Pain and suffering

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013

Two of my physician friends recently had knee surgery. Both have had good outcomes, but during their hospital stays they struggled to defend themselves against the troops of the no-pain-goes-untreated army. They have been paying attention, and realize that every medication and intervention carries a downside. So when they were badgered into taking something for pain in the immediate postop period, their inclination was to decline.

Weakened by preop fatigue, each eventually relented and "took the damn pills." The result was for each of them the worst experience of their surgical adventure. One vomited and wisely declined anything more than acetaminophen. The other became so loopy and disoriented that his hospital stay was extended by a day as the physicians and nurses struggled to make sure he hadn’t suffered a stroke.

If you had asked each of my friends whether they were having pain, they would have answered, "Sure." But, if you had asked them to rate their pain on a scale of 1-10, they would have screwed up their faces and asked, "What are you talking about?" If you rephrased the question and asked, "How does this compare to the worst pain you have ever had?" they would reply, "I’m sorry, are we talking apples or oranges?"

Pain is one of those things that doesn’t fit into any definable category. Because of their commitment to helping patients be as comfortable as they can, nurses are eager to use the tools at their disposal. They have been taught that in most cases, early mobility results in a better outcome, and that pain can discourage patients from wanting to move or even participate in their own recovery.

In the last several decades, there has been a well-intentioned but misguided movement toward asking patients to quantify their pain. I wonder whether there is much good evidence to support this effort. But it sounds oh so terribly scientific to put a number on something. Suffering is such a personal experience that pain can’t really be distilled down to a number or a smiley face emoticon. Although it requires more time and skill, a better approach for caregivers is to engage the patient in a dialogue about his or her discomfort. I suspect that most of the best nurses do just that.

Some well-crafted questions delivered with an empathetic tone will detect confounding issues, such as anxiety. From my observations and personal experience, anxiety is a powerful multiplier of pain. The more the patient understands about what is causing his pain and the more realistic his expectations are about how long it will last, the more tolerable the pain can be. But finding out what is making the patient anxious, and explaining the management options, including likely side effects, take time. My physician friends who initially declined pain medications (and certainly will again) did so because they have seen scores of their own patients suffer similar side effects. I’m sure that they share my suspicion that reports of side effects seriously underestimate reality.

When it comes to very young children and unconscious adults, we are limited in our ability to have a dialogue about discomfort. In those cases, we are obligated to treat and accept the risk of side effects. We must make inferences from vital signs and other biophysical measurements that the patient is uncomfortable. However, for the patient who can communicate, I think we should put more stock in what the patient tells us about what is bothering him, and why, than in the tracings on a monitor or some sketchy number.

While dictionaries usually make little distinction between "pain" and "suffering," it may be time for those of us who treat patients to consider assigning each word its own working definition. Pain could be reserved for the neurophysiologists and described in terms of spike potentials and neurotransmitter levels. Suffering, on the other hand, would be a much broader term that is unique to each patient’s experience and takes into account factors such as anxiety and depression. We may find with this redefinition that we are using less medication and that patients are more comfortable.

Dr. Wilkoff practiced general pediatrics in Brunswick, Maine, for nearly forty years. He is the author of "Coping with a Picky Eater: A Guide for the Perplexed Parent" and several other books. E-mail him at [email protected]. 

 Updated 9/4/13, 10/8/2013