Sleep-Deprived Physicians Less Empathetic to Patient Pain?

Batya Swift Yasgur, MA, LSW

July 08, 2022

Physicians who are sleep deprived have less empathy for patients who report pain ― and they prescribe fewer analgesics, new research suggests.

In the first of two studies, resident physicians were presented with two hypothetical scenarios involving a patient who complains of pain. They were asked about their likelihood of prescribing pain medication. The test was given to one group of residents who were just starting their day and to another group who were at the end of their night shift after being on call for 26 hours.

Results showed that the night shift residents were less likely than their daytime counterparts to say they would prescribe pain medication to the patients.

In further analysis of discharge notes from more than 13,000 electronic records of patients presenting with pain complaints at hospitals in Israel and the US, the likelihood of an analgesic being prescribed during the night shift was 11% lower in Israel and 9% lower in the US compared with the day shift.

"Pain management is a major challenge, and a doctor's perception of a patient's subjective pain is susceptible to bias," co-investigator David Gozal, MD, the Marie M. and Harry L. Smith Endowed Chair of Child Health, Missouri University School of Medicine, said in a press release.

"This study demonstrated that night shift work is an important and previously unrecognized source of bias in pain management, likely stemming from impaired perception of pain," Gozal added.

The findings were published online June 27 in the Proceedings of the National Academy of Sciences.

"Directional" Differences

Senior investigator Alex Gileles-Hillel, MD, senior pediatric pulmonologist and sleep researcher at Hadassah University Medical Center, Israel, told Medscape Medical News that physicians must make "complex assessments of patients' subjective pain experience" ― and the "subjective nature of pain management decisions can give rise to various biases."

Gileles-Hillel has previously researched the cognitive toll of night shift work on physicians.

"It's pretty established, for example, not to drive when sleep deprived because cognition is impaired," he said. The current study explored whether sleep deprivation could affect areas other than cognition, including emotions and empathy.

The researchers used "two complementary approaches." First, they administered tests to measure empathy and pain management decisions in 67 resident physicians at Hadassah Medical Centers in Jerusalem either following a 26-hour night shift that began at 8:00 AM the day before (n = 36) or immediately before starting the workday (n = 31).

There were no significant differences in demographic, sleep, or burnout measures between the two groups, except that night shift physicians had slept less than those in the daytime group (2.93 vs 5.96 hours).

Participants completed two tasks. In the empathy-for-pain task, they rated their emotional reactions to pictures of individuals in pain. In the empathy accuracy task, they were asked to assess the feelings of videotaped individuals telling emotional stories.

They were then presented with two clinical scenarios: a female patient with a headache, and a male patient with a backache. Following that, they were asked to assess the magnitude of the patients' pain and how likely they would be to prescribe pain medication.

In the empathy-for-pain task, physicians' empathy scores were significantly lower in the night shift group than in the day group (difference, -.83; 95% CI, -1.55 to -.10; P = .026). There were no significant differences between the groups in the empathy accuracy task.

In both scenarios, physicians in the night shift group assessed the patient's pain as weaker in comparison with physicians in the day group. There was a statistically significant difference in the headache scenario but not the backache scenario.

Scenario Difference (95% CI) P value
Headache -10.58 (17.58 to -3.58) .004
Backache -4.22 (-8.52 to .08) .054


In the headache scenario, the propensity of the physicians to prescribe analgesics was "directionally lower" but did not reach statistical significance. In the backache scenario, there was no significant difference between the groups' prescribing propensities.

In both scenarios, pain assessment was positively correlated with the propensity to prescribe analgesics.

Despite the lack of statistical significance, the findings "documented a negative effect of night shift work on physician empathy for pain and a positive association between physician assessment of patient pain and the propensity to prescribe analgesics," the investigators write.

Need for Naps?

The researchers then analyzed analgesic prescription patterns drawn from three datasets of discharge notes of patients presenting to the emergency department with pain complaints (n = 13,482) at two branches of Hadassah-Hebrew University Medical Center (HHUMC 1 and HHUMC 2) and the University of Missouri Health Center (UMHC).

The researchers collected data, including discharge time, medications patients were prescribed upon discharge, and patients' subjective pain rating on a scale of 0–10 on the Visual Analogue Scale (VAS).

Although patients' VAS scores did not differ with respect to time or shift, patients were discharged with significantly less prescribed analgesics during the night shift in comparison with the day shift.

Table. Propensity to Prescribe Analgesics.

Dataset (n) Night shift vs Day shift (95% CI) P value
HHUMC 1 (5000) 39% vs. 50%; OR .65 (0.58 – 0.74) < .001
HHUMC 2 (4157) 34% vs 43%; OR .69 (0.60 – 0.79) < .001
UMHC (4325) 24% vs 28%; OR .82, (0.70 – 0.95) .008


No similar differences in prescriptions between night shifts and day shifts were found for nonanalgesic medications, such as for diabetes or blood pressure. This suggests "the effect was specific to pain," Gileles-Hillel said.

The pattern remained significant after controlling for potential confounders, including patient and physician variables and emergency department characteristics.

In addition, patients seen during night shifts received fewer analgesics, particularly opioids, than recommended by the World Health Organization for pain management.

"The first study enabled us to measure empathy for pain directly and examine our hypothesis in a controlled environment, while the second enabled us to test the implications by examining real-life pain management decisions," Gileles-Hillel said.

"Physicians need to be aware of this," he noted. "I try to be aware when I'm taking calls [at night] that I'm less empathetic to others and I might be more brief or angry with others."

On a "house management level, perhaps institutions should try to schedule naps either before or during overnight call. A nap might give a boost and reboot not only to cognitive but also to emotional resources," Gileles-Hillel added.

Compromised Safety

Commenting for Medscape Medical News, Eti Ben Simon, PhD, a postdoctoral fellow at the Center for Human Sleep Science, University of California, Berkeley, called the study "an important contribution to a growing list of studies that reveal how long night shifts reduce overall safety" for both patients and clinicians.

"It's time to abandon the notion that the human brain can function as normal after being deprived of sleep for 24 hours," said Ben Simon, who was not involved with the research.

"This is especially true in medicine, where we trust others to take care of us and feel our pain. These functions are simply not possible without adequate sleep," she added.

Also commenting for Medscape Medical News, Kannan Ramar, MD, president of the American Academy of Sleep Medicine, suggested that being cognizant of these findings "may help providers to mitigate this bias" of underprescribing pain medications when treating their patients.

Ramar, who is also a critical care specialist, pulmonologist, and sleep medicine specialist at Mayo Clinic, Rochester, Minnesota, was not involved with the research.

He noted that "further studies that systematically evaluate this further in a prospective and blinded way will be important."

The research was supported in part by grants from the Israel Science Foundation, Joy Ventures, the Recanati Fund at the Jerusalem School of Business at the Hebrew University, and a fellowship from the Azrieli Foundation and received grant support to various investigators from the NIH, the Leda J. Sears Foundation, and the University of Missouri. The investigators, Ramar, and Ben Simon have reported no relevant financial relationships.

Proc Natl Acad Sci. Published online June 27, 2022. Abstract

Batya Swift Yasgur, MA, LSW, is a freelance writer with a counseling practice in Teaneck, NJ. She is a regular contributor to numerous medical publications, including Medscape and WebMD, and is the author of several consumer-oriented health books as well as Behind the Burqa: Our Lives in Afghanistan and How We Escaped to Freedom (the memoir of two brave Afghan sisters who told her their story).

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