The Patient Centered Pain Interview
George D. Comerci, Jr., MD, FACP, DAAP
University of New Mexico: Department of Internal Medicine
Pain Consultation and Treatment Center
Project ECHO Chronic Pain and Headache Clinic
Introductions
I begin the patient interview by shaking hands with the patient and by introducing
myself and my role.
“Hi, my name is George Comerci. I’m one of the pain doctors here in the clinic and you
are…?”
“What would you like me to call you Mrs. Smith?”
Most patients will say, “Oh, just call me Barb” but some will prefer a more formal
approach.
At this point, I make sure to check the environment for distractions: turn off TVs if in the
hospital and I often make it a point to turn my cell-phone to vibrate mode. I also make
it a point to turn the computer screen to the patient so that we both can view it and I
make a concerted effort to gaze at the screen as little as possible during the interview.
If the exam room is excessively cold, I offer either to move to a warmer room, or offer
the patient a blanket. (In my office I have no control over the thermostat!)
Chief Complaint(s):
I usually begin the interview with a statement like the following:
I
“What brings you in today” or “What would you like to discuss with me today” or
“What’s on your mind to discuss today”
While the patient with chronic pain often has a major pain symptom, it is very common
for the patient to have several other pain concerns. It is very important to make sure to
elicit all of the patient’s pain complaints, or they might feel that they have been
thoroughly evaluated. At this point in the interview the goal is really to get a list of the
patient’s concerns and not to explore them in detail yet. I often liberally use the phrase
“what else…” after the patients identifies his or her complaints. I ask “what else” until
the patient informs me that there are no other pain complaints. This not only ensures
that I know what the patient needs to discuss, but also avoids questions about other
pain complaints as you conclude the encounter and prepare to leave the exam room.
Set the agenda
At this point I summarize the list of complaints and indicate that I would like to explore
each one individually and then move on to other questions related to the patient’s
health such as those related to previous illnesses, habits and problems. I then explain
that a physical exam will follow this. By doing this I give the patient a sense of what is
going to happen with our time together thereby enabling the patient to know what to
expect that I will ask and do. I conclude my agenda with a statement like
“How does this sound, Barb?”
History of Present Illness
Now I would like to concentrate on each of the patient’s pain complaints individually.
The history is literally “his/her-story.” I try to accomplish this by asking the patient to
tell me “the story of your back pain, from when it started up till now.” Many clinicians
panic at the thought of allowing the patient to tell their story, worrying that there will
not be enough time to get through the history. I have found that by skillful use of open
ended questions, more directed questions (closed ended questions) and careful
guidance of the patient through the interview process that I am able to obtain a more
thorough history in a timely manner. Patients also feel that they have had the
opportunity to explain themselves better. I try to encourage the patient to disclose the
details of the pain story by abundant use of techniques that enable the patient to feel
more comfortable telling the story. These techniques are called “facilitory techniques.”
Here are a few:

Open ended questions:
“Please tell me about what your back felt
like after you heard it pop when you lifted that box”
vs. “what level was your pain when you
hear that pop” (closed-ended question
necessitating a yes/no response or a brief
response

Use of non-verbal techniques:
comfortable body language
Nodding positively, silence,

Use of verbal techniques
Affirmative statements such as: “I
understand.” “Please go on.” “Uh-huh.”

Reflective statements:
felt like I would faint
Patient: “the pain radiated to my neck and I
Clinician: “so you felt it was bad enough to
cause you to faint…”

Empathic statements
Patient: “The pain was so bad I couldn’t
work and was worried about losing my job”
Clinician: “That must have really worried
you. Losing a your job would have been
very difficult”

Emotion seeking statements
Clinician: (noting that a patient becomes a
bit tearful while describing that her spouse doesn’t
understand her pain)
“Mrs. Smith, you seem upset.
Would you like to talk about this more?

