well as of their effects in various health care settings, particularly in the provision of care to women with chronic pelvic pain. Keywords: Chronic Pelvic Pain; Biomedical Model; Qualitative Research 1. Introduction Since the days of the earliest civilizations, pain has caused intense suffering among individuals [1]. In the past, the understanding of pain was strongly influenced by Christianity, which defined pain as a means of achieving enlightenment or obtaining blessings; therefore, studies investigating the elimination of pain were dis- couraged, which, to a certain extent, delayed the investi- gation of the pathophysiology of pain [2]. In mid-1979, the International Association for the Study of Pain pro- posed the first definition that included sensory and emo- tional aspects, as well as being subjective in nature and varying among individuals: pain is an unpleasant sensory and emotional experience associated with actual or po- tential tissue damage, or described in terms of such damage [3]. In recent decades, the abovementioned measures have contributed to a better understanding of pain. However, because pain—unlike the remaining vital signs—is subjective, there is no standard instrument that allows an outside observer to measure pain in an objec- tive manner, precisely because pain is an extremely complex and individual experience. Therefore, in order to gain a deeper understanding of pain, it is necessary to consider the clinical correlates of pain, as well as the emotional, cognitive, and personality characteristics of individuals [4,5]. This context allows us to reflect on the issue of women with chronic pelvic pain (CPP), which is a disease of complex aetiology resulting from the interaction among the gastrointestinal, genitourinary, musculoskeletal, nerv- ous, psychological, and endocrine systems, as well as being influenced by socio-cultural factors [6]. Studies of CPP typically involve extensive investigation but pro- vide few conclusions; this failure to understand chronic pelvic pain leads to d issatisfaction and frustration among patients and health pr ofessionals alike, as well as to con- *Corresponding a uthor. Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 412 flicts between the parties involved. One of the elements of this complexity is th e very definition of the condition, for which there is no consensus [7]. Although there are various definitions of CPP, most, if not all, tend to state that the aetiology of the con dition is exclusively physical or behavioural and are therefore inadequate. In our opin- ion, the most appropriate definition of CPP in women is as follows: “noncyclic pain of 6 or more months’ dura- tion that localizes to the anatomic pelvis, anterior ab- dominal wall at or below the umbilicus, the lumbosacral back, or the buttocks and is of su fficient severity to cau se functional disability or lead to medical care” [8]. The overall prevalence of CPP in women has been es- timated at 3.8%, being similar to that of migraine, asthma, and back pain [9,7]. The prevalence of CPP has been estimated to be higher in developing countries [10]. For example, its prevalence in Brazil is approximately 11% [11]. The direct and indirect costs of CPP (including medical costs, as well as costs related to laboratory tests and reduced productivity) have been estimated at 39 bil- lion dollars per year [12-14]. In addition, CPP accounts for approximately 10% of all gynaecological appoint- ments, 40% - 50% of all gynaecological laparoscopies [15], and 12% of all hysterectomies [16-18]. Approximately 20% of all women with CPP do not undergo any diagnostic investigation, and 60% do not receive a specific diagnosis [19]. In addition, Silva et al. [11] found that although 90% of all women with CPP were being routinely followed at primary health care clinics and had previously complained of their clinical status, only a small proportion (4%) were aware of hav- ing the disease. The above mentioned findings show some of the reasons why women with CPP are highly dissatisfied [20]. The resolution rates for CPP are low. This might be at least partially attributable to the fact that there is a disconnect between the expectations of women with such pain and the type of medical care provided, which does not meet their needs. We believe that the difficulty health professionals have in managing the con- dition is intrinsically related to the policies and philoso- phical underpinnings that guide current medical educa- tion and practice, which are based on scientific medicine, the form of medicine derived from the Flexnerian reform of medical education in the early 20th century [21]. Abraham Flexner was responsible for the most impor- tant reform of the medical schools in the United States, his report—informally known as the Flexner Report— having had a major impact on medical education in nu- merous countries, including Brazil. The Flexner report proposed a new model of medical education and practice, based on biological evidence, individualism, specialisa- tion, and a technical approach to health, as well as on the curative. The impact of the Flexnerian