Doctor: Do not mistake your Google searches for my 8 years of medical training.
Pain Patient: Do not mistake your 8 years of medical training for my 20 years of experience with chronic, debilitating pain.
The above exchange is one that many people in pain have had with the medical professionals who are assisting in their care. However, it is important to realize that for many health professions, unfortunately very little of their formal education is dedicated to an understanding of the pain systems – let alone the nature of chronic pain. Most medical professionals do not know that you can have pain without significant tissue damage, which seems counterintuitive when you recognize that 80% of visits to medical professionals are caused by some kind of pain issue.
In my medical training, we had a one hour lecture on the somatosensory system, which included minimal discussion on the hugely important topic of nociceptive or pain systems. We also had a single one hour lecture on the primary medications used for pain – and bluntly, it focused primarily on opiates, steroids, and NSAIDs, not on other potential medications now commonly used for pain, let alone psychological treatments, pain processing or perception.
We had a session in our “doctoring” course on pain education – but the “pain” patient in that clinical scenario was actually not a pain patient at all, but a person faking lower back pain to get pain medications.
Nurses, on the other hand, often receive explicit training in pain management, both acute and chronic. This occurs because nurses are often the providers who assess pain on the front lines, in the hospital and in the clinic. While they do not have the extensive training in anatomy and physiology that physicians do, nurses do have courses sometimes explicitly dedicated to the assessment and management of pain. Similarly, while nurses receive much better training in measurement tools for pain than physicians, they also do not get much education about the plasticity of the pain systems, or the abilities for the pain system to change after exposure to chronic stimulation.
Similarly, as many of the patients who seek chiropractic care do so explicitly for pain problems, such as joint pain and back pain, chiropractors have more coursework explicitly dedicated to pain. However, chiropractors do not receive specific courses dedicated to pain, but rather learn about the causes of pain when they learn about the syndromes that can bring a person to chiropractic care.
Pharmacists, or medical professionals, likely receive the most direct education with respect to pain, but again that centers on the medications that are appropriate for pain management, and the focus on potential addiction and abuse. Their training focuses on the mechanisms of those medications, rather than the pathways and pathology that can result in pain.
So why is this lack of education with respect to pain for medical professionals important when seeking medical care for pain? Without an understanding of the subjective nature of pain (pain is defined by the person experiencing it), you can have completely inappropriate conversations about odd concepts, like “appropriate pain.”
There is no such thing as “appropriate pain,” or pain that can be expected based on what a medical professional finds through laboratory tests or imaging scans. Anyone with a basic understanding of how pain works knows that – pain is defined by the person experiencing it. Again, persons can have pain in the complete absence of tissue damage, and the pain systems can change significantly following chronic experience to stimuli approaching tissue damaging range
Why is this important for a person who is hurting?
Because of the limits of their education with respect to pain, when dealing with professionals in pain management, a person may have to show care in how they present themselves, and in how they describe their pain. Most pain physicians do not know that you can have pain without tissue damage – and other pain professionals, like nurses or pharmacists, may not understand how malleable the pain system is, and how acute pain can become chronic pain, even after tissue damage may have healed. An understanding of those biases can really help you in your interactions with medical professionals.
What Not to Do When You See a Doctor for Pain
In the course of their training, medical doctors receive specific education about how to identify malingering, or faking behaviors, for a variety of illnesses, including pain. People can have a variety of motives for seeking medical care, that do not involve actual illness. Sometimes this is just as simple as attention for a lonely person, but with pain, the primary concern is drug seeking behavior, trying to get psychologically and physically addictive substances for intoxication purposes, rather than pain relief.
This may help you to understand why your doctor is not responding to your pain complaints in a way that you consider to be appropriate. If you respond in certain ways, your doctor may be more likely to suspect that you are not being honest with her, and that you have ulterior motives in your search for pain relief.
First, do not say that your pain is higher than a 10 out of 10. To an emergency physician or a pain management physician, they would characterize a 10 out of 10 pain as literally losing a limb by traumatic amputation. It is hard for most people to imagine that anyone short of that kind of traumatic injury can have that severe pain. I need to be clear – you may be hurting that much, but if you claim that your pain is a 10 out of 10, or worse, a 12 out of 10, the physician will think that they cannot believe your accuracy as a reporter.
As pain is a subjective experience, and can only be defined by you, it is important that your doctor believes you when you tell them how much you are hurting. Also, if you rate your pain as a 10 out of 10, you have nowhere to go if the pain actually gets worse. No way to really convey how much worse the pain may have become. Also, rather than just providing a number, be sure to tell your doctor what you can do, what you cannot do, and what your goals are in seeking pain treatment. This is much better than providing a simple number on a scale.
Do not report that your pain is a 10 out of 10 all day, every day. Pain doesn’t work that way. Pain ebbs and flows. It gets worse, then it gets better, in a cyclical fashion It may still be bad, but it does improve across a given day. Anyone who says that their pain is very high all day, every day, are likely to be suspect. To be clear – there are some neuropathic pains that can be severe pretty much all the time – but even these patients do report that their pain gets better sometimes, even though it never really becomes bearable. Be sure to tell your doctor what actually does work for you – that can really help in guiding the types of therapies she might provide. Again, for almost all pain patients, some things help, just like some things make the pain much worse.
No matter how much you feel that your doctor is not listening to you, do not exaggerate how much pain you are feeling. Be as honest as you can with your doctor. If you feel that you are not being listened to, try to explain that to your medical provider. Do not give a higher number in an effort to try to elicit further attention.This can backfire, in that your provider may not believe you.
Do not ever ask for a specific medication. This is a huge red flag for potential abuse for medical professionals. If you say that there is one, and only one, medication that provides you relief, this will be a red flag for any physician. The reason for this is especially with opiates, their mechanisms are quite similar, while their intoxication effects can be quite different. If you are looking for intoxication rather than pain relief, you are much more likely to report that you would like a specific medication.
No matter how angry or frustrated you are, do your best to remain calm. First, getting angry is not likely to get you what you want. In general, people who are drawn to medicine are rational, logical people, and do not react well to threats and antagonism, and react even more poorly to extremes of emotion. Even if you are tempted to say you might need to talk to an attorney, it will never be to your benefit to tell your doctor that you think that. Threats are never a good negotiating tactic, until you are ready to burn all bridges.
If your doctor recommends alternatives to medication, try to remain open to them. Be very clear what strategies you have tried, and what worked and what did not. Another red flag is that physical therapy, occupational therapy, and other approaches did not help you at all. If you shut down any potential alternatives to medication, unless you provide a good reason, this is a red flag that you are seeking drugs.
Finally, if you hear the words “inappropriate pain,” run, do not walk, to find another doctor. Pain is a subjective experience, and pain can exist in the complete absence of tissue damage. But many physicians do not know this, or do not understand it. If they tell you that your pain is “inappropriate,” that means that according to the lab results they have, the scans, and other tests, they do not feel that the pain that you are reporting is compatible with the condition that they believe that you have. Any doctor who has this kind of bias will likely prove very hard to work with, because at baseline, they do not believe you or your report of your pain severity.