Medical education and distrust modulate the response of insular-cingulate network and ventral striatum in pain diagnosis

Abstract

Healthcare providers often underestimate patients’ pain, sometimes even when aware of their reports. This could be the effect of experience reducing sensitivity to others pain, or distrust toward patients’ self-evaluations. Across multiple experiments (375 participants), we tested whether senior medical students differed from younger colleagues and lay controls in the way they assess people’s pain and take into consideration their feedback. We found that medical training affected the sensitivity to pain faces, an effect shown by the lower ratings and highlighted by a decrease in neural response of the insula and cingulate cortex. Instead, distrust toward the expressions’ authenticity affected the processing of feedbacks, by decreasing activity in the ventral striatum whenever patients’ self-reports matched participants’ evaluations, and by promoting strong reliance on the opinion of other doctors. Overall, our study underscores the multiple processes which might influence the evaluation of others’ pain at the early stages of medical career.

The effect of uncertainty on pain decisions for self and others

“…On the one hand, pain-diagnostic cues can be characterized by a high level of uncertainty, for instance when different behavioral signs (e.g., facial expressions, posture) are inconsistent with one another, or with information from the clinical chart (presence of injury). Our study suggests that such uncertainty would promote pain underestimation, something that has been systematically observed in clinicians ( [51]; [52]), as early as during university training ( [17]; [14]), and that was associated with considerations on the reliability of patient self-reports ( [60]; [17]). On the other hand, our study also informs on the role played by uncertainty during pain management, suggesting that providers privilege mild but sure pain reductions, rather than risky but potentially more effective ones.…”

“…First, participants were instructed to map first pain experiences at ~1 on a 0-10 scale, whereas previous studies do so at ~4 (e.g., [24]). Furthermore, in the main experiment we employed a scale anchored by emojis (see also [17]). These changes were implemented to provide more accessible anchors and minimize confusion between different parts of the trial structure (Figure 1B).…”

“…Hagiwara et al, 2020). Furthermore, in the main experiment we employed a scale anchored by emojis (see also Dirupo et al, 2021). These changes were implemented to provide more accessible anchors and minimize confusion between different parts of the trial structure (Figure 1b).…”

Cognitive exertion affects the appraisal of one’s own and other people’s pain

“…Physicians and nurses are often tasked with assessing patients’ pain under tiring working schedules. As such, they often underestimate patients’ pain 1,4 , a tendency present even during early university training 79,80 . Our data directly link underestimation of others’ pain to elevated attentional demands, such as keeping multiple information in working memory, and/or monitoring competing sources of information in order to prevent the selection of an incorrect response.…”

“…Here we engaged participants in one of two demanding paradigms, involving either working memory (Experiment 1: N-Back task) or inhibition (Experiment 2: Stroop task), to investigate the effects of cognitive exertion on the subsequent assessment of one's and others' pain. Based on previous research, we expected the demanding tasks to influence intensity ratings of self-pain, albeit with unascertained direction 26,62,65 . The critical question was whether the same manipulation would influence the pain perceived in others in similar (as predicted by embodied accounts) or opposite fashion (suggested by the broaden-and-build theory) with respect to self-experienced pain.…”