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.
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.