| After graduating from medical
school, I set out to be a kids’ doctor, enrolling
in a pediatric residency. I figured that, as a pediatrician,
I’d get to play during much of my workday. Now,
at this stage of my career as a family doctor who doesn’t
deliver babies any more and who has aged along with my
patients, I don’t get to play with kids much. I
find myself caring mostly for older folks and lots of
people with chronic pain.
I did not set out to serve pain patients. Talk about a
group you don’t get to play with! These are people
who are uncomfortable and usually quite unhappy. But they
certainly need caring.
I get a lot out of my relationship with these difficult,
sometimes demanding patients whom many doctors would prefer
to avoid. Chronic-pain patients provide an opportunity
to meld medical practice with spiritual practice, requiring
me to draw on my deepest reserves of compassion and patience.
From the viewpoint of a doctor, what’s most difficult
about pain is that it’s completely subjective, and
few measures exist to quantify or rate it. One can measure
pulse rate and blood pressure and closely observe patients’
facial expressions and movements, looking for objective
tip-offs as to the severity of their pain. Watching people
when they don’t think they’re being observed
is another important source of data, especially in patients
suspected of faking or exaggerating their symptoms. There
are even businesses, frequently hired by workers’
compensation insurance carriers and their lawyers, that
clandestinely videotape injured people as they go about
their daily lives, in hope of showing them to be more
functional than they claim to be.
But no matter how you try to assess it, when push comes
to shove, pain is wholly subjective. There is no reliable
way to tell from the outside how much a person really
hurts on the inside. How bad their pain is basically comes
down to how bad they say it is.
At the extremes of life, we do sometimes have to rely
on very imperfect signs of pain. With infants, for example,
doctors have only recently learned, based on babies’
responses like crying and pulse rate, to inject local
anesthetic before doing routine newborn circumcision.
Likewise, there are specific signs that suggest trying
a pain medicine when a severely demented older person
becomes agitated.
The vast majority of the time, the best information we
health practitioners have to go on in managing pain is
patients’ own reports of how much it hurts. We may
try to quantify the suffering by asking them to put it
on a ten-point pain scale: zero being no pain and ten
being the worst pain in their life. (I’ve had plenty
of patients answer that question with “twelve.”)
Still, it’s a number that the patient gives us.
Few people fake pain. Their pain may get a boost by the
fact that it keeps them from working at a job they hate
or gives them a steady supply of narcotics or lots of
sympathy from the people who surround them. But they don’t
usually just make up a pain or even consciously exaggerate
how much they hurt. Whether or not the doctor can attribute
a hurt to a particular pathologic physiology or to a specific
anatomical disturbance, she can generally assume that
her patient’s suffering is real.
That pain is so subjective is certainly a challenge. It’s
hard to know how to treat something that I cannot measure
like I can blood sugar in a diabetic or blood pressure
in a hypertensive. It also means that, because pain is
objective, the playing field is quite level between the
patient and me. I may have all sorts of special medical
knowledge, but I have to rely almost totally on the patient
for the data I use in addressing her pain.
What I like best about pain management is that it mandates
a strongly collaborative approach rather than a prescriptive
one. Trust between patient and doctor is at the very heart
of what it takes to manage chronic pain.
In the context of that relationship, I may prescribe plenty
of pain medications for a suffering patient, including
narcotics. Of course, I try to hold narcotic doses to
the lowest level possible because side effects, ranging
from over-sedation to constipation, can severely hamper
overall quality of life. And quality of life, which includes
both comfort and function, is the goal of pain management.
I prescribe anti-depressants, anti-inflammatories, nerve
conduction modifiers, muscle relaxants, massage, chiropractic,
acupuncture, electrical stimulators, and anything else
that might help. Because of their downside, narcotics
are the last thing I add to a pain-management regimen.
That said, many of my patients get along well for years
on stable, sometimes high doses of narcotics.
It’s estimated that at least half of the effect
of any intervention for pain, even narcotics, is a placebo
effect, meaning that relief is attributable to the patient’s
expectation of improvement, as opposed to the particular
drug. Placebos work in medicine, especially when it comes
to pain.
A strong placebo effect does not mean that a pain is not
real, only that the subjective side of the experience
has been addressed in part by the patient’s anticipation
of getting better. So, no matter what I prescribe, from
morphine to massage, I always give the message along with
the prescription that I expect the patient to get much
better. If I expect improvement, so does the patient.
And if a patient expects to get better, it’s likely
to happen.
Here’s how I routinely counsel my pain patients.
I tell them to pay close attention to their hurting. Since
pain is the ultimate subjective experience, how one perceives
it is of critical importance to how much one hurts. I
tell patients to look, in their mind’s eye, right
at their pain. Where exactly is it located? How big is
it? What color is it? Does it pulsate or move? Is its
character hot, cold, stinging, dull, burning or achy?
And so on.
By perceiving it clearly, as opposed to trying to ignore,
suppress or run away from it, patients come to put their
pain in perspective. It does not occupy their whole being,
just a nameable part of it. A part they can observe.
A friend, who suffered for years with severe abdominal
pain, the cause of which was never diagnosed, explained
how she finally learned to live with the hurting. She
told me that she’d made friends with her pain. She
examined it, welcomed it, embraced it. Once she knew her
pain intimately, she was able to give it a limited place
in her life and then to get on with things. She understood
that the pain would be there taking up a certain amount
of space on the periphery of her life, not standing on
center stage dominating the drama.
That’s my closing message. Make friends with your
pain. And make friends too with a doctor you trust.
Marc Ringel has spent the majority of
his career as a family doctor working in rural communities,
including the last 12 years in Brush, Colorado. He has
written extensively, for lay and professional audiences,
about rural health, medical informatics and healing.
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