Make chronic pain visits work better (for you and your patient) : 10 steps for primary care
A practical guide for primary care
You're not a pain specialist. But chronic pain patients end up in your office anyway.
They come because the specialist has a 6+ month wait (here it’s more 1-3 years..). Or because they've already seen three specialists and no one could help. Or because you're the only one who knows their full history and will still see them.
And you've got 15-20 minutes to address their pain alongside their diabetes, their blood pressure check, the medication refills, and whatever else they brought today.
It can feel impossible. You want to help, but you're not sure how. You're worried about saying the wrong thing, prescribing the wrong thing, or making promises you can't keep. Meanwhile the patient is frustrated, exhausted, and sometimes angry before you've even started.
Here's the thing: it doesn't have to be this hard. I promise
Not because there's a secret cure, but because small shifts in how these visits go can make a real difference, for your patients and for you. When chronic pain visits work, patients feel heard, you have a clear plan, and nobody leaves defeated. That's a win for everyone.
This article offers ten practical steps to get there. They're not specialist techniques. They're tools for primary care, built around the reality of short appointments, limited options, and patients who've often been let down before.
What you'll find here is a simple ten steps guide that mirror what we're teaching patients (this is part two of a two-part series with the same structure, but different responsibilities). I hope you’ll this helpful!
This is just two sides of the same conversation
This article is the second half of a two-part series. Last week, we published "10 steps to optimize your next appointment to talk about chronic pain", written for patients with chronic pain.
Same structure. Same goals. Different responsibilities.
| What the patient is doing | What you're doing |
|---|---|
| 1Clarify their main goal before the visit | 1Clarify the patient's main goal early |
| 2Describe pain beyond a number | 2Ask about function, not just pain scores |
| 3Focus on function | 3Anchor treatment to function-based goals |
| 4Be honest about what helps and what doesn't | 4Listen without judgment, ask follow-up questions |
| 5Bring a simple timeline | 5Acknowledge what they've already tried |
| 6Mention sleep, mood, stress, energy | 6Invite emotional context explicitly |
| 7Share fears and expectations | 7Address expectations and timelines |
| 8Prioritize concerns | 8Avoid overloading the plan |
| 9Ask for clarity | 9Check understanding before ending |
| 10Leave with a clear next step | 10Reinforce continuity and partnership |
This isn't about one side doing it right and the other doing it wrong. It's about building a shared framework where both people know their role. When that happens, visits feel less like a battle and more like a collaboration.
1. Start with validation before problem solving
Before you review imaging or adjust medications, acknowledge the suffering.
This doesn't take long. A single sentence can shift the entire tone of the visit: "I can see this has been exhausting for you." Or: "You've been dealing with this for a long time, that's hard."
Validation isn't agreement with every interpretation the patient offers. It's recognition that their experience is real and that you're taking it seriously. It's the difference between a patient who feels heard and one who spends the whole visit trying to convince you their pain is real.
What doesn't work: jumping straight to "Let's look at your MRI" or, worse, "Pain is normal after a certain age." Patients hear that as dismissal, even if you don't mean it that way. Same with pivoting immediately to weight loss or lifestyle. Those conversations might be necessary, but leading with them tells the patient you're not really listening.
This isn't just about being nice, patients who feel validated are more likely to engage with treatment and less likely to escalate demands. The research backs this up: perceived empathy correlates with better outcomes and higher adherence (Hojat 2011, Derksen 2013).
2. Ask about function early
Pain scores fluctuate and mislead. "7 out of 10" doesn't tell you what the patient can or can't do. It doesn't help you measure progress. And it often becomes a source of frustration, "I told you it was a 7 last time and nothing changed."
Function gives you clinical direction. Ask: "What does the pain stop you from doing?" or "What would meaningful improvement look like for you?" These questions anchor the conversation in the patient's actual life, not an abstract number.
When you focus on function, you also get better goals. "I want to be able to walk my dog again" is something you can work toward. "I want my pain to be a 3" is a moving target that sets everyone up for failure.
This shift pays off clinically. Function-based outcomes predict long-term quality of life better than pain scores, and rehab programs built around function consistently outperform pain-focused ones (Kamper 2015).
3. Clarify the patient's main goal for the visit
Misalignment is the silent killer of chronic pain visits. You might be focused on medication safety or avoiding unnecessary imaging. The patient might want reassurance that nothing serious is being missed. Or they might just want someone to acknowledge how hard this has been for them recently.
If you don't align early, both of you leave frustrated, and they book another appointment to try again.
