How do medical students use and understand pain rating scales?

Abstract

<jats:title>Abstract</jats:title><jats:sec id="j_j.sjpain.2016.12.007_s_008_w2aab2b8c35b1b7b1aab1c16b1Aa"><jats:title>Background and aims</jats:title><jats:p>Pain is a multidimensional experience that is difficult to describe and to assess. To scale current pain, assessment refers to a maximum level of pain, but little is known about this process. Further, clinicians tend to underestimate patients’ pain, with or without patients’ own reports, and to underestimate to a greater extent with more clinical experience, possibly due to recalibration of a personal pain scale with increasing exposure to severe pain. We sought to determine how medical students rated pain in early years of clinical exposure, and in relation to experience of their own and others’ worst pains.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2016.12.007_s_009_w2aab2b8c35b1b7b1aab1c16b2Aa"><jats:title>Methods</jats:title><jats:p> An online survey sampled medical students’ rating and description of their own worst pain and of that witnessed in another; also what would cause the maximum level of pain and what behaviours characterised it. Last, they indicated their preference among pain scales.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2016.12.007_s_010_w2aab2b8c35b1b7b1aab1c16b3Aa"><jats:title>Results</jats:title><jats:p> Thirty-six medical students provided responses, the majority in their first six months of clinical exposure. Students’ own worst pain was rated a mean of 6.7/10 (s.d. 1.6) on a numerical scale; causes were diverse but with many bone fractures. Mean worst pain observed in another was rated 8.6/10 (s.d. 1.4); causes included fractures, gallstones, and sickle cell crises. Another’s worst pain was significantly higher (mean 9.4, s.d. 0.8 vs mean 8.0 s.d. 1.4) when rated after the student’s own pain than before it (presentation order randomised).</jats:p><jats:p>We found no effect of clinical exposure on estimation of worst pain in another person, nor was there a personal tendency to rate pain using more or less extreme values. Students expected pain of 10/10 to be presented with many verbal, facial and whole body behaviours, and signs of physiological stress. Collectively, behavioural descriptions were rich and varied, but with many incompatibilities: for instance, between ‘writhing’ and ‘rigidity’ expected in the person with extreme pain. Most students preferred the numerical rating scale over visual analogue and verbal scales.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2016.12.007_s_011_w2aab2b8c35b1b7b1aab1c16b4Aa"><jats:title>Conclusions</jats:title><jats:p>The study requires replication, particularly for clinical experience, where we found no significant difference in estimation of another’s pain over the first three years of medical students’ clinical exposure, but the comparison was underpowered. Despite no systematic individual difference in using pain ratings, there was a marked effect of rating another’s worst pain higher when the rater had previously rated his/her own worst pain. This suggests anchoring estimate of another’s pain in personal pain experience, and a possible way to mitigate clinicians’ underestimation of patients’ pain.</jats:p><jats:p>Medical students’ recognition of the importance of facial expression in indicating another’s pain severity was encouraging, but most students anticipated only a narrow range of behaviours associated with extreme pain, thereby excluding other authentic behaviours.</jats:p></jats:sec><jats:sec id="j_j.sjpain.2016.12.007_s_012_w2aab2b8c35b1b7b1aab1c16b5Aa"><jats:title>Implications</jats:title><jats:p>Many clinical guidelines mandate regular pain assessment for hospital inpatients, and encourage routine assessment in community and outpatient settings, in order to decide on and monitor treatment. Replication and elaboration of this study could extend our understanding of how clinicians interpret pain scales completed by patients, and how they estimate patients’ pain.</jats:p></jats:sec>

Pain in Advanced Stages of Dementia: The Perspective of Medical Students

“…Thus, they require a more difficult assessment strategy, which possibly makes the students less likely to indicate them. It is in line with the observation of Zalmay and Williams [20] who determined how medical students used and understood pain rating scales. They showed that, although medical students’ recognition of the importance of facial expression was encouraging, they expected a narrow range of other pain-associated behaviors.…”

The utility and validity of pain intensity rating scales for use in developing countries

“… 33 , 34 , 47 , 49 These findings contrast with those studies using samples from western countries, which tend to find higher preference rates for the NRS over the VRS (although several of these studies did not compare these 2 scales with the FPS or FPS-R). 15 , 31 , 38 , 48 …”