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Figure.  Comparing Mean Pain Experience and Pain Display for Preclinical and Clinical Students
Comparing Mean Pain Experience and Pain Display for Preclinical and Clinical Students

Error bars denote 95% CIs.

Table.  Characteristics of Participants
Characteristics of Participants
1.
Earp  BD, Monrad  JT, LaFrance  M, Bargh  JA, Cohen  LL, Richeson  JA.  Featured article: gender bias in pediatric pain assessment.   J Pediatr Psychol. 2019;44(4):403-414. doi:10.1093/jpepsy/jsy104PubMedGoogle ScholarCrossref
2.
Cohen  LL, Cobb  J, Martin  SR.  Gender biases in adult ratings of pediatric pain.   Child Health Care. 2014;43(2):87-95. doi:10.1080/02739615.2014.849918Google ScholarCrossref
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    Research Letter
    Pediatrics
    June 9, 2021

    Medical Student Assessment of Pediatric Patient Pain as a Function of Perceived Child Gender

    Author Affiliations
    • 1University of Michigan Medical School, Ann Arbor
    • 2Yale University, New Haven, Connecticut
    • 3Department of Psychology, Georgia State University, Atlanta
    JAMA Netw Open. 2021;4(6):e2113010. doi:10.1001/jamanetworkopen.2021.13010
    Introduction

    In 2 prior studies,1,2 individuals were shown a video of a 5-year-old child undergoing blood collection. When told the child was a boy, they rated the child as experiencing more severe pain.1,2 This study sought to assess the association of perceived child gender with medical students' assessment of the level of pain the child was experiencing.

    Methods

    The University of Michigan institutional review board deemed this survey study exempt from review because it involved benign behavioral interventions. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

    In September 2019, all students at 3 Michigan medical schools were invited via email to view the same video used in the previous studies1,2 and to complete an online survey (participants received a $5 incentive). The child in the video had given assent and parental permission was given orally. Students were randomly told the child—previously validated as gender neutral in apperance2—was a “boy” or “girl.” Participants were excluded for incorrectly defining the primary response measures of pain sensation and pain display, or, after viewing the video, incorrectly identifying the described gender (boy or girl) or hair color of the child. We asked participants: “How much pain did [he/she] experience and display during the finger stick?” We recorded ratings on 2 visual analog scales ranging from 0 (no pain) to 100 (severe pain). Subsequent questions addressed explicitly held gender stereotypes, stage of medical training, completion of pediatrics clerkship, and career interest in pediatrics.

    A priori analysis indicated 550 responses were needed to detect between-group differences with 1-tailed mean testing (t and analysis of variance) with cutoffs of α = .05 and β = 0.20 and effect size Cohen d = 0.21.2 Statistical analysis was performed using SAS statistical software version 9.4 (SAS Institute) from December 2019 to January 2020.

    Results

    Among 2712 invited medical students, 702 (25.8%) responded; 203 were excluded for failing the attention or comprehension verifications. Among the 499 medical students included in the study, 326 [65.3%] were female, 173 [34.7%] were male, and 147 [29.5%] completed a pediatrics clerkship; 248 were randomly assigned to the boy condition and 251 to the girl condition (Table).

    The mean (SD) experienced pain ratings did not significantly differ between those assigned to the boy condition (48.7 [18.3]) vs the girl condition (46.9 [19.3]) condition, nor did they significantly differ between male (48.6 [19.3]) and female (47.3 [18.6]) medical students, regardless of assigned condition.

    There was, however, a significant difference between mean ratings, for all participants, of the child’s experienced pain vs displayed pain (mean [SD] experienced pain: 47.8 [18.8]; mean [SD] displayed pain: 68.5 [17.4]; difference: 20.7 [95% CI, 18.4-23.0]; P < .001). Students having completed a core pediatrics clerkship (n = 147) rated experienced pain as less severe than did students with less pediatric clinical experience (mean [SD] pain experienced rating by students who had completed a pediatric clerkship: 42.6 [19.0] vs those who had not: 50.0 [18.3]; difference: 7.4 [95% CI, 3.8-11.0]; P < .001) (Figure). There was no significant difference between these 2 groups’ ratings of displayed pain.

    Discussion

    Previous studies using this video showed that among US undergraduate psychology or nursing students1 and a general-population sample,2 the experienced pain of a child was judged significantly differently if described as a boy vs girl. This study of medical students, by contrast, did not. It is unknown whether this null finding reflects gender-focused efforts in medical education, preexisting differences in attitudes among the samples, or insufficient power to detect an association.

    More experienced medical students (ie, having completed their pediatric clerkship) evinced a widened gap between their assessments of pain severity displayed vs experienced by the child. This gap might be interpreted as an impression of the child overreacting to a painful stimulus. Hence, our results may signal an association between greater pediatric clinical experience and an increased tendency to discount (or become inured to) the degree of pain displayed by a child when inferring the degree experienced.

    Study limitations included failure to collect information on potential mechanisms (eg, number of blood draws witnessed or performed). It is also unclear whether the findings are clinically significant given that, for example, these participants were students and not practicing professionals. Further study is required of the potential impact of different medical education experiences on students’ assessments of patient pain.

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    Article Information

    Accepted for Publication: April 13, 2021.

    Published: June 9, 2021. doi:10.1001/jamanetworkopen.2021.13010

    Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Reardon AWT et al. JAMA Network Open.

    Corresponding Author: Alexander W. T. Reardon, BS, University of Michigan Medical School, 1301 Catherine St, Ann Arbor, MI 48105 (awreardo@med.umich.edu).

    Author Contributions: Mr Reardon and Ms Andreski had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Earp, Monrad, Cohen, Freed.

    Acquisition, analysis, or interpretation of data: Reardon, Earp, Andreski, Cohen, Freed.

    Drafting of the manuscript: Reardon, Earp, Andreski, Cohen, Freed.

    Critical revision of the manuscript for important intellectual content: All authors.

    Statistical analysis: Andreski.

    Obtained funding: Reardon.

    Administrative, technical, or material support: Reardon, Monrad, Cohen.

    Supervision: Earp.

    Conflict of Interest Disclosures: None reported.

    Funding/Support: This project was funded in part by a Diversity, Equity, and Inclusion grant from the University of Michigan.

    Role of the Funder/Sponsor: The funding supported the design and conduct of the study and the collection, management, analysis, and interpretation of the data. Preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication were independent of the funding source.

    References
    1.
    Earp  BD, Monrad  JT, LaFrance  M, Bargh  JA, Cohen  LL, Richeson  JA.  Featured article: gender bias in pediatric pain assessment.   J Pediatr Psychol. 2019;44(4):403-414. doi:10.1093/jpepsy/jsy104PubMedGoogle ScholarCrossref
    2.
    Cohen  LL, Cobb  J, Martin  SR.  Gender biases in adult ratings of pediatric pain.   Child Health Care. 2014;43(2):87-95. doi:10.1080/02739615.2014.849918Google ScholarCrossref
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