Doctors can all too easily pass judgment on how we think patients should experience their pain, yet it is a deeply individual experience, says Jonathan Glass
It’s not a bucket list I was trying to tick off, but I seem to be building up experience of some of the worst pains that humans can encounter.
I had a ureteric stone back in 2003 as a junior consultant, experiencing the pathology that I have spent hours caring for. I ended up spending a night on the same ward as some patients I’d operated on earlier that day. I have experienced postoperative pain after my radical prostatectomy in 2013. Moving, straining, and coughing were pretty uncomfortable for two and a half weeks, but knowing that it was time limited made it easier to manage. I’ve had a catheter removed; I never knew quite how painful it is until I had mine removed after surgery. When it was removed it was as if a black cloud came over me for five seconds, but then it passed. The pleasure of being catheter-free meant it was an easy pain to deal with. When I had a L5/S1 disc prolapse, the resulting sciatica produced such exquisite awfulness that I was left admiring just how remarkable it was that biology could produce such pure pain, truly magnificent in its intensity.
My most recent experience of pain is very fresh. I have just experienced gout, affecting my right hallux. The pain was relentless in its imposition, awful in its failure to respond to what I could throw at it from the bathroom cabinet, and amusing in my interpretation of it on one Saturday night.
My wife and I had tickets for the theatre. Not sure whether to go because of my pain, I was eventually persuaded. It would be a distraction, I was told. We drove to town but had to park 1.2 kilometres from the theatre. I got out of the car thinking I could walk, took three steps, and abandoned the idea; instead we took an Uber to the theatre.
The play we were seeing, rather ironically, was Touching the Void, a brilliant play about the remarkable, true story of how Joe Simpson and Simon Yates descended the Siula Grande mountain in Peru after Joe had broken his leg halfway down and the two were separated. Joe’s descent alone off the mountain was a remarkable feat of human resilience and determination.
Therein lies the rub. I was sitting in a theatre watching a play about a superhuman effort to get down a snow covered peak in driving wind, with no food and a broken leg, while reflecting on the fact that I’d failed to walk along the flat, dry pavements of London from the car to the theatre. Watching the brilliant performances of the actors on the stage, I giggled to myself about my failure to take on my personal challenge by taking an Uber to the theatre.
The episode made me reflect on pain, the perception I’ve had of my pains, and how we perceive pain in others. My sciatica lasted about five months. Despite its intensity, I never took a day off work. I do remember saying to myself, if this is how I am going to be for the rest of my career (I was 48 when it occurred), what mental adjustments do I need to make to allow me to get through my day and not get overly stressed by it?
The attitude of our patients to pain is clearly influenced by so many factors other than the chemical signals ascending from the stimulus into the spine and to their brain. A person’s premorbid mental state, other comorbidities from which they experience discomfort, the support network that they have around them, and their varying mental attitudes at any one moment might alter the perception of their individual pain.
We as doctors can all too easily pass judgment on how we think patients should experience their pains and how they should be able to respond after surgery. I have heard colleagues, and have been guilty myself, of saying this one’s recovery is a bit slow, or that one’s not getting out of bed as we’d expect.
To really understand how the patient is experiencing their individual pain, however, we need to try to understand so much more about them than just considering the initial perceived painful stimulus. Taking all these other factors into account will explain why some patients bounce back from surgery, while others struggle with their recovery.
The play didn’t serve all that well as a distraction; indeed, it made me focus more on the crystallisation of uric acid in my big toe. Yet it did inspire me to change my attitude so I could overcome my challenge on that particular Saturday night. The physical stimulus causing my pain was no less on the way back than it was on the way to the theatre; what had changed was my attitude towards it and my determination to overcome it. At the end of the performance, my journey back to the car was slow and very painful, but achieved on foot.
Jonathan Glass is a consultant urologist at Guy’s & St Thomas’s Foundation Trust. Twitter @JMG_urology.
Competing interests: I have read and understood BMJ policy on declaration of interests and declare the following interests: None.