When patients complain of pain, treatment depends on many factors
The other day, my 9-year-old son came in from throwing the football with his dad, sobbing in pain. My husband told me that he’d twisted his neck when he went out for a long pass; he assured me that there’d been no rough tackles or hard falls. I was initially sympathetic, dispensing a hug and comforting words. It was only when my son insisted that he couldn’t possibly eat dinner at the table and needed to be served on the couch that I started to laugh.
I had no doubts that his neck hurt him; in fact, I was sure that it did. But as a doctor, I was convinced that it was a minor injury, probably a muscle strain that couldn’t hurt too badly. Dismissing his pain, however, did nothing to heal it. It made him start to cry all over again.
Doctors typically refrain from laughing at their patients, but we often react to their complaints of pain in a similar way. On some level, we simply don’t believe them.
It may seem insensitive, but there’s an obvious explanation. For the most part, doctors decide how they’ll treat patients based on things they can measure or see. They recommend a transfusion when a blood test reveals that a patient is anemic, apply a cast when an X-ray shows there’s a fracture, perform bypass surgery when an angiogram reveals blockage of the coronary arteries.
Pain is different. Patients complaining of incredible pain may have no outward signs of a “real” problem — meaning things that show up in tests or an exam. That leaves their complaints entirely open to doctors’ interpretations, and these can vary widely. One physician may feel great empathy toward a particular patient; another might view him as a drug addict trying to get hold of powerful prescription painkillers.
Since impressions can vary from doctor to doctor and patient to patient, two people with the exact same complaints may be treated quite differently. Physicians might prescribe a narcotic to someone they feel is believable and nothing more than an over-the-counter anti-inflammatory to someone they suspect is exaggerating.
A variety of biases appear to influence a doctors’ decision-making here. Race clearly plays a role. A study published in the Journal of the American Medical Assn. in 2008 found that white patients treated in the emergency room for pain are significantly more likely to receive opioids than blacks, Hispanics or Asians. A patient’s gender, age, occupation, and income level can also sway a doctor, the exact effect varying from physician to physician. For example, one doctor may be prone — even unconsciously — to judge a male patient as a complainer, another more ready to deem a female patient hysterical.
In addition, doctors are more accepting of some types of pain than others. They tend to buy into complaints of acute pain such as post-operative pain or the pain associated with a broken bone more readily than complaints that are long-standing. Chronic pain sufferers are often viewed as malingerers. (Individuals whose pain is caused by cancer are a general exception to this rule; doctors find them quite believable.)
Doctors also tend to believe complaints of pain when there’s medical evidence that validates them. An individual with back pain whose MRI reveals a herniated disc, for example, is likely to garner more sympathy than someone with a normal test result.
Another factor is patients’ behavior, which affects the way doctors interpret their symptoms. A 2008 study in the journal Social Science & Medicine found that “challenging” verbal behavior such as exhibiting anger or demanding a specific pain medication influenced physicians’ treatment decisions for people complaining of chronic low-back pain. Not always in the same way, however: For black patients, challenging behavior prompted more aggressive therapy with stronger medications. For white patients, it was the opposite; physicians were more hesitant to escalate treatment when individuals behaved this way.
Getting to the bottom of pain isn’t easy. “There’s some serious detective work involved,” says Dr. Eduardo Fraifeld, president of the American Society of Pain Medicine. In some cases, the physical exam can reveal evidence of underlying problems. In others, simply watching patients can be revealing: Patients with severe pain may constantly shift position, furrow their brow, tighten their lips or clench their teeth.
But for the most part, all doctors have to go on is what their patients tell them.
Can patients fool their doctors? “Absolutely,” Fraifeld says. “But ultimately you have to believe the patient. After all, that’s who you’re treating.”
As difficult as treating pain can be for doctors, it’s certainly more difficult for patients who are suffering from it and not being taken seriously. Although patients can’t eliminate all the biases at play, they can try to minimize the bias issue by being completely honest with the doctor. Hiding things and lying — even simply exaggerating — aren’t going to help.
I wouldn’t say that I fully bought into my son’s complaints: Humoring him would be more like it. I served him dinner on the couch and rubbed his neck before bedtime.
It was only the next morning when he woke up and wouldn’t move his head that I began to second-guess myself. At that point, I had no alternative but to take his pain more seriously and bring him to a doctor.
Although the doctor agreed with my original diagnosis, his approach couldn’t have been more different. He examined Clay closely, listened carefully to everything he had to say, and prescribed a soft collar and ibuprofen to help relieve his discomfort.
Twenty-four hours later, Clay was out of the collar and back to playing football. The only injury that hadn’t healed was the one that I had inflicted when I had dismissed his tears and pain.
Ulene is a board-certified specialist in preventive medicine practicing in Los Angeles. The M.D. appears once a month.