Pain rating by patients and physicians: evidence of systematic pain miscalibration

Abstract

This study is an investigation of the existence and potential causes of systematic differences between patients and physicians in their assessments of the intensity of patients' pain. In an emergency department in France, patients (N=200) and their physicians (N=48) rated the patients' pain using a visual analog scale, both on arrival and at discharge. Results showed, in confirmation of previous studies, that physicians gave significantly lower ratings than did patients of the patients' pain both on arrival (mean difference -1.33, standard error (SE)=0.17, on a scale of 0-10, P<0.001) and at exit (-1.38, SE=0.15, P<0.001). The extent of 'miscalibration' was greater with expert than novice physicians and depended on interactions among physician gender, patient gender, and the obviousness of the cause of pain. Thus physicians' pain ratings may have been affected by non-medical factors.

Ratings of global outcome at the first post-operative assessment after spinal surgery: how often do the surgeon and patient agree?

“…These findings concur with those of a previous investigation in which the underestimation of patients' pain ratings by physicians in an emergency unit setting was greater in more experienced physicians [11]. It was suggested that, when rating pain, patients are likely to have in mind the worst pain they have felt, and physicians the worst pain they have seen [11]. This difference in references points was considered likely to induce a ''miscalibration'', since people make judgements depending on their own reference points.…”

“…Using a convention in which the patient's rating was considered the ''true'' value, outcome was more commonly ''overestimated'' by senior surgeons than by juniors. These findings concur with those of a previous investigation in which the underestimation of patients' pain ratings by physicians in an emergency unit setting was greater in more experienced physicians [11]. It was suggested that, when rating pain, patients are likely to have in mind the worst pain they have felt, and physicians the worst pain they have seen [11].…”

“…The analogous interpretation in the present study would be that senior surgeons, who have likely seen more ''extremely bad results'' (or generally more extreme pain and disability) in their time, use this as the anchor for the ''extreme end'' of the scale, such that in comparison any given outcome is rated ''less negatively'' than it might otherwise be. Marquie et al [11] also considered that the greater training and years in the job might allow senior physicians to better identify which cues are relevant and to neglect those they have learnt to be unreliable. This is a positive way of looking at the phenomenon; an alternative interpretation may be that the compassion for and empathy with the patient, shown by a healthy, pain-free, active, and enthusiastic young colleague, is simply higher.…”

“…Another study compared the results from a 16-item clinical evaluation questionnaire after hip arthroplasty: for 12 items, acceptable consensus was found, although for patients with other health problems, revision surgery or mild to moderate pain there was a greater likelihood of disagreement [12]. Generally, where disagreement has been recorded in these studies, it is the case that the clinician systematically overrates outcome or underrates symptoms compared with the patient [11,12,16] and the discrepancy is more marked the more senior the clinician [11] and the poorer the patients' outcome [1,6]. To the authors' knowledge, no study has investigated this issue in any depth in patients undergoing spine surgery.…”

Taking into account the observers’ uncertainty: a graduated approach to the credibility of the patient’s pain evaluation

“…In particular, a vast range of studies point to the fact that there is a discrepancy between patients' self evaluations and judgments expressed by observers, often resulting in a phenomenon of "pain underestimation" (e.g., MacLeod et al, 2001;Marquié et al, 2003;Kappesser et al, 2004;Kappesser et al, 2006). This well-established tendency might bear major consequences.…”