No Tolerance for high pain tolerance

When it comes to providing information during a visit to your doctor, there is a “sweet spot”.

Not contributing enough will undermine the process. For example, it is reasonable to follow the statement “It hurts when I walk” with “and I love to walk” This helps me to decide what is best for you.

On the other hand, contributing too much will also undermine the process. I am more interested in what you are feeling rather than your opinion of why you are feeling something. There will be time later in the visit for you to air your theories.

A recent patient was a middle-aged woman who complained of back pain. As we went through her history, I ask her about the relationship of her pain to various activities. I also tried to understand which activities were most important to her. We were making progress- I understood what she felt and what she needed while she was learning what treatment options she had to choose from. Our progress was suddenly stymied, however. For the third time in ten minutes she told me that she had a “high tolerance” of pain.

You may be wondering how such an innocuous assertion could have so derailed us. It turns out that twenty years of practice have taught me that such assertions invariably suggest quite the opposite- she will undoubtedly turn out to have a low tolerance of pain!

Of course we can’t measure tolerance of pain in any meaningful way. We can measure pain thresholds, however. If we do an experiment where we electrically shock the skin of subjects, most subjects will describe the shock as painful around the same amplitude of stimulation. In other words, we all have relatively similar pain thresholds. Tolerance of pain, as opposed to pain threshold, involves more how we interpret our painful sensations. How often do we allow the pain to interrupt our task-at-hand? Do we assume that the pain will go away or that it will persist? Do we presume that something underneath is wrong?

In many ways this interpretive context of pain is more important than the underlying stimulus. Patients who feel the need to boast of their pain tolerance reveal an interpretive process that is already far too developed and biased. The patients with a truly high tolerance of pain have never even considered what their pain tolerance is!

You may actually have a high tolerance of pain. But do me a favor- don’t tell me about it. If you do, it will serve to undermine you. My reaction is like the knee-jerk that I am about to check on you- reflexive and uncontrollable.

When you come to see me, I am, first and foremost, interested in what you are experiencing.  Once this has been vetted, and I have had the chance to ask you questions, I am interested to hear your editorializing and theories. This is the ideal time for a meaningful conversation or teaching opportunity.

Find that “sweet spot” for a productive encounter and tell me how much you hurt and not how much you can handle.

 

Expertise

“What would you do if you had this problem?” My patient asked.

This question is problematic for many reasons. Would it surprise you if I recommended something different for my patient and myself? It shouldn’t. The art of medicine often requires applying a treatment to an individual rather than to a disease. The same disease can have different treatments depending on what each individual patient wants or needs. If I am the patient, I may choose to go on a hunch. I may avoid a treatment because the risk is too high for me. I may be a “naturalist” due to my upraising and fundamentally distrust intervention.

You ask me what I would do because you view me as an expert.

Expertise is not a level reached or a degree earned. Expertise is best understood and experienced as a dynamic, rather. It is dynamic not only because information is always being created and disseminated, but because this dynamic body of information has to be interpreted and applied to a unique individual or situation. I, as the physician, may have a good knowledge of the disease, but you, as the patient, have a good knowledge of your own body, your own risk tolerance, and your own expectations. Together — and only together — we are the expert.

Yes, it would be easier for you to hear what I would do and simply rely on that advice. My job is to often avoid what is easiest and try to recommend what is best.

The days of eminence-based medicine have been replaced by evidence-based medicine and will soon be replaced by concurrence-based medicine.

Believe me, I would rather tell you what I would do. It is quicker and easier to be paternalistic than to share in the dynamic of expertise, but by doing you a favor, I am doing you a disfavor.