model on the medical care provided to women with CPP is not entirely p ositive, as evidenced by the complaints of such women. Most of the complaints are related to the lack of a holistic ap- proach to the problem, biological aspects being priori- tised. The most common complaints are dissatisfaction with the doctor-patient relationship, the lack of an un- derlying etiology for CPP, miscommunication between doctors and patients, the lack of information regarding the condition, and inappropriate treatment. CPP imposes limitations to th e lives of tho se women and is responsib le for years of suffering, including job loss and divorce. When women with CPP seek professional help, they have an overwhelming desire to know what is wrong with their bodies [22]. In contrast, it seems that the bio- medical model of medical education does not equip medical students with the skills required in order to manage the psychosocial aspects of CPP and its various dimensions. The quality of that relationship is one of the factors that determine the level of patient satisfaction, having a direct influence on patient response to treatment [23,24]. Patients who report dissatisfaction with their encounters with physicians are more likely to show psychiatric dis- orders, aggressive personality traits [25,26], and lower adherence to treatment [27,28], as well as to report mul- tiple physical symptoms that cannot be explained bio- logically (i.e., “medically”) [25,29,30]. By context, the principal objectives of the present study were to investi- gate physician perception of the medical care provided to women with CPP and identify possible determinants of the condition for future development of continuing edu- cation programmes. 2. Methods This was a qualitative study, data were collected by means of semi-structured interviews. We interviewed seven physicians providing medical care to women with CPP treated at the CPP Outpatient Clinic of the Univer- sity Hospital, Faculty of Medicine of Ribeirão Preto, University of São Paulo, Brazil. The median age of the physicians was 30 years (range, 27 - 58 years). Among the seven doctors interviewed, four were men and three women. The interviews were conducted by one inter- viewer, with an average of 60 minutes for each partici- pant. The analyzes were performed by three evaluators in the portuguese language and after the material was trans- lated into English. The criterion used to conduct the interviews and to determine the number of participants was the saturation criterion in which the repetition of information during interviews limits the ne ed to new participants. Regarding the level of training, the participants ranged from first- year residents to professors, and the length of experience in providing medical care to women with chronic pelvic Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 413 pain ranged from 1 year to 10 years. Neither the length of experience nor the level of training of the participants had any impact on the results obtained, meaning that there were no significant differences among the answers provided by the participants. Therefore, there was no need for new thematic categories. All of the participants gave written informed consent, and the study was con- ducted in accordance with the regulations and guidelines for research involving human beings established by Bra- zilian National Health Council Resolution 196/96. We performed content analysis in accordance with the method proposed by Bardin (1997) [31]. According to Minayo [32], qualitative data analysis involves a set of operations and reflections, as well as data reorganization, all of which are carried out in o rder to determine the sig- nificance of the phenomenon under study [32]. Data analysis was performed in three steps: Pre-analysis; Ex- ploration of the material; Analysis and interpretation of the results. 3. Results Through means of detailed discourse analysis, we at- tempted to understand the range of experiences of those physicians (i.e., from medical training to clinical prac- tice). The central theme was medical training and prac- tice, and we subdivided it into five categories, which are described below. 3.1. Physician Knowledge of Chronic Pelvic Pain Physician 1: “I felt the need to know a little bit more about those diseases, about that group of patients, be- cause I had a lot of difficulty in dealing with them.” Physician 5: “Instruction regarding chronic pelvic pain is much more theoretical than practical, isn’t it? You learn what can cause the pain, but that doesn’t al- ways correlate with what the patient is telling you. Pa- tients don’t always say, ‘oh, the pain I feel is like this and that’, and then you can think of a course of action. It’s generally not ‘by the book’.” The discourse of those health professionals shows their difficulty with CPP. Physician 1 reported having diffi- culty in reconciling theory and practice in the context of treating patients with chronic pelvic pain. We believe that this is due to the subjectiv e nature of the pain, which stands in contrast with the need that those physicians have to conceptualise the disease