Physicians prescribe fewer analgesics during night shifts than day shifts

Shoham Choshen-Hillel, Ido Sadras, Tom Gordon-Hecker, Shir Genzer, David Rekhtman, Eugene M. Caruso, Koby L. Clements, Adrienne Ohler, David Gozal, Salomon Israel, Anat Perry, Alex Gileles-Hillel*

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

6 Scopus citations


Adequate pain management is one of the biggest challenges of the modern healthcare system. Physician perception of patient subjective pain, which is crucial to pain management, is susceptible to a host of potential biases. Here we explore the timing of physicians’ work as a previously unrecognized source of systematic bias in pain management. We hypothesized that during night shifts, sleep deprivation, fatigue, and stress would reduce physicians’ empathy for others’ pain, leading to underprescription of analgesics for patient pain relief. In study 1, 67 resident physicians, either following a night shift or not, performed empathy for pain assessment tasks and simulated patient scenarios in laboratory conditions. As predicted, following a night shift, physicians showed reduced empathy for pain. In study 2, we explored this phenomenon in medical decisions in the field. We analyzed three emergency department datasets from Israel and the United States that included discharge notes of patients arriving with pain complaints during 2013 to 2020 (n = 13,482). Across all datasets, physicians were less likely to prescribe an analgesic during night shifts (compared to daytime shifts) and prescribed fewer analgesics than generally recommended by the World Health Organization. This effect remained significant after adjusting for patient, physician, type of complaint, and emergency department characteristics. Underprescription for pain during night shifts was particularly prominent for opioids. We conclude that night shift work is an important and previously unrecognized source of bias in pain management, likely stemming from impaired perception of pain. We consider the implications for hospitals and other organizations employing night shifts.

Original languageAmerican English
Article numbere2200047119
JournalProceedings of the National Academy of Sciences of the United States of America
Issue number27
StatePublished - 5 Jul 2022

Bibliographical note

Funding Information:
ACKNOWLEDGMENTS. We thank the resident physicians who participated in this study. We also thank Mrs. Olga Slutzky, the HaYaData team, the HHUMC Data Research Unit for providing the clinical data for this study, and Prof. Orly Manor for advice on the statistical analyses. Last, we thank the anonymous reviewers for their constructive suggestions which contributed to this manuscript significantly. This work was supported in part by grant 2779/19 from the Israel Science Foundation to A.G.-H.; grant 354/21 from the Israel Science Foundation to A.P. and S.C.-H.; a research grant from Joy Ventures to A.P., A.G.-H., and S.C.-H.; the Recanati Fund at the Jerusalem School of Business at the Hebrew University to S.C.-H.; and an Azrieli Fellowship from the Azrieli Foundation to A.P. D.G. is supported by NIH grants HL140548, and AG061824, the Leda J. Sears Foundation, and a Tier 2 grant from the University of Missouri.

Publisher Copyright:
Copyright © 2022 the Author(s).


  • analgesics
  • empathy
  • pain management
  • shift work
  • sleep deprivation


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