Patient and physician perceptions as risk factors for oligoanalgesia: A prospective observational study of the relief of pain in the emergency department

Objectives: Previous studies have reported that pain is undertreated in the emergency department (ED), but few physician-dependent risk factors have been identified. In this study, the authors determine whether pain treatment and relief in ED patients are negatively associated with the physician's perception of whether the patient was exaggerating symptoms, and with the patient and physician's perceptions of the interaction between them, as well as whether demographic characteristics were associated with these perceptions. Methods: This was a prospective observational study of patients who were undergoing treatment for painful disorders in the ED. Before treatment for pain, patients were asked to complete a 100-mm visual analog scale (VAS) describing their pain. Demographic information and pain treatments administered were recorded. Patients completed a second pain VAS before discharge from the ED. Patients were then asked to complete three queries describing their perception of their interaction with the physician. After the patient had left the department, the patient's physician was asked to complete a query describing his or her perception of the interaction and to complete a VAS describing how likely it was that the patient was exaggerating symptoms to obtain pain medicines for nonmedical purposes. Results: There were 1,695 patients enrolled in the study; 32 patients were excluded because of missing or incomplete data, leaving 1,663 for analysis. Of these patients, 71.9% received a pain medication while in the ED. There was no association between the physician's VAS for perceived exaggeration of symptoms, the queries describing physician-patient interactions, and patient ethnicity and whether patients received pain treatment in the ED. There was a negative correlation between the physician's VAS for perceived exaggeration of symptoms and the change in the patient's pre- and posttreatment pain VAS scores. The physician's VAS score for perceived exaggeration of symptoms was higher among Native American patients than among other ethnic groups (p ≤ 0.001). The patient and physician queries rating their interaction show a decreased absolute reduction of VAS pain scores (p ≥ 0.001) and a reduction in the number of patients having at least a 50% reduction in their pain VAS score when interactions were rated "bad" and "very bad" (p ≤ 0.001). Conclusions: The physician's perception of whether a patient was exaggerating symptoms was associated with the patient's ethnic background and with both the physician's and patient's perception of their interaction. These perceptions were negatively associated with the achievement of pain relief and the change in the patient's pain VAS scores, but not with whether a patient was treated with a pain medication.