Ask directly: "What would make today's visit helpful for you?" Sometimes the answer surprises you. They may not want a new medication. They may want permission to stop a treatment that isn't helping. They may just want to know you're not giving up on them.
Avoid vague openers like "So what brings you in?", that invites a 10-minute history you don't have time for. And don't lead with your agenda ("We need to discuss your opioid prescription") before you understand theirs. You'll get further if you start by listening.
It saves time too. Agenda-setting in the first minutes of a visit reduces revisit rates and improves satisfaction (Marvel 1999). Unaddressed concerns are one of the top reasons patients come back.
4. Normalize uncertainty when present
Chronic pain often doesn't come with a clear diagnosis. And as PCPs, we're trained to find answers, so uncertainty feels uncomfortable. But pretending certainty you don't have erodes trust faster than admitting you're not sure.
The key is to pair uncertainty with a plan. "We may not have a perfect structural explanation, but that doesn't mean your pain isn't real. Here's what I think we should try." That's very different from "Your MRI is normal, so I'm not sure what's going on", which leaves the patient feeling abandoned.
Avoid phrases like "There's nothing wrong with you" or "It's probably just stress." Even if stress is a factor, leading with that sounds like you're saying the pain isn't real. Patients can handle "I don't know exactly what's causing this." What they can't handle is feeling dismissed.
Patients tolerate uncertainty better than we expect, as long as it comes with a plan (Simpkin 2016). The plan is what builds confidence, not the diagnosis.
5. Align on a shared pain model
This is where many visits derail (especially when imaging is normal).
Patients often hear "Your MRI looks fine" as "Your pain isn't real" or "It's all in your head." That's not what you mean, but it's what they hear. And once that happens, you've lost them.
Take 30 seconds to explain chronic pain in terms of nervous system sensitization. Something like: "Your imaging doesn't show damage, which is actually reassuring — there's nothing dangerous happening. But chronic pain often involves the nervous system becoming oversensitive, like an alarm system stuck on high. That's a real biological change, not something you're imagining."
Avoid "Good news! your scans are clean!" (it doesn't feel like good news to them) or "That's just wear and tear, normal for your age" (which sounds like you're saying they should just accept it). When you share the same model of what's happening, patients stop pushing for more scans and start engaging with the actual plan.
Even a brief explanation helps. Pain neuroscience education reduces catastrophizing and improves function (Louw 2011, Watson 2019). Patients who understand what's happening are more likely to work with you on the plan.
6. Address expectations and timelines
Many patients arrive hoping for quick relief. Chronic pain rarely works that way. And if you don't address this directly, they'll lose faith in the plan before it has a chance to work.
Be explicit: "Chronic pain treatment is usually gradual, we're looking at weeks to months, not days." Or: "The goal is steady improvement in how you function, not necessarily zero pain. We'll adjust as we go."
Vague reassurance ("This should help") without a timeline sets patients up for disappointment. So does scheduling a follow-up in three months without any interim check-in, it feels like being sent away. And please avoid "You'll just have to learn to live with it." That's not a treatment plan. That's abandonment.
Misaligned expectations are one of the top predictors of treatment dropout and dissatisfaction (Main 2010). When patients know what to expect, and feel like you'll stick with them through the slow parts, they're far more likely to stay engaged.
7. Invite emotional context explicitly
Sleep, mood, stress, and trauma all modulate pain. This isn't psychosomatic hand-waving , it's neurobiology. Poor sleep increases pain sensitivity. Chronic stress amplifies the nervous system's alarm response. Past trauma can change how the body processes threat signals.
But patients won't bring this up unless you ask. Either because they don't see the connection, or because they're afraid you'll use it to dismiss their pain as "just anxiety."
Ask directly: "How has this been affecting your mood?" or "Is stress making things worse right now?" And then, this is important, don't immediately pivot to a prescription. If a patient mentions they've been anxious, resist the reflex to suggest a psychiatrist in the same breath. First, just acknowledge it. "That makes sense, chronic pain is exhausting, and it affects everything." Let there be a beat before you move to solutions.
What shuts patients down: "It sounds like this might be depression" (before validating the pain) or "This could be psychosomatic" (which they hear as "it's all in your head").
Psychological factors are among the strongest predictors of chronic pain outcomes, stronger than imaging findings (Nicholas 2011). Addressing them isn't dismissing the pain. It's treating the whole picture.
8. Avoid overloading the plan
It's tempting to cover all bases: PT referral, medication adjustment, sleep hygiene handout, weight loss conversation, stress management tips, follow-up in three months.
But patients with chronic pain often have brain fog and cognitive fatigue. They're not going to remember five recommendations. They'll leave overwhelmed and do none of them.
