CENTRAL  SOUTH  DAKOTA  MEDICAL NEWS
THE CLINICAL VIEW
By: Phillip E. Hoffsten, M.D.
29  MARCH  2001

Dealing with Pain Problems

Of all the things that a person ever seeks medical attention for, dealing with pain is by far the most common reason for which people seek medical attention. There are two broad categories of concern that the person has when they have a pain. Sometimes, the pain is so bad that the person wants relief by some means. Contrary to this, many times a person seeks medical attention more concerned about the reason for the pain and what it represents. In this group of individuals, the pain itself may be tolerable but the individual is more concerned that it represents something ominous such as an appendicitis, a cancer, a heart attack or a broken bone. Most often, a person seeks medical attention wanting both questions answered. They want to know why they hurt and then they want relief of the pain and almost always in that order.

Before proceeding with a discussion on how to deal with these two questions, two basic facts will help with an understanding of how healthcare professionals approach these questions. The first fact is that 7 out of 10 people who come to healthcare attention because of a pain problem do not have a disease. This means that 7 out of 10 times when a person comes to the doctor and asks why they have a pain, no answer will be found. Most of the time this is unacceptable and just unbelievable to the person with the pain. They know that pain is not normal, and if they have pain then something must be wrong. The attitude is almost always, "There must be something wrong, and Doctor, it is your job to find out what it is." It needs to be understood that depending upon the circumstances and the characteristics of the pain, 7 out of 10 times no matter how many tests the doctor does, an explanation or a disease or a broken bone or a cancer or some other such problem will not be found. Healthcare professionals can frequently recognize the group of individuals who have a pain but have nothing dangerously wrong based upon the history and the story that the person tells and on the basic physical exam at the time that they are seen. The healthcare professional can form a remarkably accurate picture of those that have something dangerously wrong and those that do not.  For that group of individuals who do have something dangerously wrong, the procedures are relatively straight forward. There is something very satisfying in knowing that a pain has been dignified and believed to be secondary to a disease process such as a heart attack, a cancer, an appendicitis or a broken bone. In these individuals, even when the specific disease cannot be cured, pain relief can always be provided by various means.

For the healthcare professional, the 70% of pain problems that are not secondary to a specific cause present the biggest challenge. I do not think that I have ever met a person who was comfortable accepting that their pain was "all in their head" or that they were a "head case". As soon as the patient feels that the healthcare professional believes the patient has an imagined pain, there is a definite dent in the doctor/patient relationship. It is probably the most common reason patients go to another healthcare professional seeking second opinions.

Before proceeding with how to help this group of individuals, the second medical fact I alluded to above needs to be considered. The second medical fact is that healthcare professionals do not necessarily have to know the cause of a pain in order to relieve it. Sometimes, patients have the feeling that doctors are not doing their job if they simply treat the pain but do not find the cause. While it is most satisfying to know the cause of the pain, most of the time this is not going to be achieved but relief of the pain still needs to be provided. While there is a tendency for healthcare professionals not to provide pain medications for individuals in whom they do not have a specific cause for the pain, this is not a good practice. The individual's pain needs to be cared for and comfort provided even when there is no specific disease or recognizable cause for the pain.

With the above, we can now address the question of how to deal with the 7 out of 10 people who have a pain and no structural abnormality or recognizable disease process that can be identified. Most of these people have a self-limited discomfort that will spontaneously go away. They need to be provided pain medication for relief until the problem self-resolves and the majority of these patients are comforted by the knowledge that there is not a dangerous disease process that their pain represents.

Now we come down to the reason why I am writing this column. What about that nifty gritty group of individuals who have persistent disabling pain and no disease process can be found. Last week, I mentioned the concept of a "neurotic symptom". I said this was a symptom that came to someone when they had a problem that they were unable or unwilling to deal with.  I gave the example of an individual on Wall Street with a headache because the stock market was not behaving in the way they wanted. To my surprise, I had several irate calls this past week from individuals telling me that they were insulted that a healthcare professional would suggest that their pain was neurotic. To them, their pain was absolutely real and the healthcare professional was incompetent when they could not find a cause for the pain.

First, it needs to be said that a person's pain is their own, and it is absolutely real, not imagined. But, as mentioned above, just because a person has a pain, does not mean that they have a disease, and as mentioned above, relief of that pain still needs to be provided. It is not productive or useful to continue to seek a structural or disease process in an individual when in fact the pain represents another problem the person is unwilling or unable to deal with. There comes a point when further testing is a disservice to the patient.

As an example, I am reminded of the story about a man who was down on his hands and knees sifting through the sand on the beach looking for his watch. Another person walked by and inquired about what the man was doing. The second person then started helping to look for the watch. After a short time, the second man asked the person who had lost his watch exactly where it had been lost. The man who had lost his watch volunteered that he had lost it while swimming about a mile out in the ocean. The second person questioned why he was looking for it here on the beach. Where upon the man who had lost his watch said that the water was not as deep here, and it was easier to look for it here on the beach.

This story provides the backdrop for one of the calls that I got this last week. A young lady has had abdominal pain over an extended period of time. For almost four months, she has had abdominal pain that has interfered with her ability to go to work and with her social functions with friends and family. She began evaluation with one physician who did basic tests and found nothing wrong. The patient was given Tylenol to deal with her abdominal pain but found no relief. She then sought medical attention from a second physician with a similar result after more tests had been done. I then saw this individual, reviewed the previous history, checked several more examinations and still found no disease process to explain her abdominal pain. I arranged for her to be seen at Mayo Clinic where she remained for an unusually long period of time. After 10 days of tests and evaluations, she was told that she had a "chronic pain syndrome". She was provided with medications to help deal with her pain but she was still dissatisfied that no cause for her pain had been discovered. On returning home, she used the Internet and diagnosed herself as having gallbladder disease. Gallbladder tests were repeated with no abnormality found. Using the Internet again, she felt that she had endometriosis. Evaluations were initiated but she wanted her tests done at Mayo Clinic and returned there. The gynecologist at Mayo Clinic did not agree that she had endometriosis. Her total testing and evaluation was expensed at more than $75,000 and still with no disease process demonstrated. Eventually, psychiatric care has been instituted and this individual will be helped in dealing with the psychiatric problem that her abdominal pain represents. The analogy to her looking for a watch on the sandy beach when it was lost a mile out at sea is obvious. It needs to be understood that doing more testing with x-rays and blood tests when the person has a psychiatric problem is a disservice to the patient.

To conclude, this is a very difficult area in the healthcare profession. We make every effort to honor and dignify a person's complaints even when they do not represent a specific disease process. However, we continue to struggle with how to best help patients come to the recognition that their pain may not represent a disease process but instead is related to problems the person is unwilling or unable to deal with.