Visit Linearity in Primary Care Visits for Patients with Chronic Pain on Long-term Opioid Therapy

J Gen Intern Med. 2022 Jan;37(1):78-86. doi: 10.1007/s11606-021-06917-z. Epub 2021 Jun 22.


Background: Physicians and patients report frustration after primary care visits for chronic pain. The need to shift between multiple clinical topics to address competing demands during visits may contribute to this frustration.

Objective: This study creates a novel measure, "visit linearity," to assess visit organization and examines whether visits that require less shifting back and forth between topics are associated with better patient and physician visit experiences. It also explores whether visit linearity differs depending on the following: (1) whether or not pain is a major topic of the visit and (2) whether or not pain is the first topic raised.

Design: This study analyzed 41 video-recorded visits using inductive, qualitative analysis informed by conversation analysis. We used linear regression to evaluate associations between visit organization and post-visit measures of participant experience.

Participants: Patients were established adult patients planning to discuss pain management during routine primary care. Physicians were internal or family medicine residents.

Main measures: Visit linearity, total topics, return topics, topic shifts, time per topic, visit duration, pain main topic, pain first topic, patient experience, and physician difficulty.

Key results: Visits had a mean of 8.1 total topics (standard deviation (SD)=3.46), 14.5 topic shifts (SD=6.28), and 1.9 topic shifts per topic (SD=0.62). Less linear visits (higher topic shifts to topic ratio) were associated with greater physician visit difficulty (β=7.28, p<0.001) and worse patient experience (β= -0.62, p=0.03). Visit linearity was not significantly impacted by pain as a major or first topic raised.

Conclusions: In primary care visits for patients with chronic pain taking opioids, more linear visits were associated with better physician and patient experience. Frequent topic shifts may be disruptive. If confirmed in future research, this finding implies that reducing shifts between topics could help decrease mutual frustration related to discussions about pain.

Keywords: chronic pain; opioid analgesics; physician-patient communication; primary care; visit linearity; visit organization.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adult
  • Analgesics, Opioid*
  • Chronic Pain* / drug therapy
  • Humans
  • Office Visits
  • Pain Management
  • Physician-Patient Relations
  • Primary Health Care


  • Analgesics, Opioid