Talking about a revolution – let not compassion die when facing the challenges of chronic pain management

Welcome back to guest blogger Dr. Henriette Poulsen, M.D, Denmark:

Almost a year has  passed since the US international Institute of Medicine (IOM) released its report, documenting that chronic pain affects a very large part of the population – and has an estimated cost of $560 billion to $635 billion per year – a huge part of the total health care expenditures.

The IOM report included a blue print, describing how chronic pain management has to be changed in order to make it better and to increase the quality of life of numerous Americans as well as to reduce costs. A change in pain management is urgently needed in the US – and the rest of the world. However chronic pain management has far from been revolutionised yet.

Stanford dean, Philip A. Pizzo M.D, and Professor Noreen M Clark Ph.D, chair and vice-chair of the Committee on Advancing Pain Research, Care and Education behind the IOM report have co-authored a request to the medical community to engage in the facilitation of the cultural change which is necessary to revolutionise pain management¹. The request was recently published in the New England Journal of Medicine and insistently urges that the misunderstandings which are currently preventing patients from the best possible, evidence based, patient centred care are eradicated by education. Education of primary physicians and other health care professionals as well as PUBLIC education because patients as well as relatives and employers must take an active part in pain management to ensure its success. Misunderstandings regarding the use of opioids, the insufficient treatment of elderly pain patients, the co-existence of pain and depression, the failure to use a broad, interdisciplinary approach to pain treatment and the failure to recognize chronic pain as a something very different than acute pain lasting a longer time are outlined.  Topics, which all previously have been discussed on the Picture of Pain blog.

The lack of proper communication between patient and carer is marked out as a major challenge. Mentioning once more that one truly frustrating and fundamental fact of pain – that it can felt by the patient – and  only the patient! Not by nurses, doctors or relatives.

But WHY doesn’t the cultural transformation, the revolution happen? Is the alleviating of suffering not the most fundamental obligation of any health care provider? How can we accept not to understand enough, not to know enough to ease the pain of our patients the best way possible? How can we as empathic doctors, nurses, physiotherapists etc deny people treatment – and decide NOT to improve our knowledge – and decide that it must be someone else’s problem?

A review article with a title including the telling but daunting expression; “The Extinction of Empathy” was published in November 2011². It is described how the body-mind dualism view of illness still plays a significant role in the way chronic pain patients are viewed by most health care professionals. That is, that pain is considered to be either a result of a disordered bodily machine or the result of a “disturbed mind”. When” objective” evidence of a bodily lesion cannot be found, it is often concluded that a “disturbed, weak mind” must be the cause. This in turn often leads to stigmatization of the patient – and also in line with the above mentioned – makes the patient’s complaints of pain someone else’s problem.

More over it is described that instead of considering each patient as an individual with a unique combination of factors resulting in the pain, pain patients are often labelled and classified in one of several categories of negative stereotypes.  As a result chronic pain patients risk becoming “one of those patients”;  Before even properly examining the patient or listening to the story, a part of our mind have already decided that we KNOW how this is going to end – nothing will be found and the patient will never stop complaining… SO WHY EVEN BOTHER?

Even thinking this way prevents so many patients from an improved quality of life as most often SOMETHING can be done. And chronic pain IS NOT a static situation but changes over time. Basically stigmatizing and labelling patients reduces the capacity of positive empathy and results in negative empathy, judgement and a lack of compassion.

To resolve the negative impact this has on pain treatment and communication the authors suggest an intersubjective or “third  space” in which the experiences of both patient and clinician are shared and negotiated, neither being an “expert” compared with the other. In my opinion and experience the DoloTest® plays an important part in facilitating this “third space” as it represents the patient’s expert-knowledge and emphasizes the importance of this in the decision making. Furthermore the DoloTest® result can be interpreted equally by the patient as well as the clinician, as the visual representation of the result is available instantly and the areas covered by the DoloTest® have been specifically chosen as the areas of health related quality of life which matters the most to patients.

1. Pizzo PA et al: Alleviating Suffering 101 – pain relief in the United States. New England Journal of Medicine.2012.  366(3) 197-9
2. Cohen M et al: Stigmatization of Patients with Chronic Pain: The Extinction of Empathy. Pain Medicine. 2011. 12(11) 1637-43.

Henriette Poulsen, M.D. (2012). Talking about a revolution – let not compassion die when facing the challenges of chronic pain management Picture of Pain Blog