Take pains to treat them

Short White Coat is a blog about learning to be a doctor. Posts appear here as part of White Coat Notes. Ishani Ganguli is a third-year Harvard medical student. E-mail her at shortwhitecoat@gmail.com.

It's evident from the first cut of the scalpel, one of the earliest take-home messages from the OR: Surgeons inflict suffering in their work to relieve it. But unlike the diseased organ itself, the pain caused by operating on it is tough to definitively isolate and remove. My week-long elective with the Brigham and Women's post-op pain service (POPS) provided some insight into the challenges of this often under-appreciated pursuit.

Pain is subjective, the sensory experience of it closely tied to our emotions, thoughts, and memories. Attempts to measure pain -- whether they involve a line-up of cartoon faces wearing smiles and grimaces of varying intensity or even a pages-long questionnaire designed for research-level precision -- inevitably fail to capture these nuances.

In emergencies and on morning rounds, not surprisingly, the quick-and-dirty number scale wins out. In practice, the task feels foolishly put-on: "So sorry to hear you're in pain -- and how might you rate that feeling on a scale of 1 to 10?," I ask my patients after stirring them from sleep at 5 a.m. And the same number can mean vastly different things to different people: One particularly stoic 89-year-old might confide to me that her 3-out-of-10 pain keeps her from sitting up in bed, while the next patient reclines in his bedside chair and declares the full 10 before returning his attention to a re-run of Different Strokes.

What these metrics do offer is some internal validity -- to a large extent, we can meaningfully compare responses by the same person over time and titrate the care accordingly. And there’s more to this care than intravenous morphine or lidocaine delivered straight to the spinal canal: On POPS, we talk about the distinction between using placebos and taking advantage of the placebo effect. The former -- say, calling a sugar pill medicine -- is a clear no-no. But using the power of suggestion to boost a patient's expectations for a drug ("This will REALLY help") is entirely legit-- and borne out by a number of studies.

In part because of the inherent subjectivity of pain, the practice of alleviating it has long been overlooked. Services like POPS are a relatively recent phenomenon and are still largely underfunded and understaffed, if you ask those involved. (Surgeons, as a rule, do follow pain control closely. It’s just that POPS does it for a living, and the reimbursements are scanty.)

At the same time, clinical experience demonstrates an intricate connection with recovery --better pain control eases labored breaths, racing hearts, and the risk of dangerous blood clots in leg veins (comfortable patients walk more). The result, in study after study, is shorter hospital stays and better outcomes.

Then there’s quality of life. The clear benefit to patients was captured one morning as we checked in on our final case: a woman who was notorious for giving her care staff a hard time. She had been yelling at the nurses and anyone else who would listen, and began to treat us in kind until we revealed our identity. As the hints of a toothless smile broke through her battle-weary face, she said, "Just the people I was hoping to see."