Original Article

CME Article: Historical Alternans in the Emergency Department (H.A.t.E.D.) for Pain: An Analysis of Patient Pain Descriptors to Attending and Trainee Clinicians

Authors: Brandon M. Carius, DSc, MPAS, PA-C, Michael D. April, MD, PhD, Craig S. Pedersen, MD, Steve G. Schauer, DO, MS


Objectives: The concept of “historical alternans” (HA), a teaching folklore term referring to different descriptions of patient histories to trainees versus attending clinicians, can cause disjointed care and be a source of frustration for the trainee. Increased focus on the proper evaluation and treatment of pain in the emergency department (ED) setting prompts an evaluation of the HA concept as it relates to pain.

Methods: We conducted a prospective observational pilot study comparing pain descriptions given to attending and trainee clinicians in the ED using a five-question pain description survey. Trainees included emergency medicine physician residents, emergency medicine physician assistant residents, off-service residents, and students. Trainees completed the first survey and attending clinicians repeated survey questions after at least a 10-minute washout. Surveys include descriptions of pain as part of patients’ primary concern, severity indicated by a verbal numerical rating score (VNRS), and pain location, quality, and duration.

Results: During a 10-day period, surveys were completed for 97 patient encounters. Most trainee clinicians were emergency medicine physician residents (53%), followed by emergency medicine physician assistants (32%), students (13%), and off-service residents (2%). Pain complaints centered on the abdomen (18.5%), chest (12%), and knee (6%). Differences in pain description were found in the majority of cases (55%), with most having one categorical difference. The majority of categorical differences were VNRS (38%), although the difference in scores was not statistically significant (P = 0.20). Medical students had the highest variance in VNRS difference compared with attending clinicians. There was no significant difference in described duration (P = 0.99) or quality of pain (P = 0.99) between trainee and attending clinicians.

Conclusions: Most patient encounters had at least one difference in categorical pain descriptors between trainee and attending clinicians. Although differences in severity of pain were present, they were not significant. HA does occur in the ED setting, but the magnitude of difference may be minimal.

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