We are a surgical orthopedic practice. Every day we see patients in pain. We ask them to describe it; location, duration, sharp or dull, constant or intermittent, but we really have no way of measuring someone else’s pain. The tools we use now are inadequate and the information we get from them is misleading.
Our job as medical professionals is to assess our patients and to treat their pain safely and appropriately. This gets harder all the time as opiates are prescribed frequently, and are expected by most people, especially in the Emergency room. Those lovely Press Ganey scores (patient satisfaction surveys) are going to be low if we don’t send someone home with some kind of medication.
There are many different ways for the patient to tell us how much pain they are in. There is the “0-10” Numeric pain scale, the Visual Analog scale (a horizontal line where the patient marks on the line where their pain intensity level is), or the Wong-Baker Pain Scale where faces range from Happy (0) to severe (10) for the patient to point at to visualize their pain. In all of these, the number is supposed to be 0 for no pain and 10 for the worst pain imaginable. This is where things get tricky. If you have ever been in labor or had a kidney stone, you are actually aware of how bad pain can be. You know you can’t actually function (walk, talk, laugh with your friends) when you have a 9/10 pain. You certainly cannot go to work, drive your car and go out to dinner, and yet, at least 50% of patients who walk through the door have a 9/10 pain level. Why?
Part of it is our fault. Patients are told in the hospital they will get one pill for 5/10 but two pills for greater than 7/10 (who actually thought of that???) Patients feel that they will not get any attention for a lower, more realistic pain score. They are unaware that we look at movement, facial expressions and demeanor along with listening to what you are saying. If you tell me you have a constant 3/10 back pain with elevations to 5-6/10, I am much more likely to believe you than if you sit in on our exam table, swinging your legs and talking on your phone and tell me it is 9/10 all the time.
“I have a high tolerance for pain”. Most common phrase in a Dr.’s office. Second most common is “I’ve just gotten used to it”. First of all no one can actually judge their tolerance for pain. The mechanism of pain is where the tolerance comes in. If you have a disc or bone pressing on a nerve root, the pain is excruciating. If you have a broken bone, soft tissue injury or just had surgery, the level of pain is different for each. You do not “get used to” pain. It decreases. Trust me, the first labor pain is the same as the last. You do not get used to it.
It’s very difficult to get a patient’s actual symptoms described to you. You need to observe, listen closely and be non-judgmental. You need to see what else is going on in your patient’s life. Pain is linked closely with depression. If your patient is going through a loss, such as a divorce or a death in the family, you can be sure the pain they feel will be increased. The opposite is also true. A happy, well-adjusted patient will generally report much less pain for a similar injury.
What can we do? We as medical professionals need to listen and observe our patients better. We need to actually explain the pain scales and make sure a 3/10 is treated with the same level of concern as a 9/10. We need to treat the mechanism of pain instead of the symptom itself. Using ice, elevation and anti-inflammatories instead of narcotics, massage and stretching instead of muscle relaxers. We need to realize that sometimes people do need pain medication and give it to them without bias or judgement. Until we find a better way of measurement, it is up to us to use our training and our observation skills to “feel their pain”.
- Azimi P, Nayeb Aghaei H, Azhari S, Shazadi S, Khayat Kashany H, Mohammadi HR, Montazeri A. An Outcome Measure of Functionality and Pain in Patients with Low Back Disorder: A Validation Study of the Iranian version of Low Back Outcome Score. Asian Spine J. 2016 Aug;10(4):719-27. PubMed PMID: 27559453
- Shaw WS, Hartvigsen J, Woiszwillo MJ, Linton SJ, Reme SE. Psychological Distress in Acute Low Back Pain: A Review of Measurement Scales and Levels of Distress Reported in the First 2 Months After Pain Onset. Arch Phys Med Rehabil. 2016 Sep;97(9):1573-1587. PubMed PMID: 26921683