Pain for Your Thoughts
ROB THOMAS, PRESIDENT, AUSTRALIAN MEDICAL STUDENTS’ ASSOCIATION
One of the more difficult issues dealt with on a daily basis in medicine is patients with pain – not to mention the chronic pain patient. Pain is difficult to describe, complex in nature and specific to the individual. Unlike many other symptoms, chronic pain is largely invisible, hard to prove and even harder to disprove. It comes with a range of comorbidities, such as unintended weight gain, social isolation, and an increased rate of mental health conditions. Depending on one’s age, cultural background and personal experience, the experience of pain may vary widely.
Doctors, particularly junior doctors, find it especially hard to acknowledge chronic pain, probably because it is so difficult to treat. Our “fix it” mentality means that we find it testing when there is no simple solution. An opioid will dull it for now, but what does that do for the patient long term? Pain requires more than just a prescription. It requires scans, blood tests, referral to allied health and management plans. From this we ask ourselves, as young medical students or doctors, is there an acceptable level of pain that one should expect to live with? And who would determine that acceptable level? The medical staff? The patient?
We are taught to ask patients to scale pain on an arbitrary 0-10 scale. This scale may in fact be telling us more about a patient’s tolerance for pain than their symptom, and indeed may confuse the treating doctor who may suspect a high subjective score to be driven by a desire for strong pain medication. This may be an alert to staff to acknowledge and validate their pain, as well as to provide a plan of care in the treatment of it. The truth is the patient wants to lower their pain, they are not just “drug seeking”. The patient wishes to have their pain at a level under where it currently is. This would enable them to do activities of daily living, self-care and to get back to their everyday routine, where possible. Our journey with the patient is to navigate that pain with them, manage it and ensure a plan is put in place.
The next patient into your general practice is John, a 26-year-old man with a complaint of chronic back pain. You take a full history and find no red flags – in fact, his pain has already been investigated previously and found to be non-specific “musculoskeletal”. He has no significant past medical history and is otherwise well. His pain is currently 7/10 and constant for the past two weeks. He’s obviously in distress – what do you do?
Of course, there is no easy answer in a case like this, and that’s something that students need to be aware of. In particular, the use of non-evidence-based treatments must be acknowledged as “potentially helpful” – if nothing else, it can give patients hope. Adjuncts to the chronic health management plan could be physiotherapy, chiropractics, Pilates and other allied health referrals. The patient journey up until walking through your door will affect how they respond to your suggestions, and it’s important that we become comfortable with the uncertainty that is chronic pain.
Pain is an exceedingly difficult topic to cover in such a short passage. Junior doctors and medical students need to acknowledge the complexity of the nature of pain, then assess, treat and come up with a management plan. The patient journey starts with validating the patient’s pain and them trusting you enough to come back to develop a plan.