A surgeon’s perception of a patient’s pain is subject to
inherent biases, which have been shaped and molded by
experience. Unlike the patient, physicians cannot rely
on internal cues and must make external assessments
and judgments based on whether the patient is being
truthful, what is an acceptable or expected amount of
postoperative pain, reasonable treatment measures, and
what may be drug-seeking behavior. There are several
ways to approach pain treatment to shift the mind-set
regarding postoperative pain management; however,
the largest body of evidence-based protocols is issued
through the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical
Care and Recovery (ISCR), which the American College
of Surgeons (ACS) recently launched in collaboration
with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD.
Formerly known as the AHRQ Enhanced Recovery
After Surgery (ERAS) program, ISCR provides multidisciplinary strategies for effective perioperative pain
management and requires therapeutic agreement
among surgeons, anesthesiologists, as well as patients
and their families.
Implicit bias and the perception of pain
A major hurdle facing physicians who seek to alter their
prescribing patterns is a lack of awareness regarding the
effect of their implicit biases on assessment and treat-
ment of patient pain. Although many facets of patient
care are likely to be influenced by the subtle attitudes,
assumptions, and stereotypes that constitute an indi-
vidual’s unconscious judgment, the evaluation of pain is
uniquely susceptible to these biases given the subjective
nature of an individual’s response to painful stimuli.
Factors known to influence a provider’s assessment of
patient pain include patient-reported symptom sever-
ity, judgments regarding patients’ trustworthiness, the
provider’s preconceived notion of how painful a par-
ticular procedure “should be,” prior clinical experience
in managing various disease states, and the degree of
empathy that a prescriber feels toward any given patient
or patient population.
1 Most often, internal conflict
arises when patient reports of pain symptoms are incon-
gruent with objective clinical signs.
Although visual aids, such as the Wong-Baker
FACES Pain Rating Scale, may diminish the subjective nature of a patient’s pain complaints, physicians
are trained to approach these assessments with some
2 Although a clinician would be justified to
question the reliability of a comfortably resting patient
who cries out in “10/10” pain upon stimulation, studies have demonstrated a correlation between patient
appearance and how trustworthy they seem to their
physician. Furthermore, pain judgment biases have
been shown to be rooted in clinicians’ perceptions of
patient ethnicity, age, gender, skin color, socioeconomic
status, and attractiveness.
3 Unsurprisingly, many of
these same factors influence the prescribing patterns
of analgesic agents.
One factor shown to mediate implicit attitudes
about pain assessment is clinician experience. Previous
experience is of particular relevance when considering
the capacity of surgeons to appropriately manage post-operative pain. Whereas inexperienced trainees may
underestimate the pain associated with fascial sutures
or “minor” anorectal procedures, they may be equally
as likely to overmedicate a “squeaky wheel” patient on
a busy call night. On the other hand, experienced providers may consciously or unconsciously undertreat
patients who remind them of prior drug-seeking individuals or they may fall into the trap of overtreating
pain complaints to achieve improved patient satisfaction scores. One common thread in many of these
potential scenarios is the physician’s failure to appreciate implicit biases. Use of procedure-specific ERAS
protocols is among the recently proposed methods to
combat implicit biases.
Opioid treatment of chronic pain
Opioids are the traditional treatment for acute surgical
pain, but they are poor treatment choices for chronic
pain. Approximately 11. 2 percent of adults in the
U.S. experience chronic pain, 3 to 4 percent of whom
are maintained on chronic opioid therapy.