May 10, 2017

Context, Safety, and Communication Style Affects the Patient’s Pain Experience

How we experience and interpret events in our lives is critically dependent on the context in which we frame them. This framing can be shaped by previous experiences, expectations, beliefs, social context, emotions and many other variables (see previous blog post). The experience of pain is not an exception.

As clinicians, we have numerous assessment scales for pain: the Wong-Baker Faces, 0-10 Numeric Rating Scale, Visual Analog Scale, Verbal Pain Intensity Scale, the McGill (where is your pain?) Questionnaire, Neuropathy Pain Scale, and the Descriptor Differential Scale to name a few. These are all inarguably valuable tools that help us chart specific pain variables (intensity, location and quality), but they don't begin to address the context in which our patients understand their own pain experience.

Here is an example of the shifting of contexts. A small child is playing outside with several friends. He trips, falls on one knee, pauses briefly to brush it off before returning to play without missing a beat. Alternatively, this same small child who has missed a nap, scored some candy from a neighbor and eats a late lunch falls on his knee. The outcome of the second scenario is quite predictable—he begins to cry and is nearly inconsolable.

The same thing happened to the child's knee in each instance. In the first case he had the capacity to handle it, both physically and emotionally. In the second scenario, a lack of sleep and skewed blood sugar levels affected his pain tolerance.

Pain is also less painful when we are confident that we are safe. This was demonstrated early in the history of pain research by a famous paper about wounded soldiers in WWII, which showed that they experienced surprisingly little pain considering the severity of their injuries. It was determined that this was because the wounded solders were relieved to be off the battlefield.1

In addition to context and safety, how we help our patients describe their pain becomes important. Healthcare professionals often use metaphors to explain complicated concepts that are both misunderstood and hard to convey in a meaningful way to patients. The metaphors we tend to use to describe pain are often negative (damage/weaponry) and neurological (fire/electrical wires). While these metaphors do tend to explain pain to some extent, they are not sufficient and can be detrimental to a patient’s internal framing of their experience of pain. How well can we convey safety to those experiencing pain with metaphors like frayed wires, stabbings and shootings? And remember, pain is less painful when we are confident that we are safe.1

Communicating clearly with our patients about pain and having a keen awareness of the circumstances surrounding the patient’s pain experience, will help us tackle this growing issue more holistically for our patients.

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