in physical terms. This indicates that greater weight is given to the biological aspects (i.e., the “concrete” aspects) of pain, an approach that is in accordance with the Flexneriano model of medical education and practice. According to Lima & Trad [33] the subjectivity of pain makes it invisible and unquantifiable, which is why health professionals have difficulty in managing it. Al- though the management of chronic pain has posed a ma- jor challenge for health professionals, chronic pain has not been given weight in the curricula of medical schools, being strongly associated with the ideas of injury and protection (i.e., a symptom that reveals an underlying condition to be inv estigated and diagnosed) [34]. Physician 3: “I think that CPP is not well taught to undergraduate students, who spend very little time within each specialty. In medical schools today, there is a trend toward a more general approach to medical education rather than a focus on specialization, on specialties.” The physician in qu estion believes that the difficulty in managing CPP is due to the fact that undergraduate stu- dents spend very little time within each specialty. The great importance given to specialization has a direct im- pact on the medical care provided, which becomes frag- mented; a patient is seen as parts rather than as a whole. Although a disease is a biological, material phenome- non, the human response to the disease cannot be meas- ured objectively. It is evident that the curricula of medi- cal schools have not equipped students with the skills required in order to treat individuals humanistic. The fragmentation of health care into specialties tends to ob- scure physician perception of biopsychosocial aspects, meaning that such aspects are ultimately overlooked by physicians, who fail to co rrelate them with patient health status. 3.2. Stereotypical Views That Health Professionals Hold of Chronic Pelvic Pain and of Women with the Disease Physician 6: “Well, you know, it’s too early to tell, I ha- ven’t been to the outpatient clinic that often, and, I think it’s a problem that is difficult to treat, the patients are difficult, so, I suppose I still have a lot to learn about CPP, and, well, I haven’t studied it, I mean, I haven’t done any research on my own, but we do have the outpa- tient clinics, where we can follow patients closely, and, anyway, I don’t think we learn that much about the sub- ject at university.” Physician 1: “It’s difficult, isn’t it? Doctors always want to solve everything, and all of those things that sometimes you just can’t find the cause of... you see, in the case of CPP, you can’t always find a cause that is treatable, sometimes you even think you’ve found some- thing, but you can’t solve the patient’s problem, which sort of causes some frustration, you know, this is why I don’t like it very much.” Some of the health professionals interviewed in the present study emphatically stated their distaste for pro- viding medical care to women with CPP. This is proba- bly a reflection of their inexperience with and lack of knowledge of the condition. That viewpoint has become a consensus among health professionals in training and Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 414 specialists. The setting of treating CPP has become stig- matised, health professionals having disseminated a negative view of the disease. According to Salmon [35], the uncertainty regarding the aetiology and treatment of CPP is what concerns health professionals the most, given that it can threaten the authority on which medical knowledge and practice are based [35]. Ponte & John- son-Tribino36 showed that 85% of health professionals reported frustration when treating patients with chronic pain, a finding that is in agree ment with those of the pre- sent study [36]. The lack of training of health professionals in manag- ing chronic pelvic pain has had an impact not only on how the disease is viewed (i.e., negatively) but also on how women with the disease are stereotypically viewed, i.e., as having multiple complaints, as being annoying, and as being problematic. Physician 7: “Now, it is a d ifficult type of patien t, isn’t it? We see it quite often. That’s exactly why you’re con- ducting this study, because residents, those who are younger and inexperienced, they say, ‘listen, there’s no way you can treat that patient, she complains of every- thing, she has multiple complaints, there’s just no way, there’s no treating her, everything hurts (laughs), noth- ing works, nothing heals, and everything hurts’.” Physician 1: “The typical profile is, women with seri- ous social and family prob lems; one had been left by her husband, one had children who had been killed in acci- dents, one had been left by her family, one had well-es- tablished psychiatric probl e ms .” Physician 2: “It’s a patient who complains a lot, a pa- tient who ends up having a lot of anxiety, depression... it’s an ANNOYING patient.” The stigmatisation of women with CPP by health care providers is also related to the chronic nature of the dis- ease, which entails difficulty in patient monitoring; be- cause