This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

Clinicians across medical settings commonly euphemize or understate pain — a practice that has concerning implications for patient trust, consent, and care quality.

Intrauterine device (IUD) placement offers an instructive case study, and highlights the need for transparency in describing painful medical procedures. IUDs are one of the most effective forms of birth control, and tens of millions of women have them placed every year. Clinicians typically describe the pain associated with IUD insertion as “uncomfortable… but short lived” or “three quick cramps.” But patients who have undergone IUD insertion have described it as “on a cosmic level,” “such blinding agony I could barely see,” and “like someone shocking my cervix with a taser.”

Although some patients experience little pain with IUD insertion, most patients experience moderate to severe pain. Clinicians’ language thus paints a picture of pain that is less severe than that which many patients experience – and this is not unique to IUD placement — often, clinicians refer to pain as “pressure” or call a painful procedure “uncomfortable.”

There are likely several reasons why physicians downplay pain. First, clinicians may not know how much a procedure hurts. Second, clinicians may understate pain to alleviate patients’ anxiety or reduce the pain they experience. Third, if clinicians believe a procedure is in a patient’s best interest, they may downplay the pain associated with it to increase a patient’s likelihood of giving consent.

In some cases, clinicians may not know how painful a procedure is. For instance, one study found that physicians assess IUD insertion to be about half as painful as patients report it to be. But after performing a procedure many times, clinicians should have a reasonable sense of the range of reactions patients typically have. If they’re unsure, they should ask patients, or read accounts of patients who have undergone that procedure.

There is also evidence that describing the pain associated with a procedure can increase patients’ reported pain and anxiety. Downplaying expectations may thus reduce pain. This is an important consideration and justifies not disclosing how painful a procedure is for patients who do not want to know.

But there are several problems with this approach. For one, patients can talk to their friends or access information online about other patients’ experiences of a procedure, undermining any potential analgesic effects of downplaying pain. In addition, there are other ways to reduce pain that do not involve misleading patients. Finally, while failing to disclose how painful a procedure is may marginally reduce how much it hurts, there are often substantial discrepancies between patients’ and clinicians’ assessments of pain.

Indeed, most studies that have looked at this question have found that clinicians underestimate pain relative to patients, and that for more painful procedures, clinicians’ underestimation is even more pronounced. So patients may still experience more severe pain than expected, undermining their long-term trust in their clinicians.

Clinicians may also recognize that telling a patient how painful a procedure is decreases the likelihood a patient will consent to that procedure. Clinicians may accordingly understate the unpleasantness of procedures that they believe are in a patient’s best interest. For instance, IUDs work extremely well (and are the most commonly used birth control among physicians). For most patients, the pain associated with IUD insertion lasts for minutes, while IUDs last for years. Clinicians may thus feel that IUDs are the best option for many patients and may downplay the pain of having one placed to increase the likelihood that patients will choose to get one. While this approach is understandable, patients are entitled to choose what care is in their interest. Some may reasonably decide that they do not want to risk incurring severe short-term pain, even if the long-term benefits are substantial.

In addition to undermining trust and the validity of a patient’s consent, downplaying pain may lead clinicians to undertreat it. Indeed, clinicians frequently underrecognize and undertreat pain, and women and people of color are particularly likely to have their pain overlooked.

Admittedly, the pain associated with IUD insertion has proven challenging to treat. For instance, many patients are advised to take Advil before the procedure, despite evidence that it doesn’t help. Other interventions also don’t work very well, leading the American College of Obstetricians and Gynecologists to conclude that “more research is needed to identify effective options to reduce pain for IUD insertion.”

But in highly resourced settings, where anesthesia, narcotics, and anti-anxiety medications are available, clinicians can control patients’ procedural pain. For instance, the default is to sedate patients for colonoscopies, even though many patients who have received colonoscopies without sedation report that it is not very painful. Conversely, patients are rarely offered sedation for IUD insertion, even though this would eliminate their pain. Sedation comes with its own risks, but patients are generally given the option of taking on these risks when pain is viewed as sufficiently severe. When pain can be managed and it is not, this reflects value judgments (i.e., about a patient’s ability to tolerate a given level of pain).

Being able to place IUDs in an office without sedation works well for many patients and makes IUDs more accessible. But fear of pain may lead some people to choose a less effective form of birth control or forgo it entirely. Given how well IUDs work, this is unfortunate and preventable.
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Ultimately, for IUDs and other important medical procedures, clinicians should ask patients how much they want to know about a procedure and describe the range of pain most patients experience for those who wish to know. If patients are concerned about the level of pain they might experience, clinicians should provide them with a range of effective options for managing that pain. Failing to engage in these conversations risks undermining trust, compromising the validity of consent, and undertreating pain.