Emotion handling statements
Clinician: “It’s often good to get these
worries off your mind and to talk about them even
though they may be painful”
As the history unfolds, it will be necessary for the clinician to intersperse more directed
(closed) questions to obtain a complete pain history which has the following elements
The 7 Dimensions of the Pain Symptom

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Location of the pain(s)
Temporal factors of the pain: when does it occur in relation to daily
events/activities
Intensity of the pain (pain scale)
Quality of the pain
Radiation of the pain
Modifying factors (what makes the pain worse/better)
Associated symptoms (what else does the patient experience with the pain)
Prior Treatments of the Pain

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Prior consultations
Imaging
Pain-related Surgeries
Injections

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Medications [which ones, response to each]
Non-Interventional treatments such as: physical therapy, integrative treatments,
etc.
Functional Consequences of the Pain

How is the pain affecting the patient’s life with regard to :
Job/family/recreation/intimate relationships?

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What can’t the patient do that they could do previously?
What fears does the patient have about the pain?
What does the patient think is causing the pain and what does the patient think the
outcome of the pain will eventually be?
Summary of the History of Present Illness
After I have obtained a detailed pain history, I usually summarize in a few sentences the major
points of the patient’s pain concerns. This has two important purposes: First, it ensures that I
have understood the patient’s concerns and that my understanding is accurate. Second, it
assures the patient that he/she has been listened to.
“So Barb, I understand that your biggest concern is the pain in your low back which began after
your injury at work in 2004, which has caused you to not only lose your job but which has also
had a lot of other negative impacts on your life. I also heard you tell me that you were
concerned about headaches that occur daily, as well as some pain that you are having in your
knees when you climb stairs. Is that right?”
If there are no modifications needed in my understanding of the history, I proceed to the more
clinician-centered portion of the interview. While I continue to use good facilitative techniques,
I tend to utilize more focused, closed ended questions from here on. I also tend to use
transitions statements as I go from major topic to major topic.
“Barb, at this point, I would like to focus on other information about you that will help me
understand the whole medical picture. So now, I would like to ask you some questions about
your emotional health.”
Psychological History
It is unusual for a patient with chronic pain not to have related psychological or
emotional issues directly related to the pain syndrome or, perhaps not related but
important nevertheless. When approached sensitively and non-judgmentally, most
patients do not mind discussing their psychological history. Indeed, failure to elicit a
psychological history is a significant omission when interviewing the patient with
chronic pain. It is suggested that the following be discussed:
Adverse childhood events

Child abuse, significant family events that had an impact on the person (father
imprisoned, mother addicted to narcotics, etc.)
Current and past psychologic diagnoses:

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PTSD, depression, bipolar illness, suicide attempts
Treatments for psychologic problems
Social History
Another essential part of the history of the patient with chronic pain is the Social
History. Exploring the patient’s living arrangement, support system, education, and
occupation as well as the patient’s habits (good or bad) have a significant impact upon
pain and outcomes with chronic pain. Sometimes, I announce to the patient that a
sensitive question is coming so as not to make him/her feel awkward. This is a good
rule to follow during any part of the interview.
“Barb, my next few questions have to do with any problems you might have had with the
law. Are you ok with that? [Before asking questions about the criminal history]
Education: It is important to have some understanding of this in order to gauge the level
and sophistication
Living situation: home life, significant other(s), family, support system, financial security
(can they afford food, rent, etc.)
Occupation: nature of job, disability, unemployed, job security, workman’s comp, etc.
Criminal History: especially with regard to drugs/alcohol
Habits, past and present: drugs, alcohol, tobacco
Past Medical History
Past and current medical problems
Surgeries
OB/GYN History
Medications
Medication allergies and intolerances
Family History
Usually first degree relatives only
ROS
•
General/Constitutional
•
Neurologic
•
Psychological
•
Musculoskeletal
•
Digestive
•
Urologic
•
Endocrinologic
•
Vascular
•
Hematologic
•
Rheumatologic
•
Cardiovascular
•
Upper Respiratory and Pulmonary