Night has fallen. Sadly, you are doubled up with pain. You want to go to the hospital for help.
Your timing might be unfortunate, going by a new study published Monday in PNAS by Israeli and American researchers that found emergency-room doctors are significantly less likely to prescribe painkillers during night shifts.
Pain is difficult to quantify objectively. How many times has a caregiver asked, “How much does this hurt on a scale of one to 10?” How do you know? What are you supposed to say? Giving birth hurt more than the falling tree crushing your foot, so say that’s nine versus six, reserving 10 for the pains of hell? Who knows?
Even so, every time people go to the ER, there are standard tests and questions: your blood pressure is measured and, if relevant, you are asked to quantify your pain.
But the multidisciplinary team behind this paper, led by Prof. Shoham Choshen-Hillel of Hebrew University and colleagues, suspected that sleep-deprived, irritable doctors on night shift may feel short on empathy for their patients.
Indeed they may, according to their findings, summed up in their title: “Physicians prescribe fewer analgesics during night shifts than day shifts.”
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Yes, if you go to hospital at night with a painful complaint, you may be less likely to get pain medication, the researchers say, based on analyzing the feelings of 67 Israeli emergency doctors who filled out questionnaires, and analyzing no fewer than 13,482 discharge letters for patients in Israel and the United States who went to hospital between 2013 and 2020 with a chief complaint of pain: headache, back pain, and so forth. (About 9,000 were Israeli discharge letters and the rest from Missouri, Choshen-Hillel says – that’s where their U.S. research partner was located.)
What was the theory, at core? That the timing of physicians’ work might be a previously unrecognized source of systematic bias in pain management. So it seems to be.
Ouch, I say ouch
Pain is not a rare problem. Almost 60 percent of American adults above 18 say they felt pain in the past three months, the authors say. There is no parallel figure for Israelis, but Choshen-Hillel says she suspects it’s probably similar.
The researchers’ first step was questionnaires for 67 resident doctors, some after a 26-hour shift, some before it. They found the post-night shift doctors tended to evince less empathy with their patients, as shown in their subdued emotional responses to pictures of people in pain. The post-night shift doctors also consistently scored actual patients low on pain assessment charts.
The next step was statistically more interesting: checking actual medical decisions made by ER doctors in the United States and Israel based on the discharge letters. Indeed, across all data sets, physicians were a fifth to a third (20 to 30 percent) less likely to prescribe painkillers during night shifts compared to day shifts.
At night, they even tended to prescribe fewer painkillers than generally recommended by the World Health Organization, the researchers say. This bias remained significant even after adjusting for patients’ reported levels of pain, patient and physician demographics, type of complaint, and emergency department characteristics, the researchers claim.
“The researchers explain that even medical experts, who strive to provide the best care for their patients, are susceptible to the effects of a night shift,” said co-author Anat Perry.
What on earth is one to do with this information? Asked how to get a testy, sleep-deprived, past-empathy doctor to heed your agony, Choshen-Hillel points out that you just have to tell them. You will get the medications you need.
So, if asked how much something hurts from one to 10, don’t roll on the floor begging to be put out of your misery for nothing but don’t be a hero.
Or, if you’re the shy type who shrinks at describing your pain, you might want to try to wait for morning.
Meanwhile, the team is discussing the problem with Hadassah medical staff in Jerusalem, with the idea of a tech fix to this painful problem, through text messaging. Why not, hasn’t text messaging solved all your other problems in life? The text message would be an automated one from the system, noting that Patient X has reported a high level of pain but Doctor Y did not prescribe analgesic, and is Doctor Y sure about that decision?