```html Are medical students biased toward chronic pain patients?

Are medical students biased toward chronic pain patients?

Genevieve Pourzan, B.A.1, Alberto Tamayo B.S.1, Muhammad Nabeel, M.D., M.P.H.1
1Michigan State University, College of Human Medicine
Correspondence should be addressed to G.P. (pourzang@msu.edu)

Background: Little research has been done into exploring medical students' perspectives of chronic pain patients despite increasing media attention on the opioid epidemic and their encounters during medical school.

Methods: To investigate, all medical students at Michigan State University College of Human Medicine were emailed an invitation to voluntarily participate in an online survey. Students were randomized between two identical patient vignettes, one was the control and the other was identical with the exception of a history of chronic back pain and opioid dependence. Students were then asked a series of questions regarding their perceptions, biases, and attitudes towards the patient in their vignette. Eleven questions were asked using a 0-10 scale.

Results: Results between the control and pain patient were quantified using an unpaired t-test. Students rated the chronic pain patient worse than the control in 8 of the 11 questions. There was no significant difference between the control and pain patient in the remaining 3 questions.

Discussion: Our survey showed that medical students had more negative perceptions of chronic pain patients in terms of their health, self-care, self-discipline, and compliance. Students believed a chronic pain patient would require higher levels of patience, be more annoying, and students felt less positive towards a chronic pain patient compared to a control. Although these results may not correlate with clinical differences in practice, medical schools should be aware of how medical students' perceptions of chronic pain patients could affect the quality of care provided as future physicians.

Introduction

Medical students, who are destined to encounter pain-related complaints in practice,1 often have little personal or medical knowledge of pain prior to matriculation. Students may be more likely to develop their understanding of chronic pain from media consumption and by picking up cues from physicians they work with in medical school. Over the last decade, the media has focused on the opioid epidemic, which has shaped our national understanding of chronic pain and pain treatment. In addition a student's perception could also be contributed to working one-on-one with attending physicians whose own biases may shape a student's schema of a patient population. And, often times primary care providers are more biased towards chronic pain patients.2 Bias being defined as an "inclination or prejudice for or against one person or group, especially in a way considered to be unfair."2 Reasons cited by primary care providers for less positive feelings towards chronic pain patients include, difficult patient interactions,3 comorbid psychological issues,4 requiring more time,4 worries about dependence and addiction,4 and compliance.4

While primary care providers feel more negative towards chronic pain patients, medical students are not bound by the same patient-provider relationship as physicians, nor face any prescribing scrutiny.

Despite the lack of quantitative studies establishing medical students have a negative perception towards chronic pain patients, there have been preliminary evidence supporting this theory. In a qualitative review of forty-four first year medical student journals, researchers found 75% of references to pain patients were negative, noting concerns about truthfulness and opioid prescribing.5 Other studies examined medical students' judgment of the level of pain in chronic pain patients using differing degrees of medical evidence, empathy, and accountability in vignettes and found that these variables can influence students' perception of chronic pain patients.6,7 Finally, in an interview with eight medical students, researchers at the University of Toronto reported that students working with chronic pain patients found their experiences frustrating due to the incurable nature of chronic pain and believed those encounters held little educational value.8

Methods

In order to address the question 'Are medical students biased towards chronic pain patients?' an online survey was developed. The study qualified for exemption by the Michigan State University IRB. All medical students (year 1 through year 4) at Michigan State University College of Human Medicine were emailed an invitation to voluntarily participate in an online survey through Qualtrics.

Although a few studies have analyzed medical student judgement towards chronic pain patients, none had developed a questionnaire to investigate medical student bias towards chronic pain patients versus a control, so our questionnaire was modeled after a study assessing medical student bias towards patients with obesity.9 The survey was divided into two identical vignettes, one was the control patient and the other included a history of chronic back pain and long-term opioid use (See Figure 1 and Figure 2). Students were randomized into one of the two patient vignettes. After reading the patient vignette prompt, students were asked a series of questions regarding their thoughts on the vignette patient. Eleven questions were asked regarding students' perceptions of the patient in the vignette using a 0-10 scale. Questions were meant to assess differences in students' perceptions, biases, and attitudes towards chronic vs. non-chronic pain patients. Questions asked included the following:

Figure 1: Control Vignette

Name: Anthony Brown

Age: 55

Problem List:

Current Medications:

Figure 2: Chronic Pain Vignette

Name: Anthony Brown

Age: 55

Problem List:

Current Medications:

