Rethinking pain’s under-treatment in the ED – Part 2

In the previous blog post, I described how I came to lead the writing of an article about pain being under-treated in the emergency department (ED) [3].  The article presents an argument for the plausibility of two new hypotheses for why pain is still under-treated in the ED, despite efforts to improve things.  We invite the reader to consider whether pain’s under-treatment in the ED can be attributed partly to (1) “an epistemic preference for signs over symptoms on the part of some practitioners”, and (2) “some ED practices that themselves worsen pain by increasing patients’ anxiety and fear”.  In this blog post, I explain what we mean by this.

The first hypothesis looks at the practitioner’s putting more stock in observable features than in what the patient says when it comes to knowing how much pain the patient is in.  Examples of observable features include whether the patient’s knee is still dislocated, whether the patient is grimacing or flinching, whether the patient can manage to duck outside for a cigarette, whether the patient’s heart rate is elevated, and so on.  A practitioner might put more stock in observable features than in what the patient says because they want to minimise the scope for any misrepresentation.  A patient can fabricate, exaggerate, hide, or downplay their pain, and they can do this intentionally (as in the case of drug seeking) or unintentionally (as in the case of forgetting how much pain I was in yesterday).  But if, for this reason, a practitioner tries to piece together how much pain a patient is in, drawing on observable features like so many pieces of evidence, then under-treatment can follow.  The piecing together might take a fair amount of time and in this way delay the use of effective pain medication.  The practitioner might fall prey to one or another bias and under-estimate the patient’s pain (we cite evidence of systematic under-estimation).  And the practitioner might frighten the patient who, correctly or not, senses some distrust coming from their practitioner, and the fear can worsen the pain.  All of this can contribute to pain’s under-treatment.  So runs our logic, in any case; I’m interested to know what you think.

As for our second hypothesis, we describe some ED practices that might themselves worsen pain by increasing patients’ anxiety and fear.  Imagine you’re the patient.  You wonder why you’re still in pain.  You suspect that your doctor distrusts you.  You aren’t told what is happening, how long the wait will be, what will happen next.  And you feel looked at as though you were a broken machine, rather than a human being who is suffering.  All of this can frighten you, and the fear can worsen the pain.  So runs our logic, in any case; again, I’m interested to know what you think!

Among the unexpected boons of this work was coming to appreciate how much the management of my own pain had aligned with best practice, and finding inspiration in the compassion and dedication of my interviewees, which came through very clearly.  Another unexpected boon lay in teasing out the distinction between signs and symptoms.  The philosopher Ludwig Wittgenstein talked of ‘grammar’, drawing attention to the ways in which we find it meaningful to speak and respond to one another.  I could find no satisfying ‘grammatical’ explanation of the sign-symptom distinction.  It seems to come down to ‘who’ more than ‘what’.  Symptoms are experienced then reported by the patient, whereas signs are obtained via observation undertaken by the practitioner.  Along these lines, pain is a symptom, but tenderness is a sign, since tenderness is elicited by the practitioner during clinical examination.  The practitioner must sometimes translate what the patient says into terms that are tractable to medical knowledge, whereas signs are already elicited in these terms.  But as far as I can tell, there’s not much more to the distinction: talk of ‘subjective’ and ‘objective’ obfuscates more than it clarifies, I suspect, at least when it comes to pain.  I draw attention to this part of the article because a handy bit of thinking could otherwise fall by the wayside.

About Drew Carter

Drea CarterDrew Carter is a moral philosopher, with a particular interest in health ethics.  He is a  Research Fellow in Ethics in the School of Public Health at the University of Adelaide, and has a BA(Hons) in Philosophy and History (Unimelb) and a PhD in Philosophy (ACU).  His main research area is the ethical allocation of health care resources, but he is also interested in improving efforts to conceptualise, study and treat pain by drawing on insights made by philosophers such as Ludwig Wittgenstein and Iris Murdoch.  His work on pain was supported by the Brocher Foundation.


  1. Price DD, Psychological and neural mechanisms of the affective dimension of pain. Science, 2000. 288(5472): p. 1769-72.
  2. Peeters PA and Vlaeyen JW, Feeling more pain, yet showing less: the influence of social threat on pain. J Pain, 2011. 12(12): p. 1255-61.
  3. Carter D, Sendziuk P, Eliott JA, and Braunack-Mayer A, Why is Pain Still Under-Treated in the Emergency Department? Two New Hypotheses. Bioethics, 2015.