This piece was originally published on Bill of Health, the blog of Petrie-Flom Center at Harvard Law School.

In my junior year of college, my pre-medical advisor instructed me to take time off after graduating and before applying to medical school. I was caught off guard.

At 21, it had already occurred to me that completing four years of medical school, at least three years of residency, several more years of fellowship, and a PhD, would impact my ability to start a family. I was wary of letting my training expand even further, but this worry felt so vague and distant that I feared expressing it would signal a lack of commitment to my career.

I now see that this worry was well-founded: the length of medical training unnecessarily compromises trainees’ ability to balance their careers with starting families.

In the United States, medical training has progressively lengthened. At the beginning of the 20th century, medical schools increased their standards for admission, requiring students to take premedical courses prior to matriculating, either as undergraduates or during post-baccalaureate years. Around the same time, the length of medical school increased from two to four years. In recent decades, the percentage of physicians who pursue training after residency has increased in many fields. And, like me, a growing proportion of trainees are taking time off between college and medical school, pursuing dual degrees, or taking non-degree research years, further prolonging training.

The expansion of medical training is understandable. We know far more about medicine than we did a hundred years ago, and there is correspondingly more to teach. The increased structure and regulation of medical training have made medical training safer for patients and ensured a standard of competency for physicians. Getting into medical school and residency have also become more competitive, meaning many trainees feel they must spend additional time bolstering their resumes.

However, medical training is now longer than it needs to be. Many medical students do very little during their fourth year of medical school. Residency programs also require trainees to serve for a set number of years, rather than until they have mastered the skills their fields require, inflating training times. And many medical schools and residency programs require trainees to spend time conducting research, whether or not they are interested in academic careers. While many trainees appreciate these opportunities, they should not be compulsory.

There are many arguments for shortening medical training. In other parts of the world, trainees complete six-year medical degrees, compared to the eight years required of most trainees in the U.S. (four years of college and four years of medical school). The length of medical training increases physician debt and healthcare costs. In addition, it decreases the supply of fully trained physicians, a serious problem in a country facing physician shortages. Since burnout is prevalent among trainees, shortening training could also mitigate burnout. And critically, the length of medical training makes it challenging for physicians to start families.

Because medical trainees work long hours, have physically demanding jobs, and are burdened by substantial debt, they are sometimes advised or pressured to wait until they complete their training before having children. But high rates of infertility and pregnancy complications among female physicians who defer childbearing suggest this is a treacherous path.

Starting a family during training hardly feels like a safer option. In my first year of medical school, I attended a panel of surgical subspecialty residents. I asked whether their residencies would be compatible with starting a family. The four men looked at each other before passing the microphone to the sole woman resident, who told us she could not imagine having a child during residency, as she didn’t even have time to do laundry, so instead ordered new socks each week.

In my second year of medical school, a physician spoke to us about having a child during residency. I asked how she and her husband afforded full-time child care on resident salaries. She confided that they had maxed out their credit cards and added this debt to their medical school debt to pay for daycare. There have been encouraging anecdotes, too, but these have often involved healthy parents relocating, significant financial resources, or partners with less intense careers.

Admittedly, shortening medical training would not be a magic bullet. Physicians who have completed their training and have children still face myriad challenges, and these challenges disproportionately affect women. Maternal discrimination is common, and compared to men, women physicians with children spend more than eight hours per week on parenting and domestic work and correspondingly spend seven fewer hours on their paid work. Nearly 40 percent of women physicians leave full-time practice within six years of completing residency, with most citing family as the reason why.

However, shortening medical training would enable more trainees to defer childbearing until the completion of their training. This would help in several ways. For instance, while most trainees are required to work certain rotations (e.g., night shifts), attending physicians often have more flexibility in choosing when and how much they work. In addition, attending physicians earn much more money than trainees, expanding the child care options they can afford.

In recent years, many changes have been made to support trainees with children, from expanding access to lactation rooms, to increasing parental leave, to creating more child care facilities at hospitals. But long training times remain a persistent and reduceable barrier. To address this, medical schools could only require students to take highly relevant coursework, reducing the number of applicants who would need to complete additional coursework after college. Medical schools could also increase the number of three-year medical degree pathways and make research requirements optional. Residency and fellowship programs could create more opportunities for integrated residency and fellowship training and could similarly make research time optional.
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It will be challenging to create efficient paths that provide excellent training without creating impossibly grueling schedules. But this is a challenge that must be confronted: physicians should be able to balance starting a family with pursuing their careers, and streamlining medical training will facilitate this.

Haley Sullivan, Emma Pierson, Niko Adamstein, and Sam Doernberg gave helpful feedback on this post.