Prioritize one or two meaningful changes per visit. Be specific. Instead of "You should exercise more," try "I'd like you to try a 10-minute walk three times this week and tell me how it goes." Write it down if you can, or have them repeat it back.
Clear and achievable beats comprehensive and forgotten. A patient who actually does one thing is better off than a patient who leaves with ten recommendations and does nothing.
Cognitive overload tanks adherence, this is true across chronic disease management, not just pain (McGuire 1996). Simpler plans get better results.
9. Check understanding before ending
Patients often nod without clarity. This isn't defiance, it's cognitive overload, especially in someone who's been in pain for months or years and might also be dealing with medication side effects, poor sleep, or brain fog.
Before they leave, ask: "Can you tell me in your own words what we're going to try?" This isn't a test. It's a safety check. It reveals confusion early, improves adherence, and shows the patient you actually care whether the plan makes sense to them.
If they can't summarize it, simplify further. One thing. One clear next step.
What doesn't work: "Any questions?" asked while you're already standing up and reaching for the door. Or: "The pharmacy will explain the rest." That's not a handoff, that's a gap where things get lost.
Teach-back is one of the most reliable ways to improve recall and follow-through (Schillinger 2003). Patients forget 40–80% of what we tell them. Checking understanding isn't optional, it's how you make sure the visit actually counts.
10. Reinforce continuity and partnership
Chronic pain is longitudinal by definition. Unlike acute problems, it doesn't wrap up in one visit. Patients need to know you're not giving up on them, that you'll keep working on this together even when progress is slow.
Closing statements matter. "We'll see how this goes and adjust from there." "You're not on your own with this." "If things change before your next visit, call me."
What patients dread hearing: "There's not much more I can do." Or being referred to a pain specialist as a way to end the relationship rather than expand the team. Even worse: "At this point, you just need to manage it." That's not a plan, that's surrender.
Therapeutic alliance predicts chronic pain outcomes as strongly as the specific treatment used (Ferreira 2021). The relationship isn't separate from the medicine, it's part of it.
When the visit goes sideways (that can happen)
Not every visit goes smoothly. Sometimes patients arrive angry before you've said a word. Sometimes they want something you can't provide. Sometimes you're both just tired.
Here's how to handle the common stuck points.
The patient is angry or hostile
They're not angry at you specifically, they're angry at a system that has failed them. Don't take it personally (you can read my book review about “the 4 agreements” to help you as well!), but don't tolerate abuse either.
In this case: "I can see you're frustrated, and I don't blame you. Let's see if we can figure out a path forward together." If it escalates: "I want to help you, but I need us to be able to talk calmly. Can we reset?"
The patient wants something you can't or won't provide
Usually opioids, sometimes imaging or referrals.
You can try here: "I hear that you're hoping for [X]. Let me explain my concern, and then I'd like to understand more about what's driving that request." This opens a conversation instead of shutting it down. "I don't prescribe that" without explanation feels like a wall.
The patient doesn't believe your explanation
Especially about central sensitization or normal imaging.
What you can say: "I understand this is different from what you expected. Can I explain a bit more about how chronic pain works? It might help the plan make more sense." Avoid "The science is clear" (condescending) or "You need to accept this" (authoritarian).
The patient has seen five specialists and nothing has worked
This is demoralizing for both of you.
Your option here: "That sounds exhausting. It makes sense that you're frustrated. I may not have a magic answer either, but I'm willing to keep trying with you." That's often what they need to hear — not a solution, but a commitment.
You're running out of time
The most common problem of all.
You can say: "We're running short today, but I don't want to rush this. Can we schedule a longer visit to focus on your pain specifically?" Or: "Let's pick the most important thing for today and book a follow-up for the rest."
Acknowledging the time constraint is better than rushing through and leaving the patient feeling dismissed.
There is always a bigger picture :
Chronic pain care often falls to primary care by default. Specialists have long waits. Pain clinics have strict criteria. And someone has to be there for the patient in the meantime.
That's you.
These ten steps won't turn a 15-minute visit into a cure, I know that. But they can turn a frustrating visit into a productive one. One where the patient feels heard, you have a plan, and both of you know what comes next.
Validation isn't soft. Clarifying goals isn't extra. Checking understanding isn't optional. These are clinical skills, as much as any procedure or prescription.
Here's what I've learned from years in practice as a surgeon, a family physician and chronic pain doctor, hearing patients describe every appointment they've had before they got to me: the visits they remember, the ones that changed things, weren't always the ones that fixed the pain. They were the ones where someone finally listened and tried to help them.
Remember, you don't have to fix the pain to help the patient.
