When it comes to pain - who hurts more?

"Men vs Women on Pain- Who hurts more"?
This is the title to the article that was recently published in the TIME magazine: http://healthland.time.com/2012/01/23/men-vs-women-on-pain-who-hurts-more/

The abstract for the original study the article was basing its information on, can be accessed here:
http://www.ncbi.nlm.nih.gov/pubmed/22245360

The original study's main objective seems to be, to highlight the value of electronic medical record in driving scientific research as it provides ready access to a huge pool of patient information. Then it appears to end with the calls for "increased attention to this idea" of sex differences in pain scale ratings.

The main conclusion from the study:

- Women report higher pain intensity than men, up to one whole point higher than men in a 0-10 scale.

The explanation suggested for this:
- Hormonal differences
- Cultural/social stereotyping with men being tough especially if a female nurse is the one asking the question.

This information is well known to the clinician community. Up to 80% of the patients in the head and neck pain population are female. It is true that research has time and again evaluated the role of hormonal factors influencing pain quality and presentation in female versus male patients. Also, there are studies that validate the influence of cultural stereotyping in patient's pain ratings and hence these two explanations are valid and appropriate references.

However, I do find it is interesting how Dr. Atul Butte ends the interview with the Time magazine.

“The reasons may be biological or they may not be, but we should still be aware of the bias that patients have in reporting pain,” he says. He is hoping to continue the research by following up these results with surveys of patients’ ratings after they were treated for pain. That may help doctors to better address the real pain patients may be feeling."

Ouch...
What Dr. Butte calls as "bias that patients have" here, can very well be the context of the patient's suffering that needs to be assessed clinically. When a patient rates his or her pain, the number is an indicator of both the physical intensity of the pain and the pain's emotional impact on the quality of his or her life and overall wellness. There are numerous studies in epidemiology that analyses subjective data like pain through questionnaires that do not ENTIRELY rely on the 0-10 pain scale. For example, more and more studies look at the impact of the patient's pain on the quality of their life using concurrent assessment tools for those.


Hence calling the pain scale differences as patient "bias" is quite off the mark. It is also unfortunate that the TIME magazine ends with the statement on , "better understanding of the patient's real pain" ....


An effective clinician believes the following:
"All of the patients' pain is real...It is the clinician's work to assess, evaluate and help them manage the symptoms- physical, emotional and all. To the patients, pain validation is at least as significant as the pain cure. The true bias in pain assessment lies with the doctors and that's where the awareness needs to be. 

The "art" in pain management

I enjoy art. To experience art, and especially to experience art in the making, is timeless. Why talk about art in a pain blog?

When I was in dental school and then in grad school, echoes of phrases such as  “the art and science in medicine…the art and science in dentistry” would be heard throughout the course of many lectures and talk. The art in medicine and dentistry was predominantly meant as the skill-set that required expertise in technique. However, to me, the “art” in health care is the openness and creativity that underlies every doctor-patient interaction.

Every patient, new or previously known to the doctor is a new experience. Each time the doctor interacts with a patient, the space is open. It is magical if both the participants walk in with an open-mind. Although, It is quite something to watch the pre-conceptions color a conversation, it makes it more exciting as the space opens up in that conversation to allow for a healing interaction – both ways.

The technique in health care- both medicine and dentistry is imperative. Without it there is no core. It is the very skeleton to that trusting bond between the doctor and patient. But the art is the life of that interaction. Art lies where the doctor uses his or her intellectual, emotional and technical skill sets in a creative, patient-centered manner. It lies in steering the conversation as it un-folds. It lies in being open from moment to moment to receive what the patient has to say and then guide appropriately, in terms of the treatment.

In my clinical practice, when I present treatment options, often times I use the analogy of an empty room with multiple doors. The patients choose the treatment that suites their belief, their needs and personal goals. The technical expertise lies in defining those treatment choices for the patient, but it is indeed an art, in exploring the patient’s needs in their own terms and then watch it all unfold in front of you.  Art give that interaction a certain element of timelessness. Already, for a lot of chronic pain patients, time is irrelevant, as they have tried so many “interventions” and treatments over so many years. Hence, sometimes, a patient conversation lasts 60 minutes and sometimes its 10 or even 5 minutes, but the time is only guided by the patient’s goals. It can also be influenced by the doctors intentions, but I have found it best to be a receiver and then a guide than first the guide and then the receiver.

So, this is something I emphasize to visiting students here…allow your expertise to be your core strength, but develop an openness to your patients, and a certain awareness…develop a compassion to listen to your patients and a certain readiness to be in the moment of those three important words…clinical decision making…because there in lies the he-“art “ of medicine.