Many medical journals will publish ~1,000-word opinion pieces written by medical students. There is a lot of luck involved in getting these published, but here are tips others have given me, as well as lessons I have learned on how to do this:

1. Presubmission inquiries are helpful. Many journals allow (or require) you to email them a short blurb about your piece before you formally submit it. It’s good to use this option when it’s available, especially if you haven’t written a draft yet. You’ll usually hear back quickly and may save yourself and the editors time (and the headache of formatting citations).
2. Collaborate with people you like and respect. I have been assigned some amazing mentors and stumbled across some brilliant collaborators (it was helpful to be born into the same family as two of them). But I have also signed onto some projects with people I didn’t work well with, and none of these wound up getting published. For me, figuring out who to work with is mostly about compatibility, and this means identifying my own strengths and weaknesses (e.g., my writing is dry, so it’s good for me to work with people who have beautiful prose). Some ways I’ve tried to determine whether I’d work well with someone are: collaborating with them on a low-stakes/non-academic project, talking with other people they’ve worked with, meeting to assess vibes/communication style, reading other things they’ve written, and asking them for feedback on my writing. One litmus test is: if we got some reviews back on this piece, would I trust my co-author(s) to revise and resubmit this without my input? (I’m not saying I’d ever do this, but it’s good to know your collaborators well enough to make this assessment and to have this level of confidence in them.)   
3. Be candid with people at the outset. During early brainstorming sessions about a piece, it’s useful to a) discuss how much time everyone can commit and over what time period b) outline the basic arguments for the piece (and make sure everyone roughly agrees) and c) clarify authorship order and roles. This is particularly important if you’re working with people you’re close to because you do not want to let work disputes harm your relationships. One litmus test for figuring out who should be first author is: who wrote the first draft of the piece? Having said this, sometimes circumstances change, and it becomes necessary to rethink authorship order. Authorship is definitely not worth burning relationships over. People are way more likely to work with you again if you were generous with them (about authorship, time, feedback, etc.) and if they're good collaborators, they will remember and pay it forward. Plus, it’s easy to overestimate how much work you have done.
4. Get feedback on your ideas before you spend time writing them. These conversations can also be useful for figuring out how to frame an issue (e.g., what aspects of it are people interested in and what parts are they confused by?). Another way to get feedback on an idea is to tweet about it, although this presents some theoretical risk of getting scooped. On occasions I’ve done this, it’s helped me figure out whether people cared about an issue and agreed with the take.
5. Get feedback before you submit your piece. This is pretty obvious. But one less obvious way it’s been useful: sometimes someone will tell you you’re aiming too low or too high. Last year, I sent a piece that wasn't very good to some friends, and one of them gently pointed out some major problems with it, and so I ended up turning it into a blog. On the other hand, I sent a blog post draft to a few friends who were like “you should publish this,” and after some serious revisions, I did.
6. Shoot your shot. If people you respect have given you good feedback on an idea or a piece, it’s worth aiming high, especially with a presubmission inquiry. After all, there are a lot of journals and some of them publish a lot of short pieces.  
7. Writing on time-sensitive issues is risky. I have had mixed success writing about things that are time-sensitive (petition to rename these pieces "deciduous"). On the one hand, lots of journals will want to publish a piece about a hot issue, and there are probably good, novel takes that haven’t been written yet. On the other hand, if you miss the window of opportunity, you may not be able to publish your piece at all. (RIP our article about whether medical students should be considered health care workers for the purposes of vaccine triage: it got reviewed, but by the time we got the R, most medical students had been vaccinated.) If you’re writing on a time-sensitive issue, submit a presubmission inquiry, consider sending the piece somewhere it won't be peer reviewed, and think about collaborating with someone who can help it move through review quickly. In other words…
8. Consider finding someone senior to work with. I have only co-authored opinion pieces with friends/sisters. You may not need someone senior on your piece, especially if you’re writing about something you know a lot about (e.g., something specific to the medical student experience). I have never felt that my work wasn't taken seriously just because I was a medical student, and it can also be really fun to work with your friends. But having someone senior involved may often lead to a better product and increase your odds of getting it published. Senior people may have connections with editors and may be able to advocate for your piece more effectively.
9. Have a backup plan. Have a short list of journals +/- a blog in mind before you start writing, and write with their word counts in mind. It is time-consuming to undertake major revisions (e.g., cut your piece in half) after each rejection.
10. Write takes you’re excited about and think are true and important. I have only ever regretted getting pulled into projects I wasn’t excited about. Revising a piece for the 7th time is hard enough, even when you care about the issue. An added benefit is that even if you have a hard time getting your piece published, you’ll have read and thought a lot about an issue you care about.

Medical trainees will change the culture of medicine for the better (as generations of prior trainees have done for us), and we can accelerate this change by sharing our opinions.