of the diagnostic and therapeutic limitations, the resolution rates for chronic conditions are low. 3.3. Doctor-Patient Relationship Physician 4: “You have to listen to the patient’s com- plaints, you cannot underestimate them, but you can’t overestimate them, either, otherwise you’ll be contribut- ing to her attributing all her problems to that pelvic pain... You might contribute to h er somatising th e pain a bit, if that’s the case, right?” As previously described, we believe that the doctor- patient relationship problems in the context of CPP are intimately related to the stereotypical view that health professionals hold of those women. This creates a com- munication barrier between doctors and patients, the consequence being that the real needs of women with CPP are not met by the type of medical care provided by health professionals. Some of the statements clearly show that the physicians are insecure as to what criteria should define the threshold between believing and disbe- lieving in the discourse of women with CPP: “you can’t underestimate [the complaints], but you can’t overesti- mate them, either”. The mind-body dualism imposed by the biomedical model is in opposition to the multifaceted nature of pain. According to that fragmented view, the aetiology of the condition is exclusively physical or psychological, meaning that the pain is either “real” or “imaginary”. In this sense, health professionals and patients grow in- creasingly apart in the setting of providing/obtaining treatment for CPP, the therapeutic relationship being often replaced by a relationship of distrust. The benefits of a doctor-patient relationship that is based on an effective communication process include higher diagnostic accuracy, reduced number of lawsuits, increased treatment adherence, optimization of health resources, increased satisfaction, and better results in treating various conditions [37,38]. According to Morris [39], communication does not replace medical technol- ogy; rather, it aids in understanding the emotional and social factors that aggravate the condition. Neither ex- treme is ideal; there is a need to strike a balance between the two [39]. 3.4. Technical/Interventional Model Physician 4: “I think that, because the symptoms are ex- tremely vague, sometimes clinical examination alone, sometimes the patient is unable to give you correct in- formation, so you end up having to adopt a more invasive approach.” Physician 1: “The diagnosis of chronic pelvic pain is problematic, I think we still have a long way to go, I think certain mechanisms are missing, I mean, not that our facility lacks anything, but the fact is that CPP is a clinical diagnosis and is often secondary to a disease that requires an imaging test, blood tests, something that explains the pelvic pa in.” The discourse of the participants reveals an over-reli- ance on the use of technology in the treatment of indi- viduals, an approach that is consistent with the bio- medical model of medical education and practice. The principal objective of the medical care provided to women with CPP has been to diagnose and treat the con- dition, other needs related to the h ealth-illness contin uum being put aside. That leads us to ask, “What are the real health care needs of women with CPP?” This excessive interventionism—characterised by the tyranny of ancil- lary tests; excessive fragmentation of patients into organs and functions; and inattention to emotional and psycho- social aspects—originates from the increasing techno- logical sophistication of modern medicine and its sci ence-based approach [40]. Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 415 Initially, this over-reliance on technology might be re- lated to the need to visualise (i.e. , biologically conceptu- alise) the pain. Subsequently, it is related to the need to establish an accurate and definitive d iagnosis, which will in turn lead to the desired resolution of the symptom. However, the participants also attributed their overreli- ance on technology to their difficulty in understanding the complaints of women with CPP. According to the participants, because the complaints are subjective, inva- sive methods are needed in order to establish an accurate diagnosis. Grace [41] and Price et al. [42] conducted qualitative studies investigating the perception that women with CPP have of the type of medical care received. The find- ings of those studies constitute evidence of the technical approach to health and show that health professionals reject and underestimate the complaints of those women, defining the symptoms on the basis of test results. In ad- dition, women with CPP have reported that their anxie- ties are not allayed during medical appointments [41,42]. Some of the consequences of the over-reliance on tech- nology in the health care setting include a strain on the doctor-patient relationship, the risk of iatrogenic compli- cations, excessive specialization; institutionalization of medical care, and increased health care costs. 