Why do Healthcare Professionals Underestimate Pain and its Consequences - and does it matter ?

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We know from many studies that healthcare professionals (HCP) generally make significant underestimations of their patients’ pain intensity and the impact of the pain. But why, and what can we do to improve that?

In a Finnish study from primary care 738 patients rated their pain on a VAS-line and at the same time their GPs also rated the patient’s pain. There were generally significant underestimations made by the GPs and this discrepancy was increased in those patients who rated their pain most severe [1]. This has been demonstrated for all kind of HCPs, nurses, physicians, physiotherapists, psychologist etc. The phenomenon is extended beyond pain and also includes the pain’s impact on the patients Quality of Life (QoL). In one study looking at cancer patients, the physicians reported patients to have fewer problems/symptoms than patients did for all QoL domains except for physical and social functioning [2].

There seems to be several factors influencing this underestimation. HCPs tend to concentrate on the organic origin of pain, and to view pain as subordinate to diagnosis and treatment of the disease; they also tend to underestimate the psychological and psychosocial components of pain, which means that they generally view the patient’s subjective experience as secondary. This leads to an underestimation of pain.

This is mentioned in a just published study [3]. Furthermore in studies aimed at investigating levels of knowledge about pain management methods, decision-making processes, or doctors’ knowledge regarding pain management, there is evidence of a discrepancy between knowledge effectively possessed (mediocre) and self-evaluation (positive) as expressed by doctors and nurses [3,4,5].

More, probably a lot more, factors are influencing this. It seems as if the extend of miscalibration is greater with expert than novice physicians (!), physician gender, patient gender [6], communication verbally and non-verbally, the supposed origin of the pain and much more.

Pain is – by definition – subjective, and HCPs will never be able to fully understand the individual patient’s pain and its impact on their QoL. Not even their relatives are able to fully understand this,: Only the patient knows how it feels and what the pain does to their life and QoL.

Based on this it seems obvious that we must measure the patients experience of pain, and many HCPs do that, even though there is still a long long way to go. Many HCPs find these pain ratings difficult to deal with since they are not “absolute objective” as a blood pressure measurement is. This also means that pain scores cannot be compared between patients, or to put it otherwise, the patients are their own reference since they themselves define the anchors of the VAS. Your “45” on a 0-100 VAS might – and normally will – be different than my “45”. This makes the idea of deciding to treat patients to a well-defined VAS-pain score as not meaningful, since this is exactly comparing the scores and neglecting all the other aspects of the pain experience.

So is pain measurement meaningful? Both yes and no. Yes because it is an indication of the patient’s pain intensity, no because it is only part of the truth, as demonstrated in a recent study looking at the connection between VAS-pain score and use of pain medication – there were absolutely no connection [7]. Measuring VAS-pain score alone is like measuring blood sugar alone in diabetes and neglecting blood pressure, cholesterol etc. – and we don’t do that, do we?

To improve all this with the ultimate goal of getting optimal pain control, HCPs must extend their understanding of pain from a disease oriented view looking at pain alone to a more patient centred or individualized approach including other factors of living with pain than the symptom alone. And understand, that it changes over time.

In my opinion it is even more important to let the patient him or herself understand the concept and complexity of their life with pain. The patient is their own best helper, the only one who can set the goal for the treatment and the only one to know when it is reached, but they must have help form HCPs each contributing with their speciality and competences.

Take a look at the DoloTest website.

Reference:

1. Mäntyselkä P, Kumpusalo E, Ahonen R, Takala J. Patients’ versus general practitioners’ assessments of pain intensity in primary care patients with non-cancer pain. Br J Gen Pract 2001, Dec;51(473):995-7
2. Petersen MA, Larsen H, Pedersen L, Sonne N, Groenvold M. Assessing health-related quality of life in palliative care: Comparing patient and physician assessments. Eur J Cancer 2006, May;42(8):1159-66.
3. Montali L, Monica C, Riva P, Cipriani R. Conflicting representations of pain: A qualitative analysis of health care professionals’ discourse. Pain Medicine 2011.
4. Green CR, Wheeler JRC, LaPorte F, Marchant B, Guerrero E. How well is chronic pain managed? Who does it well? Pain Medicine 2002;3(1):56-65.
5. Watt-Watson J, Stevens B, Garfinkel P, Streiner D, Gallop R. Relationship between nurses’ pain knowledge and pain management outcomes for their postoperative cardiac patients. J Adv Nurs 2001, Nov;36(4):535-45
6. Marquié L, Raufaste E, Lauque D, Mariné C, Ecoiffier M, Sorum P. Pain rating by patients and physicians: Evidence of systematic pain miscalibration. Pain 2003, Apr;102(3):289-96
7. Suzanne G, Maryann C, Jayme S, Charles A, James S, Linda B. Pain scores are not predictive of pain medication utilization. Pain Research and Treatment 2011;2011

Kim Kristiansen, M.D. (2011). Why do Healthcare Professionals Underestimate Pain and its Consequences -and does it matter ? Picture of Pain Blog : why-do-healthcare-professionals-underestimate-pain-and-its-consequences