  1. Estimate the health of the patient
  2. Rate the patient's level of pain
  3. How well does the patient take care of himself?
  4. How self-disciplined is the patient?
  5. Rate the seriousness of the medical problem
  6. How much of a waste of time is this patient encounter?
  7. How much patience will be required during this encounter?
  8. How annoying can this encounter become?
  9. What is your personal desire to help this patient?
  10. What is the likelihood that the patient will comply with medical advice?
  11. What is your overall level of positivity towards the patient?

Results

Up to 128 students responded to the chronic pain patient survey and up to 129 different students responded to the control patient survey. Using GraphPad, an unpaired t-test for each question was run to assess statistical significance between the means.

The results were extremely significant when students rated the chronic pain patient poorer in terms of health (p = 0.0001, t= 6.6930, df= 255), worse self-care (p= 0.0012, t= 3.2779, df= 253), requiring a higher level of patience during the encounter (p=0.0002, t= 3.7609, df= 252), and lower positivity towards the chronic pain patient (p=0.0004, t= 3.5788, df= 250). There were additional statistically significant differences as students rated the chronic pain patient as having lower self-discipline (p=0.0475, t= 1.9917, df= 252), causing a higher level of annoyance (p=0.0148, t= 2.4537, df= 253), and poorer compliance (p= 0.0048, t= 2.8435, df= 250). Students also rated the chronic pain patient as having higher amount of acute pain compared to the control (p=0.0001, t= 4.7258, df= 252). There was no difference in medical students' desire to help (p=0.1992, t= 1.2873, df= 254), feeling the encounter is a waste of time (p=0.3368, t= 0.9623, df= 254), or assessing the seriousness of an acute presentation (p=0.297, t= 1.0451, df= 253) between the chronic pain and control patient.

Graphs of response data for each question are shown in Figures 3-13.

Figure 3: Health Rating (Control mean 7.05, Pain mean 6.06, p=0.0001)
Figure 4: Pain Level (Control 4.98, Pain 5.85, p=0.0001)
Figure 5: Self-care (Control 7.19, Pain 6.50, p=0.0012)
Figure 6: Self-discipline (Control 6.89, Pain 6.55, p=0.0475)
Figure 7: Seriousness (Not significant)
Figure 8: Waste of time (Not significant)
Figure 9: Patience required (p=0.0002)
Figure 10: Annoyance (p=0.0148)
Figure 11: Desire to help (Not significant)
Figure 12: Compliance (p=0.0048)
Figure 13: Positivity (p=0.0004)

Discussion

Pain-related complaints are one of the leading causes for doctor visits in the United States.1 In addition, there has been increasing media attention surrounding chronic pain and the opioid epidemic. Our survey showed that medical students had more negative perceptions of chronic pain patients in terms of their health, self-care, self-discipline, and compliance. Students felt a chronic pain patient would require higher levels of patience, be more annoying, and students felt less positive towards a chronic pain patient compared to a control.

There were some limitations to this study. As the experience, understanding, and perception of pain are multifactorial there is endless amounts of both qualitative and quantitative data that can be gathered on the topic. For the purposes of a narrow study, this survey exclusively examined students' perceptions of a chronic pain patient versus a patient without chronic pain. In addition, the survey did not assess student against provider attitudes regarding chronic pain patients, and therefore there is no data measuring the magnitude of difference between student and medical provider bias. Finally, the online questionnaire did not stratify for gender, age, or medical student year, so further understanding of how gender, age, and clinical experiences shape perceptions cannot be deduced from this data.

In addition, this study did not assess if there would be a difference in future patient care based on student bias. Nevertheless, a previous study has shown that primary care providers who are biased towards chronic pain patients are more likely to under-treat and mismanage these patients.12 Although our results may not correlate with clinical differences in practice, medical schools should be aware of how medical students' perceptions of chronic pain patients could affect the quality of care provided as future physicians.

We advocate that medical schools, residencies, and physicians be mindful of stigmas towards chronic pain patients, and incorporate chronic pain concepts into an educational curriculum. Addressing this pervasive stigma in the medical community may be an important first step towards treating the millions of patients who suffer from chronic pain and effectively combating the opioid epidemic.

References

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  3. Oxford dictionary. https://www.lexico.com/en/definition/bias. Accessed November 20, 2019.
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Harvard Medical Student Review Issue 5 | January 2020

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