3.5. Need for a Multidisciplinary Team Physician 6: “I think it should be a bit more integrated, especially in those patients in whom you can’t find a specific cause. Oh, [integrated] with psychology, physic- cal therapy.” Physician 6: “I believe that patients with chronic pel- vic pain need a multidisciplinary approach.” Physician 5: “In my opin ion, it is very difficult to treat women with chronic pelvic pain because there is a very strong psychological component; you have to address that.” The abovementioned statements show that the respon- dents recognise the importance of a multidisciplinary ap- proach. However, their belief in the importance of a mul- tidisciplinary approach is related to the difficulty that they have in managing aspects that are outside the realm of the technical and experimental. Therefore, the respon- sibility of addressing issues oth er than those o f biological nature is handed over to other health professionals, which contributes to the fragmentation of health care. According to Ferreira et al. [43], the treatment of chronic pain requires the involvement of an interdisci- plinary team including physicians, nurses, physical therapists, and psychologists. The teams should provide information regarding the disease, as well as explore is- sues such as self-perception, attitude, and self-care in order to help those women develop better strategies to control the behaviours and experiences related to the disease [43]. 4. Discussion The limitations of the biomedical model become evident in the chronic pelvic pain care setting. The canons of biomedicine require that individuals be “pigeonholed” into pre-established disease categories often ignoring the multifaceted nature of the CPP. In recent decades, how- ever, there has been an increasing concern over the training of future health professionals. The curriculum guidelines for undergraduate medical courses recom- mend the inclusion of ethical and humanistic dimensions that allow students to develop attitudes and values to- ward citizenship, in an attempt to combine technical ex- cellence with humanistic traits. In clinical practice, there has been a search for alterna- tive methods of care (such as psychotherapy, acupunc- ture, and support groups) that permeate an ethical and humanistic model. Such methods allow us to achieve an integrated view of individuals, thereby making subjective expression, meanings, and worldviews central to the un- derstanding of illness. For some decades, the humanization of care has been on the agenda of certain entities supported by the World Health Organization. In recent years, the Brazilian Na- tional Ministry of Health has invested in improving hos- pital management and the medical care provided to the population, in an attempt to build a culture of humanistic care. The concept of humanization of care is based on the idea of a model that is focused on the possibility of communication and dialogue between users and health professionals. One of the gr eatest challeng es in provid ing humanistic health care lies in reconciling quality health care—anchored in a well-established body of knowledge and based on the regularities of the health-illness contin- uum—with the subjective dimension and the sociocul- tural background of patients. However, in order to achieve a health care model that is based on such prince- ples, we need to go beyond the standard application of norms and rules of scientific medicine [40]. On the other hand, there are some important analogies to be made within the context o f the CPP to emphasize the complex- ity of the condition. For example in the appropriate use of terms such as “disease and illness”, where the latter term, which is more appropriate for the condition in question, is considered a complex interaction of psycho- logical, social, medical or even the subject of the experi- ence and self-attribution sometimes. This analogy leads us also to reflect about the concepts of nociception and pain. Studies have shown that brain regional changes, which occur only after input of the nociceptive CPP, play an important role in chronic pain. These changes, since it occurred, may contribute to a perception of pain contin- ues even after the disappearance/removal of the initial Copyright © 2012 SciRes. IJCM
Biomedical Perspectives about Women with Chronic Pelvic Pain: A Qualitative Analysis 416 nociceptive stimulus. Additionally, whether pain be- comes chronic depends on the interaction of various fac- tors, namely the persistence of the peripheral pain gen- erator, the antinociceptive capacity, and (maladaptive) neuroplasticity of the pain system [44]. Accordingly, the problem involving the CPP must not be limited of the biomedical model or quality of care. 5. Final Consideration In the present study, we investigated the perception that health professionals have of the problems related to the treatment of chronic pelvic pain. Although the present study is by no means definitive, we believe that it pro- vides the basis for further discussion of the model on which medical education and practice are currently based, as well as of the possibility of adjusting or even restruc- turing that model. 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