When does it start hurting?

I’m more and more interested in pain as an experience which is dealt with by medicine. Yesterday, I heard an interesting story of how pain is reported. Here is my account of what I heard.

The story is about a session with final-year students of medicine in a medical university in Poland. The class were asked to talk to a patient (played by an actor) who was in pain. The pain was described by the patient as very severe. Needless to say, the students wanted to put a number on the experience (‘very severe’ is not accurate enough, apparently), and the patient decided that the pain was 10 out of 10. The students decided that the patient should receive analgesia and the patient was interviewed again. This time the patient told the doctors (i.e. the students) that the medication had had significant effect and that the pain was significantly reduced. And here we come to the most interesting part of the story.

The patient was asked to rate the pain again and decided that it was 4 out 10. On this statement, one of the students decided that the information in the clinical notes should be that the patient was not in pain. The academic taking the class was taken aback and wanted an explanation. The student explained that such a significant reduction in pain warranted the statement he had proposed. A discussion ensued about what constitutes being in pain as opposed to not being in pain. The student and his fellow students were relatively unhappy to admit that 4 out 10 still constitutes (or at least might constitute) significant pain and the fact of reduction of pain does not mean the patient is pain-free.

If I had been in the class, I would have reminded the students a simple linguistic fact that people are often unaware of. If you use an adjective in the comparative degree (e.g. ‘smaller’, ‘prettier’, ‘stronger’, ‘nicer’) to describe someone or something, the adjective only makes a comparison and does not offer insight into the basic characteristic of the object. That is to say, someone who is stronger than someone else might not be strong generally, someone who is nicer that someone else, might still be quite obnoxious, and so on, and so forth. And so, less pain offers no insight whatsoever into how much pain there is/was. Because ‘less pain’ offers only insight into the change of the status quo, not into the status quo itself.

The session ended with some students deciding that, thank goodness, because of their chosen specialisms they will not need to deal with people’s pain and talk to them about it. After all, they are doctors and not communicators. They are there to treat people not to talk to them.

I was listening to the story with disappointment, but without much surprise. To be honest, this is what I would have expected to hear, except that in Poland a lip service of major commitment to empathy, hand-holding and general wonderfulness has not yet evolved. So, students are allowed to speak their minds in those respects. They are not yet taught to make a pained expression of “how very much I am with you”, British doctors (OK – some British doctors) are so adept at making.

Despite the fact, that things seem obvious, I would imagine, I still would like to make some comments.

1. My first comment is about the extraordinary readiness to assume that the patient is pain-free, even though the patient says that he is just under the mid-point of the scale. It would be easy to think that the student is just stupid, that students are not taught empathy. To be honest, these are not convincing arguments.

I was trying to find who said that it is easy to bear someone else’s pain. I was unsuccessful. I still think medics are really good it at it. After all, it is I who is in pain, not the medic, and perhaps pain in the first part of the scale is not worthy of note. It is insignificant pain – something I know very well (here is a link to a post on my insignificant pain). Basically, insignificant pain is eminently ignorable.

Or perhaps it’s about the success. After all, much pain has been reduced, so we’ve done our job. How much more can we do?! We can’t do miracles, can we? You should be grateful that we’ve done so much. Shut up and endure.

Or perhaps it’s about the scale. If you look at pain intensity scales using graphic material (usually – faces), such as the visual analogue scale and its versions, you will see that the second and third face on the scale are not represented as suffering. In other words, if we do such scales, we tell doctors that we are, roughly, OK, still (barely) smiling. The idiocy of such representations cannot be overemphasised, yet, there you are. This is an accepted way of measuring pain.

And so, from lack of empathy all the way to how medicine all the way to how medicine looks at pain, we, patients with chronic pain are doomed.

2. The second point I want to make is about communication. As I said, I am disappointed but not surprised with rejection of communication as important in medicine. You are unlikely to hear this in the UK, medics here are all for communication, after all, they are even assessed on communication. And yet, I keep being ICEd by doctors and they keep ignoring what I say. I also keep calling it out: Aaaah, the ICE questions, at which point the medic starts laughing as if he or she had been found out doing something naughty.

It’s only in hospital almost a year ago, no one asked me the ICE questions. I must admit that I was fairly grateful. At least I was spared these forced attempts to construct a ‘clinical alliance’ or some such.

And so, instead of writing about how important communication is in medicine, I would like to pose a different problem. How many doctors actually believe in that? How many medics actually believe that it is important to listen to their patients? Well, to me. You see, just about every other day I read on Twitter tweets by doctors about listening and how crucial it is. And I keep wondering why they say this.

And here I would like to briefly introduce Paul Grice. Grice’s claim to significant fame is his Cooperative Principle in our understanding of communication. Basically, when we communicate, we should be cooperative, that is to say we should be truthful, not say too much/too little, be relevant and be clear. And if all the doctors already know that it’s important to communicate and to listen, why would you need to keep saying this? Either (some) medics don’t know about it (or don’t buy it) or you are not being cooperative (maxim of relevance) when you say such things. I repeat – why is it necessary to keep telling medicine something it already knows and accepts. Or so it says.

And so, I leave you, doctor, with this question. Do you really want to talk to me, doctor? If you do, gosh, you’re in for a ride.


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