Feeling Your Patient's Pain

   For most of us, medical students and physicians alike, treating patients in pain can be, well, a pain. Aside from having to know which medicines to use and how to use them, there's the issue of not being able to objectively measure what we're treating, as well as the unfortunate reality that some patients abuse narcotics. Patients in pain can really put our bedside manners to the test.

   The following are some pearls, from the perspective of a general internist who works with medical students and who was a medical student himself not all that long ago, on how you can interact with people who are hurting. By "pain" I'm referring to the physical kind, although the same principles may apply for emotional pain.

1. Address pain before you address anything else.

   As a medical student, you may be the first person on your team to sit down with a patient to interview and examine him. If you are pressed for time, you may be tempted to proceed with this even if the patient is in pain. It's easy to justify; after all, the sooner you get information from the patient, the sooner you can help him, right?

   While there are certain situations where pain has to be put on the back burner, these are very rare. Imagine how distressing it must be for the patient to be asked questions about family history or to get a full neurological exam when writhing from abdominal pain. (Believe me, I've seen it happen.) Show the patient that you care by getting your resident or attending physician and making sure that the person's pain is addressed first and foremost.
2. When a patient says he's in pain, even if he has a history of substance abuse, believe him.
If you haven't seen a situation like this yet, you will:

"A patient comes in to the hospital after a fall and complains of excruciating leg pain – "15 out of 10," he says. He looks uncomfortable but not that uncomfortable. The leg is visibly bruised but, according to the x-ray, not broken. The patient is a "frequent flyer" with a history of substance abuse. Your resident's or attending physician's assessment? He's exaggerating, probably playing the system for pain meds."

   In general, if a patient has reason for pain and says that he's in pain, I believe him. I call this the "innocent until proven guilty" principle. Nothing is potentially more toxic to the therapeutic relationship than questioning the veracity of what a patient is telling us from the very beginning.

   Pain is, by its very nature, subjective. There is no way for us to definitively know if another person is in pain. That said, just because we can't objectively quantify pain doesn't mean we should dismiss it.

   Don't get me wrong; I'm always on the look-out for narcotic abuse. If a patient says he is in pain but he seems completely comfortable, or if I know the patient is getting narcotics from multiple providers, I'll respectfully question the claim of pain. Otherwise, I'm going to take his word for how he feels. Keep in mind that even people with a history of substance abuse can experience excruciating pain. Between the 2 evils of undertreating pain or inadvertently indulging addiction, I'd much rather err on the side of the latter.

3. Empathize, but realize that you don't really know how the patient feels.

   When faced with someone who is suffering, many medical students want to share their own struggles as a way of trying to empathize with that person. For instance, if you have a patient who broke her arm and is in pain, and you once broke your arm, it's only natural to want to talk about your experience.

   Tread carefully here. This goes back to the point that pain is an intensely personal experience. While some patients might find it comforting to hear someone who isn't in pain say that he's been through something similar, others might find it isolating or condescending.

   I encourage my medical students to let the patient take the lead. Share a personal experience only if the patient gives you an opening, and only if you are comfortable sharing it. Otherwise, keep the focus on the patient. Show her you care by giving her space to talk. One of the most meaningful things that we as healthcare providers can do for someone in pain is just be there, and listen.

   In summary, treating a patient in pain can be challenging. But, like with most obstacles, the flipside is that it presents an opportunity to make a difference. As a medical student and later on as a doctor, if you give patients the benefit of the doubt, realize that you don't know exactly how they feel, and address their pain first, you'll go a long way toward establishing a strong relationship.