"But when I come home…": How patients with chronic musculoskeletal pain account for their absent pain during naturally occurring clinical consultations.

When patients' embodied experiences cannot be conveyed to clinicians in real-time, the challenges of reaching a shared understanding between patient and clinician are enhanced. In this study, we explore how patients with chronic musculoskeletal pain manage the situation of knowing that they regularly experience pain, yet exhibit minimal signs of it during clinical consultations. Utilizing a multimethod, conversation analysis approach and an interactional perspective, this paper analyzes 10 naturally occurring consultations at a specialized rehabilitation clinic in Norway. The analysis shows that patients account for the absence of pain by referring to i) specific events, ii) pain tolerance, and iii) pain periods. Such accounts were typically triggered by null findings (i.e., the absence of findings in technological and physical tests) in the physical examination and clinicians' positive summaries of patients' bodily conditions. Patients resist clinicians' positive stance by accounting for absent pain, cautiously challenging the clinicians' epistemic stance. If clinicians do not pursue patients' accounts, this might lead to a misalignment between patient and clinician which can obstruct efforts to reach a shared understanding of the pain. These findings may have general relevance for clinical consultations where patients' symptoms are difficult to measure and validate biomedically. Understanding how patients account for absent pain can enhance clinician-patient communication and improve clinicians' understanding of patients' everyday circumstances and thereby improve the outcome of consultations.