The Re-Education of a Physician in the School of Pain
The journey of a physician from student to pain patient to acceptance.
Posted Jul 17, 2019
Since childhood, I have suffered from severe stabbing headaches. Then in my first year of medical school, during anatomy lab, as we peeled back the scalp of our donated cadaver, I saw a nerve poking out of a circular muscle on the back of the skull. With a flash, I knew without a doubt that I was seeing the physical source of my pain. But despite having identified it, it would be another five years before I was diagnosed with occipital neuralgia. Thus, my first lesson in pain management: Even being in the medical field, getting accurate, effective, pain treatment is a lengthy and difficult process. Throughout medical school I learned about pain receptors and pain pathways in the nervous system, but little about how to treat pain.
Most of my experience treating pain came bedside, from supervising residents who passed down what their senior residents passed down to them. I have pocket handbooks from each institution with tips on dosing medications or how to order a PCA. On rounds, there were short snippets of advice from attendings. I recall only one lecture on pain treatment in all of residency. Board exams had little to no content on pain management. Pain is a complex physical and psychological process and medical training shortchanges it. Yet, no one can dispute that pain, whether chronic or acute, can dictate or limit one’s activities, work, and mood. In part due to the shortchanging in training, it is no surprise that physicians I met as a patient, for the most part, were underprepared to work with chronic pain.
Unfortunately, several years into my career in pediatrics I learned more than I ever wanted to about pain. I developed shingles/zoster and then post-herpetic neuralgia (PHN) from the resulting nerve damage.
I learned that my medical school training and residency were poor preparation for the journey ahead. Further, many of the “facts” about pain and its treatment that I learned bedside were incorrect. PHN is nerve pain, which is a tricky beast. Nothing really works well for it. I learned in school that NSAIDs, acetaminophen, and opiates all “don’t treat nerve pain." But I have since learned that is simply incorrect. They all work in some people to a partial and variable degree and with varying side effects and risks, some of which are intolerable to patients.
On the flip side, nerve pain agents such as TCAs and gabapentinoids, touted in medical school as cure-alls, also work to varying degrees in different people, but many cannot tolerate the side effects. In a discussion before a procedure with one of my pain physicians I was told that if a treatment works to lower pain by 30 percent then it is considered successful. For drugs in the process of getting FDA approval, the benchmark for success is 20 percent. Interventional strategies have similar success rates but are only accessed at specialty pain clinics or academic centers and are out of the reach of many.
Thus, I have had to alter my expectations and learn that going from a pain score of 9 to a 6 is a “success.” I had to learn that moderately severe pain was better than super severe pain and that layering on different medications that each give 10-30 percent pain reduction until you finally reach a place that is livable is a daily titration.
In my journey with neuralgia, I also learned about complementary methods of pain control. All of these were only discussed in training as a side note and mostly dismissed. These methods, as long as they don’t break the bank and don’t cause harm, can be very helpful. For example, electrical stimulation in the form of TENs makes a difference but few medical providers are knowledgeable enough about its use to prescribe therapy. Topicals such as menthol, methyl salicylate, and lidocaine help in a pain flare.
Music is a welcome calming agent. Aromatherapy can help. Physical modalities such as physical therapy and massage help. Psychological therapies such as CBT and ACT can also reduce the experience of pain. Personally, skills learned from my pain psychologist have helped me more than any other pharmacological intervention. Learning to live your life with the involvement of pain that may not go away is difficult and a guide is invaluable.
However, none of these interventions were ever mentioned in my medical training even though all of these methods have minimal side effects and add benefit. Even better, most are available without a doctor's prescription.
Living with chronic pain is a bit like an unwelcome and burdensome dance partner. Pain affects all aspects of daily life. Hoping to go out for a dinner or celebrate a family event? You better hope your “dance partner” is up for it and willing. Many an event that I have been invited to has been curtailed due to pain. I have had to accept partial events and partial participation and take joy in what I can experience and try not to mourn what I am not able to participate in. Pain has taken away some of my independence. Some days I cannot put on my own shoes or bend over to reach a low drawer. I cannot grocery shop independently or go to events in big stadiums/arenas. An additional challenge is that this dance partner is invisible to others who at times cannot comprehend my limitations. I have had to accept my new limits. I have had to accept this. It wasn’t an easy process and took the guidance of a trained pain psychologist.
Mindfulness, gratitude, and compassion all have played a big role in my healing from neuralgia as well. I had already started a mindfulness practice before the shingles/zoster, but it became more meaningful and important as I faced issues related to living with chronic pain.
I began to see mentions of gratitude from several angles, both in the pain community and the mindfulness community, so I began chronicling my gratitude even on bad weeks and found it helpful to reflect on what is working rather than what was not. I also read up on compassion therapy/compassion-loving-kindness meditation, which circle around the same ideas - that we must treat ourselves with the same compassion and love that we treat our family and friends. Adopting attitudes of gratefulness and compassion has been vital in managing my life with pain.
Pain has taken many things from me. Accepting my limits and learning to live a life with pain that holds meaning and value is a daily journey. Acceptance and gratitude have helped me heal despite my physical pain level not really decreasing all that much. Overall this journey has been a re-education of a physician, now patient, in the lessons of pain.