Archives for posts with tag: pain

A patient writes (and I share with her permission):

On the night of April 20 after dinner I felt a great pain in my left shoulder and up along my neck. Chills and the pain prevented my sleeping. This pattern continued, severely, along with utter exhaustion by 3-4 PM every day and no appetite, through the 28th, while the pain began to extend into my left rib area, under my left breast. The 3rd night I remembered I had the 800-mg ibuprofen pills that Dr. B had given me, which I began taking every night thereafter, and it helped me sleep somewhat better. While all these symptoms persisted, after 4-5 days the overall pain began to slowly decrease a bit. On April 25, with my brother’s insistence, I went to the doctor. I was assigned to a Dr. A, who is working under Dr. D. She was worried that I might have had a heart attack, though we have no heart problems in my family. The nurse administered an electrocardiogram test, which turned out normal. Dr. D (whom I haven’t seen in 15 years or so!) also examined me. They had me get a chest x-ray and a blood test (for kidneys?) Dr. A phoned me today saying that these uncovered no problems, though a couple of little irregularities which she said are too minor to bother about. It was these that prompted me to have her send you the results, and this note of mine will give you their context.

All that being fine, now I have to return, on my own, to my original theory of what caused all this pain, sleeplessness and weakness. From early on I suspected that in working assiduously on the computer all day of April 19 and 20, I was unconsciously leaning strongly on my lower left arm and elbow – not having the perfect ergonomic set up for working on the computer. Nothing like this has ever happened to me before, though periodically I have tried to deal with the seemingly incorrigible constraints limiting my desk and desk-chair arrangement for using the computer. Though when I saw the doctors on April 25 I told them this admittedly-lay diagnosis, it didn’t interest them in the least, but now I”m pretty sure it explains what I experienced – though still not the complexity and severity of it.

Since you’re interested in the patient-doctor relationship, I thought I’d share with you my reflections on this happy-ending experience. (Though your book does help us a lot to understand the physician’s point of view). What I observed is that these highly trained physicians – both in “general internal medicine” – either weren’t interested in the “muscles and nerves” dimensions I had first proposed as a diagnosis, or else they didn’t have the basic knowledge or expertise to deal with what I related. I realize that they went for the potentially-fatal possibilities like heart, lung, kidney. Good. That’s reassuring. But even when I asked, before they dismissed me, what they would suggest about the severe pain and other symptoms, in the event that the tests showed nothing serious — even when I wanted to bring them back to the original problem, which still persisted – they offered no ideas about what might have caused all that I was going through, much less offered any details about how it might have happened, or guidance about what to do. And today when Dr. A phoned with the results, if I had not asked her specifically, she would not have addressed the problem itself. (She was not aware the pain had declined) When I did ask, she advised me to talk to a physical therapist, which I will.

Despite your excellent clarifications in your book, and re-orienting the patient’s perspective, we laypeople aren’t as compartmentalized in trying to think through our medical problems as you doctors are, though of course most of us are aware that the medical profession has various specializations. In my little episode, I thought that in the end the doctors I consulted would remember that I had come to them with a severe pain, and that they would eventually come back to addressing that. They seem very relieved that the worst hadn’t happened; but… hello? what about “me”? okay, if my heart, lungs and kidneys are okay, but what do you have to say about my pain and what might have caused it? and what should I do about it? I guess my original expectations in going to them were unrealistic.

Today, really for the first time, I feel fine. No pains. I hope I haven’t wasted your time with this little narrative, which I have not written out of frustration, but as part of our common interest in the “patient-doctor” interface.

I think everyone who sees patients, and treats a lot of them with a particular condition, comes to see that condition as a microcosm of all of medicine. And that’s the way with me and pain. For some reason – perhaps it’s because I tend to see these patients more frequently than others – I think I have more of them.

Pain, and I mean here chronic pain, has certain characteristics which are shared with many other chronic diseases. Such elements of illness are often overlooked, and focusing on the forms they take in pain might be useful in conceptualizing them.

  • Often, medicines for chronic pain [as for other conditions] don’t work that well.
  • For many people with chronic pain there is no one “medical” cause that explains their symptoms.
  • Other stressors – whether psychological, psychiatric, or social – play an important role in the severity and treatment of pain, and frequently these are un- or undertreated.
  • Pain is a symptom experienced by nearly everyone at some time or another. Thus many people think they know what chronic pain is like. But if I’ve heard one thing from every one of these patients, the occasional bout of acute pain does not reflect the experience of chronic pain.

Do you have – or have you had – chronic pain? Do you agree with these assessments? And what should we do to improve matters?

Ritual circumcision and legal objections to it are in the news. There are two separate but related questions:

1. Whether it’s in the state’s interest to forbid it;

2. How parents are supposed to balance the risks and benefits.

Let’s take the second one first. No one denies that circumcision involves pain and suffering to the child. The long-term psychological damage does not seem to be demonstrated anywhere and seems implausible on its face, given the number of people who have been circumcised and lead happy, psychologically whole lives.

The medical benefits are beyond the scope of this post. However, one kind of benefit that is not generally reckoned, at least in secular analyses, is the benefit to the child from the ceremonial or religious aspects of the ritual. I’ve seen it said that children cannot be considered members of any group of people, since that distinction is reserved for adults. This is silly, of course. We assign children to groups all the time (“Jewish,” “African-American,”  ”creative type”) recognizing that these categorizations will only be fully appropriate when the child is of age. That doesn’t mean a child can’t partially participate in the life of a group or enter into the group even upon infancy. Otherwise we would never go to the trouble of – say- giving the child a name, because only adults are completely realized individual personalities. Ritual circumcision is done to confer belonging in a tangible way.

The first and second question share one consideration. Is the pain done to the child by circumcision exceptional enough to put it beyond the pale? It’s hard to say. You could imagine a situation in which the state adopts a default position of disallowing circumcisions, while allowing certain exemptions. But circumcision is by no means the only case in which we cause a child short-term pain for longer term benefit. We draw their blood and give them vaccines. Some people let them cry to teach them to sleep alone. When they’re older, they get braces. 

We spend a lot of time making children uncomfortable for their benefit. The fact that circumcision causes pain does not necessarily make it morally problematic. 

Two movements approach change in Judaism in different ways. Orthodoxy constructs a myth according to which change does not occur, at least consciously, in the halachic process. It is imposed from without, sure, by social forces and non-Jewish perfidy, but never by poskim themselves for the purpose of change itself. 

Conservative Judaism claims that they have the steering wheel of halachic change in their hands and turn it only when moral considerations become urgent and primary. The Bandaid must be ripped off at some point when the gap between moral reality and halachic text becomes too great to bear. This is painful, as can be seen from this teshuvah, where – even in egalitarian synagogues – the number of women wearing tallis and tefillin are few and far between. A halachic change was made for moral reasons, and it was painful but necessary.

Orthodoxy deals pain, too, but in a different way – to classes of people excluded from the halachic process. People change faster than Orthodox halachah. Gays and lesbians and women are two obvious groups that are considered only very slowly.

Pain is part of life, and I don’t think either of these groups has a monopoly on it, or – conversely – a magic formula to avoid it. You pays your synagogue dues and you takes your choice.

I saw a patient of mine this week: someone he loved died. He said, “I felt like I went to bed one day and got up the next day a different person.” 

I wonder whether he’ll be happy someday as that new person. Or if that new person, to be authentic, must always have that pain. If the latter is true, to make it better would be a lie. 

Creative Commons image by theilr