Medical students need exposure to chronic pain patients

www.kevinmd.com/blog/2016/09/medical-students-need-exposure-chronic-pain-patients.html

Pain. It permeates every aspect of medicine, crawls into the deepest corners of our practices, sinks its claws in and stays put. Opiates are at the center of a vicious national debate, and our patients are trapped in its clutches. But my thoughts are less on medications, protocols, and procedures and more on how we approach the patient who cries pain. Through everything I have observed, as a caretaker and student physician, I have come to a concerning conclusion: The burden is on the patient to prove his or her pain.

A patient recently repeated a remark made by her previous doctor, who had declared she was not in “that much” pain. My patient’s response was simple: “How do they know how much pain I am in? Only I know how much pain I am in!”

She was right. When a patient has any sort of pain, our question is always, “On a scale of one to ten, how bad is it?” They answer, and we immediately judge whether the number fits the presentation. Does the patient really look like an eight out of ten? Are they writhing in enough pain to satisfy us?

This is a ridiculous routine. Do not ask and then ignore what they say. Obviously, clinical judgment is an indispensable tool, so if a patient comes in with 10/10 pain but they are resting at ease on the emergency room stretcher, you can likely delay the exploratory laparotomy. But consider assessing their pain in context.

I recently saw a young lady who called her abdominal pain 10/10, but was interacting pleasantly, with no grimacing nor guarding, and only occasionally rubbing her right flank and flinching when the pain periodically recurred. On further exploration, she had never in her life experienced any significant pain – not even a sprained ankle for comparison. For her, this was the worst pain she could imagine.

Conversely, the judgment that follows mention of 12/10 pain is always the same: “There is no twelve,” we say out in the hallway, “they are just being dramatic.” But if we already ignore 8/10 pain, it follows that a patient may declare twelve out of ten pain to get our attention.

My sister demonstrates a useful paradigm. She is in chronic, bone-deep pain at all times. Her joints ache, her muscles spasm, her head pounds… daily. She suffers from Ehlers-Danlos syndrome and is in constant agony, but was blessed with a spirit that keeps her motivated and enables her to present a deceptively happy face. When she submits to going to the emergency room, we know she must be in unimaginable pain: pain bad enough that it is worth the mistreatment she will endure. Why? Because she internalizes her agony and thus she does not fit the stereotypical picture of a person in pain. So doctors write her off as exaggerating when she quietly uses her words. She does not appear worthy of their time.

I recently cared for a cranky elderly patient who had been reporting pain for days. At first, every question was met with a glare and a growl, but I was determined to be thorough and tried my hardest to coax out the quality of the pain. After several days of this, we had a breakthrough: the patient began to cry while describing shooting, burning pain, plus aches and cramps that made physical therapy too daunting. I returned to my chief and asked to change the patient’s orders: in addition to the typical opiates, I added gabapentin for neuropathic pain, muscle relaxants and heating pads for the cramps, and a B12 titer to address the paresthesias and fissures at the corners of my patient’s mouth. Impressed with my initiative, the chief agreed. When I arrived the next day, the labs showed a B12 level just below normal limits; I had been right. I went to see the patient and was met with a hesitant smile. The new regimen was beginning to work.

“That is what is missing in medicine these days,” my patient explained, “no one takes the time to listen, and no one took my pain seriously, until you did.”

So what is the “right” kind of pain? I once witnessed a resident describing an ER patient with pelvic pain as “actually not that crazy looking,” as if her presentation automatically implied mental instability. When my team told her the “good news,” that she could go home because we had not found any pathology, the patient, with a tortured expression, I will never forget, explained that it was not good news because we had not given her any help, any answers, or any hope. I trailed after my team as they left the room, embarrassed to be associated with them.

These attitudes are not universal, although it can feel that way to the patient. I strive to emulate physicians who approach patients with respect and an open mind. One such attending once explained how everyone has his or her own way of coping. “Some patients shout about it, some get very quiet, others look distracted, and still others joke about it, so you cannot take anything at face value.” It was some of the most important advice I ever received.

The best-case scenario is when pain has an obvious source and will resolve naturally, as with fractures and post-operative pain. But when patients start to complain disproportionately, or when no clear cause exists, we start to write the patient off in our minds. We run our battery of tests, while rolling our eyes.

What is it about pain that makes us want to judge patients, accuse them, and abandon them? Why do we go into medicine and then find ourselves surprised when our patients report pain? Pain is the body’s way of telling us that something is amiss, even if it is the pain receptors themselves! This does not mean such pain is a figment of the patient’s imagination, and it does not mean everyone must react identically. There is no available method to compare pain, and yet we still try to do so, because nuance is too hard to document, and too scary to treat. We do not understand pain well enough to treat it adequately, and we have no way of quantifying it other than asking “well, is it really bad? Or really bad? Or just … bad?”

I believe the solution starts at the foundation, as soon as we begin medical school. We need exposure to these patients, to understand what we are facing, so we are not surprised when we reach intern year. We must hear their stories, of mistreatment and misjudgment. Treatments are limited and outcomes are often poor; thus, our burden is enormous. We must stop the cycle, and we must remove the burden of “being believed” from the patient. We are the providers, and it is time to change how we understand and treat pain.

Sarah Cohen is a medical student.

Filed under: General Problems