“I feel my world shrinking, and it terrifies me,” she said. She used to be an athlete and yoga practitioner. Now she was one more patient in the Pain Clinic hoping for an explanation and a cure. As we talked, I felt I was standing on both sides of the divide between patient and doctor. Pain is a universal human experience, and I could easily “feel her pain” as her limitations increased. However, she had come to me and to this clinic for treatment, not just for empathy. And that was not so easy.
In the first year of medical school, we learn how to talk about the symptom of pain, what the patient experiences. Where is it? When did it start? What makes it better or worse? This focus on the patient’s perspective in the Patient–Doctor I course leads to a compassionate but theoretical understanding of pain. We ask them, “On a scale of zero (no pain) to 10 (worst pain imaginable), how would you rate yours?” The answer may say more about the patient than the pain.
In the second year of medical school, we become more objective. Rather than talking about the symptom of pain, we observe the sign of “tenderness,” an experimental variable we can elicit. As we learn the physical exam in Patient–Doctor II, we report that a particular part of the body demonstrates “tenderness to palpation”—that is to say, it hurts when poked.
We learn ways to produce certain kinds of tenderness that are essential to making a diagnosis. We are told to not-so-accidentally bump into the bed to jostle an irritated abdomen and produce the typical signs of peritonitis. This condition can also cause rebound tenderness, a painful sensation when the abdomen bounces back suddenly after being compressed. The classic way to test for it without the patient suspecting is to listen with the stethoscope for bowel sounds, gradually indenting more and more, then suddenly letting go and watching for the patient to wince. Such maneuvers are meant to be clinical, not cruel. But we still apologize for them.
As second-years, we also learn about the Waddell signs, controversial tests and criteria intended to ferret out pain with a psychological cause, conscious or otherwise. These include complaints of pain that do not make anatomical sense, or tenderness that occurs in response to nonpainful stimuli and disappears when the patient is distracted. While our instructors have shied away from teaching us that positive Waddell signs necessarily mean a patient is malingering, discussing them reinforced how problematic pain can be for medical providers. Whose pain is “real,” and does it have to be real for us to treat it?
Now I am five months out of the classroom and into my third year of medical school, and it seems every patient I meet has pain. The humanism and pathophysiology of the first two years have given way to this year’s emphasis on management and treatment, and nowhere else is this transition more apparent than in dealing with pain.
My first-year training in empathizing with patients prepared me to recognize the constant anxiety that gripped the young man with raging ulcerative colitis, and connect it to his apprehension before the colonoscopy that would finally decide whether he would have his colon removed. He had made it through several colonoscopies before without much discomfort, but during this one not even the maximum doses of painkillers and sedatives, much less anything I had to offer, could keep him from crying out in pain and fear.
My second-year pharmacology class helped me understand why the drug addict writhing in his bed complaining of back pain had developed a tolerance to opioid pain medications, so that even massive doses would feed his addiction but not relieve his suffering. But no class taught me how to help someone like him. He had violated his “pain contract” with the outpatient pain clinic by seeking drugs from more than one doctor, so he was no longer welcome there.
As a third-year, I have had many opportunities to hone my skills of interviewing and examining, but for me to advance to the next level of medical training, I will also have to act: to give treatment. Medicine’s capacity to manage pain or any medical condition is imperfect, and the stakes are high. My responsibility now is to master the use of medications from ibuprofen to morphine, and to use them judiciously, balancing skepticism with sympathy as I assess the patients’ pain and attain the physician’s power to relieve it.
Miya Bernson is a third-year medical student at HMS.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.
