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Tired night duty doctors biased in pain management – Israeli-US study

Exhaustion, burnout and ‘physician fatigue’ have a negative impact not only on doctors’ well-being, but also on patient care, a study has showed. According to its findings, physicians are less likely to prescribe pain medication during a long night shift than they are during a new day shift.

The researchers, from universities in Israel and the US, hypothesised that during night shifts, factors like sleep deprivation, fatigue and stress could reduce a doctor’s empathy for a patient’s pain, and cause them to under-prescribe pain relief medication.

Based on their results, they conclude that night shift work is an important and previously unrecognised source of bias in pain management, reports News24.

Co-author and psychologist Anat Perry, from the Hebrew University of Jerusalem in Israel, said: “Our finding is that night shift work is an important and previously unrecognised source of bias in pain management, possibly stemming from impaired perception of pain.”

Even medical experts, who strive to provide the best care for their patients, are susceptible to the effects of a night shift, he added.

The researchers recruited 31 resident doctors in Israel who were working day shifts and 36 who were about to end a gruelling 26-hour shift. They were all given hypothetical scenarios about a female patient with a headache and a male patient with backache.

Those who were nearing the end of their shift rated the pain of the patients as less severe. They were also less likely to prescribe painkillers to relieve the patient’s pain, compared with those who were at the start of their shift.

“These results highlight the need to address this bias by developing and implementing more structured pain management guidelines and by educating physicians about this bias,” study co-author and paediatric pulmonologist Dr David Gozal from the University of Missouri School of Medicine.

Pain management is a huge challenge in the modern healthcare system. More than 50% of US adults report experiencing pain in the past three months.

Second part of study

In the second part of the study, which was to verify their initial findings, the research team analysed actual medical decisions made by emergency room doctors in the US and Israel. They looked at more than 13,400 discharge letters for patients, collected between 2013 and 2020. Their analysis revealed that doctors were 20%-30% less likely to prescribe pain medication during a night shift.

Worryingly, many of the cases examined showed that doctors failed to adhere to World Health Organisation (WHO) recommendations by not prescribing painkillers.

“The fact that the divergence of analgesic prescription from the general WHO guidelines is greater during night shifts suggests there is indeed an under-prescription during night shifts, rather than an over-prescription during the daytime,” said Gozal.

Even after controlling for factors such as the level of pain reported, the type of complaint, and variations in emergency departments, the bias was still present, the team found, suggesting this might be due to a lower level of empathy for patient pain when doctors are themselves feeling worn out.

Implications for other workplaces

Considering these results, the team suggests implementing more structured pain management guidelines in hospitals. But more than this, they also underscore the need to improve physicians’ working schedules to avoid empathy or decision fatigue.

“Our findings may have implications for other workplaces that involve shift work and empathic decision-making, including crisis centres, first responders, and the military,” said co-author Dr Alex Gileles-Hillel, a paediatric pulmonologist.

This study may have focused on doctors, but “these results should probably matter to all people who are sleep-deprived”, he added.

The research appears in the peer-reviewed journal PNAS.

Study details
Physicians prescribe fewer analgesics during night shifts than day shifts

Shoham Choshen-Hillel, Ido Sadras, Tom Gordon-Hecker, Shir Genzer, David Rekhtman, Eugene M. Caruso, Koby L. Clements, Adrienne Ohler, David Gozal, Salomon Israel, Anat Perry and Alex Gileles-Hillel.

Published in PNAS on 27 June 2022

Significance
Adequate pain management is critical for patient health and well-being. Here we use a laboratory-based experiment and an analysis of archival data over seven years from Israeli and US hospitals to test the effects of night shifts on pain management. We show robust evidence that physicians’ pain management decisions are impaired during night shifts. We argue that even medical experts, who try to provide the best care for their patients, are susceptible to the effects of night shifts. Our findings highlight the need to implement more structured pain management guidelines in hospitals and seek improved physician working schedules. We discuss implications for workplaces that involve shift work and empathic decision-making, including crisis centers, first responders, and the military.

Abstract
Adequate pain management is one of the biggest challenges of the modern healthcare system. Physician perception of patient subjective pain, which is crucial to pain management, is susceptible to a host of potential biases. Here we explore the timing of physicians’ work as a previously unrecognised source of systematic bias in pain management. We hypothesised that during night shifts, sleep deprivation, fatigue, and stress would reduce physicians’ empathy for others’ pain, leading to under-prescription of analgesics for patient pain relief. In study 1, 67 resident physicians, either following a night shift or not, performed empathy for pain assessment tasks and simulated patient scenarios in laboratory conditions. As predicted, following a night shift, physicians showed reduced empathy for pain. In study 2, we explored this phenomenon in medical decisions in the field. We analysed three emergency department datasets from Israel and the United States that included discharge notes of patients arriving with pain complaints during 2013 to 2020 (n = 13,482). Across all datasets, physicians were less likely to prescribe an analgesic during night shifts (compared to daytime shifts) and prescribed fewer analgesics than generally recommended by the World Health Organization.

This effect remained significant after adjusting for patient, physician, type of complaint, and emergency department characteristics. Under-prescription for pain during night shifts was particularly prominent for opioids. We conclude that night shift work is an important and previously unrecognised source of bias in pain management, likely stemming from impaired perception of pain. We consider the implications for hospitals and other organisations employing night shifts.

 

PNAS article – Physicians prescribe fewer analgesics during night shifts than day shifts (Open access)

 

See more from MedicalBrief archives:

 

Exhausted junior doctors putting patients’ safety at risk — NHS survey

 

UK doctors working ‘unmanageable’ hours — Royal College of GPs

 

Forget ‘resiliency training’ for doctors – the entire system needs to change

 

High stress prompts nearly half of younger SA doctors to consider quitting — Philips survey

 

NHS trials sleep pods for doctors’ and nurses’ power naps

 

 

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