Some things in life are definite. Some are definitely not. And some are somewhere in between.
Same goes in healthcare and medicine. When you see a hyperactive deep tendon reflex or produce an upper motor neuron sign via Babinski or Hoffmann’s, its pretty obvious. Usually, there isn’t much debate about its existence. There may be some back and forth about the degree to which it exists or to its implications; but, again, most parties will agree “that just happened.”
Same goes for an infected wound. One look, maybe one smell, most people can agree about the degree of bacterial colonization (i.e. infection or no). We can take this further with abnormal heart sounds, clubbing of the digits (indicative of lung/heart disease), or yellowing of the sclera indicating jaundice. The list can go on, but it doesn’t need to. There are a host of objective signs that indicate the presence of disease or pathology. We can even go further with laboratory diagnostics and imaging studies to attempt to confirm or rule out suspicions about the presence of a disease processes.
We have quite a body of information and resources at our disposal when trying to figure out what is wrong with the patient sitting before us. Even more than that, we have gained enough knowledge to decipher and utilize people’s reported symptoms, their subjective report, to aid in this process. As fraught with bias and inaccuracy as an individual’s own perception of their situation could be, we still have found ways to weed through the minutiae and find bits of key detail that aid in the diagnostic process. It could be how long their symptoms have been present, or what activities exacerbate their symptoms. You might ask, “Do you have any popping or clicking? Or feelings of instability?” Or if the patient reports numbness or tingling in a certain area. All of these details paint a little more of the broad picture of the patient’s condition. And one of the most helpful details when painting that picture is pain.
If the person is experiencing pain as a part of their condition, their report of the location of the pain is immensely important…if not necessary. What is less important about the pain, potentially unnecessary in some situations, is the intensity of the pain.
Judging by our healthcare system’s infatuation with the pain scale, you might disagree with me. We probe our patient’s constantly (or at least we are told to) about the severity of their pain.
“Would you say it’s about a 5 or a 6 out of 10?”
But what does this tell us about the patient’s progress? Or his disease state? Certainly, knowing if the patient feels better than he did before is usually an indication of improving conditions, but a number scale is not necessarily beneficial for this (especially in light of a modern understanding of pain). In fact, patient’s and practitioners routinely undermine the validity of such a scale as a quasi objective measure. Ask a patient in apparent excruciating pain what their pain number is, and they may report anywhere from 5 to 20. And the clinician often turns to the patient questioning her reported pain level, “Is it really a 10/10? Do you need to go to the hospital?” (<–insert cynical emoji face).
All of this gets me back to my original thoughts; while the existence of pain is concrete (with the exception of those malingerers), it’s intensity and severity is incredibly subjective and individual. Pain is one of those things that lies in the in-between of definitive certainty and potential ambiguity. While we now know that practitioners should avoid questioning the reality of a patient’s pain, we can also conclude that their intensity of pain can be misleading, not reflective of the actual state of tissue damage (if any exists), or altogether irrelevant (potentially).
Pain is one of the most important diagnostic features we have, yet it remains one of the most fickle and subjective parts of the human experience.