Before enrolling in this course and because of my training I have always embraced the International Association for the study of pain ( IASP) definition of pain. “ An unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage”
Through this module I have realized that what is more important than the definition IASP has provided for pain is their qualifying statement that pain “is always a psychological state, even though we may well appreciate that pain most often has a proximate physical cause."
I worked as a General Practitioner in a rural community for several years before doing my postgraduate studies.
A housewife in her forties, had consulted my rooms 3 times. Presenting with lower abdominal pain, aggravated by sexual intercourse.
On examination there was some excitation tenderness. My clinical diagnosis was pelvic inflammatory disease (PID). I prescribed some antibiotics , and painkillers. However, there was no improvement.
On her third visit, I changed my approach. Over and above the pain killers, I referred her to a gynaecologist for investigation and further management. Fortunately, she had a health insurance so she could afford to pay for her medical expenses.
When she agreed to go and consult the Gynaecologist, I felt a sense of relief as I knew that there would be someone who was likely to be able to assist her with her chronic abdominal pain.
After consultation and investigations, the gynaecologist decided to do a total abdominal hysterectomy (TAH). Three months post total Abdominal hysterectomy she came to visit my practice. The pain was back. The pain was worse than before the TAH.
I wanted to scream in frustration and felt a sense of despair thinking of what this patient must have been going through. I consoled myself in that I still had a solution to this problem. I picked up the phone and referred her back to the gynaecologist.
The outcome was disappointing. The patient came back to tell me that the gynaecologist had told her that he had done his job there was nothing else he could do for her anymore.
To quote his heart-breaking and dismissive words “ I was trained to deal with the uterus and all its ailments , now that you no longer have a uterus , you are not my patient anymore.”
Failure to fully understand another person's pain experience creates a barrier to fully empathize with the patient.
I felt really frustrated, helpless and angry. Frustrated because I did not know what to do for her anymore. Helpless because there was no one to help me solve this lady’s chronic pain. Angry because of the gynaecologist’s lack of empathy and his attitude towards this patient.
I had a busy practice. There were patients waiting to be seen. My greatest challenge, in hindsight, was understanding how do I deal with the demands of chronic pain in a busy practice.
I had a feeling that this was more than just a somatic pain. Possible manifestation of a psychological problem. What was the problem?
I decided to give myself time and try and understand her pain. Fortunately I had a good rapport with my patient. I had to approach this sensitive matter carefully. After spending more than one hour with her I had an answer.
Her husband was sexually abusing her daughter.
She was scared that if she approached her husband about this problem her husband would leave her. She was unemployed. She could not support herself. She did not want to report the matter to the police. My next question to her was, could she recall exactly when she started experiencing the pain?
On the night she had sexual intercourse with her husband after discovering that he was sexually abusing their daughter. The pain started that night.
I looked back and I realized I had missed the diagnosis. I had sent her to the gynaecologist to have her chronic somatic pain treated, instead of sending her to a clinical psychologist to have her psychological state treated. I felt guilty. I had allowed her to be subjected to a surgical intervention that was not necessary.
She was forced to undergo a procedure to remove a body part that had no illness.
This module has also opened my mind to the fact that pain management can be challenging, demanding, draining even; each unique biopsychosocial assessment requires considerable thought, energy, evaluation, planning, discussion, explanation, and time.
When I look back, I wish I had had access to the knowledge of pain that I have acquired over the last six weeks.
Pain management is best delivered by multidisciplinary and multiprofessional teams.
This incident happened years ago but it has helped strengthen all what I have learned about pain in this module, in the last six weeks.