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The search for an objective measure of pain

The search for an objective measure of pain
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How much does it hurt? You might think this is one of the simplest questions in health and medicine. But in fact, that can be a remarkably difficult question to answer objectively.

Consider a doctor who has two patients who grimace and use similar words to describe their pain. Can the doctor be sure they are feeling similar levels of pain? What if we usually underestimate their suffering? What if one has suffered for a long time and got used to it? And what if the doctor has certain biases that mean he is more likely to believe one patient than another?

Pain is a difficult beast to fight, difficult to measure and therefore difficult to treat. Pain can be a major distress signal and not addressing it could mean a missed opportunity to save a life – or it could be something much more minor.

For such a universal experience, pain remains a mystery, especially the task of determining a person’s degree of pain. “We understand it so poorly,” says Emma Pierson, a Stanford University computer scientist who studies pain. “In particular, the fact that human physicians are often baffled by why a patient is in pain suggests that our current medical understanding of pain is quite poor.”

The gold standard for pain analysis currently relies on patients self-reporting how they feel, using various locations on a numerical scale (0 as no pain, 10 as worse pain) or on a system of smiling faces.

“The first step in properly treating pain is measuring it accurately and that’s the challenge,” says Carl Saab, who leads a pain research team at the Cleveland Clinic in London. “The standard of care these days is based on ‘smiling faces’ that enigmas emergency rooms.” This system can be confusing for patients, he says, and particularly problematic when treating children and non-communicative patients.

Then there is the issue of whether the patient’s assessment is believed. A study has revealed a widespread notion that people tend to exaggerate the level of pain they are in, despite little evidence to suggest such exaggeration is common.

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Without an objective way to measure pain, there is room for bias to creep into clinicians’ decisions. “Pain has an especially large impact on underserved populations, and their pain is particularly susceptible to being overlooked,” says Pierson.

Unfortunately, false beliefs about pain are widely held among physicians. In 2016, a study found that 50% of white medical students and residents in the United States had very dangerous and misconceptions about black people and their experience of pain. Another study found that almost half of medical students had heard negative comments about black patients from their senior colleagues, and the level of racial bias among these students increased significantly during their first four years. of medical training.

These prejudices date back to historical attempts to justify slavery, including false claims that black people had thicker skin and different nerve endings. Now, black patients in the United States are 40% less likely to have their pain treated than white patients. Hispanic patients, meanwhile, are 25% less likely than white patients to have their pain treated.

Racial discrimination is not the only form of prejudice that influences pain treatment. The prejudices around “hysterical women” are still well known in medicine, especially around pain. A review of 77 separate research studies found that terms like “sensitive” and “complaining” are more often applied to women’s reports of pain. A study of 981 people found that women who came to the emergency room because of pain were less likely to receive pain relief and had to wait 33% longer than men for treatment. Additionally, when men and women reported similar levels of pain, men received stronger drugs to treat it.

Social expectations about what is “normal behavior” for men and women drive these patterns, says Anke Samulowitz, who studies gender bias at the University of Gothenburg in Sweden. These biases are in addition to “medically unwarranted differences in how men and women are treated in health care.”

There are, she notes, sometimes genuine reasons why men and women might receive different treatment for a particular complaint. “Differences associated with hormones and genes should sometimes lead to differences, for example, in painkillers,” she says. “But not all of the observed differences in the treatment of men and women with pain can be explained by biological differences.”

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