Sunday, October 14, 2007

More ER "Wisdom"

If you've ever wondered why you were treated like a criminal, whiner or a lump of meat when you walked into your local ER complaining of pain, here's another ER doctor to enlighten you with her wit and wisdom. Like most medical folklorists, her "truisms" amount to little more than personal prejudices based on anecdotal evidence that have already been refuted by science and are not even particularly logical, but are nonetheless shared by far too many medical professionals who have a perverse need to feel superior to their patients or to rationalize callous and unethical behavior by themselves or their colleagues. But regardless of whether they are scientific, logical or even ethical, these beliefs can and do influence the care that patients can expect to receive from their doctors, and are routinely used to pigeonhole patients into categories for easy disposal. What should be an attempt by every doctor to treat each person as an individual and with dignity and respect, and to use medical science to tailor the treatment to each individual's needs, very often devolves into a kind of depraved personality contest where you are obligated to please your doctor in return for treatment, like a peasant seeking favor from a king. This kind of dehumanizing, judgmental mentality tends to arise almost of necessity in any for-profit system in which human beings are little more than cash cows to be thoroughly milked and then put out to pasture as quickly as possible. Allowing beliefs like this to influence the medical care a patient receives is grossly unethical and ignorant, but it is the rule rather than the exception for people with chronic pain to experience abuse and denial of care based on self-serving and unscientific beliefs just like these.

I have included my own responses to each of her "truisms" but some of the comments on the original article are pretty interesting as well. Of note are the responses from doctors and nurses that express their approval of these callous and bigoted stereotypes, and then turn around and accuse the people who objected to these stereotypes of being "offensive" and unsympathetic to doctors and nurses! Narcissism in action. I'm sure I'll be accused of "anti-practitioner bias" which is the boilerplate rebuttal to all critics of the medical system and physician ignorance.

Ten ironies and truisms of the ER

1. Really sick people usually don't have many complaints. They are too sick to. Whether because of illness or trauma, people with life-and-death kinds of problems usually don't complain much. They are either unconscious or all their energy is focused on staying alive.

Translation: if you are able to talk, that chest pain you are experiencing is nothing to be concerned about, because if it was something serious, you'd be speechless. If you really had appendicitis, you wouldn't be able to complain about it. Ditto for cancer, AIDs, malaria, bubonic plague and every other "major" illness: if you can bitch about it, you're okay.

This is apparently what they teach doctors in the "best medical system in the world."

2. The converse is also true: people who aren’t very sick but think they are often complain a lot. While I try to remain caring about whatever problem is important to each patient, often the first sign that a patient is more-well-than-sick is that they have the energy to complain articulately or profusely about what troubles them.

See response to #1

3. A corollary to items 1 and 2: at any given time, the most demanding patients (and patient families) are usually the least sick patients in the ER. As noted above, they have energy to be demanding.

People who don't make some attempt to communicate what's wrong with them receive no medical care. It is interesting to note my friend was married to an ER doc who reported the exact opposite: that people who complain the most or make the most noise are seen right away, if only to shut them up, while people who play the "good patient" and remain silent and stoic, get to die alone in the waiting room.

4. Once again, the converse is also true: the least demanding patients (and their families) are usually the most sick.

And probably the most likely to die in the ER due to being ignored.

5. The tougher someone’s persona is in the outside world, the more they are likely fall apart over minor trauma or simple ailments. Gang-bangers who were just arrested for trying to shoot someone cry for their mothers when they learn they have to get a tetanus shot; Harley-Davidson riding, leather-wearing, tobacco-spitting, hard-drinking bikers who take minor falls, swear and whine and complain and say over-and-over again “how much is it going to hurt?” when they learn they have to get stitches.

This holds true for doctors, as well. The more macho, arrogant and dismissive a doctor is about something as horrific, stressful and life-altering as years of unremitting chronic pain, the more likely he/she is to have low tolerance for trivial matters like whether some biker can take the pain of a needle or not. If doctors get upset over trivial things like this, you, as a chronic pain patient, know exactly how long they would last if they ever had to experience the mind-numbing stress of being in constant pain.

6. People who say they are not sick, usually are. A variation of truism #1, many people who are genuinely sick but do not want to be ill deny pain or problems. These are usually hard-working individuals who want to get out of the hospital and go on with their lives. I have seen men argue that they were not having heart attacks even as they clutched their chests and were wheeled off to the cardiac catheterization lab. Others argue that their new left-sided facial weakness and inability to walk is not that big of a deal and cannot possibly be caused by a stroke.

Translation: denial is a positive characteristic in patients. If you're not in denial, you're not really sick. A corollary to this is you admit you're an alcoholic or a drug seeker, you're not. If you deny it, you are. If you have chronic pain, you are whether you deny it or not.

7. A surprisingly large number of people with tattoos are afraid of needles.

Or maybe there's just a surprisingly large number of people with needle phobia who get tattoos.

8. People who state they have allergies to non-narcotic pain medications are usually drug-seeking. The list of allergies they provide is a not-so-subtle way to attempt to get the health-care provider to give them the narcotic pain medicine of their choice.

Do patients have to hide their adverse drug reactions to avoid being labeled a drug-seeker? Apparently so with those doctors who would rather see a patient writhe in agony or die from a bad drug reaction than risk giving a "junkie" a free high. Since knowing what works and asking for it by name will also get you branded as a drug seeker, patients may of necessity due to doctor ignorance and bigotry have to develop roundabout ways of trying to ask for what they know they need. Motrin is not a panacea.

Beyond this, it is incredibly ignorant and dangerous to dismiss reports of adverse reactions (or "allergies") to drugs, as non-error adverse drug reactions kill over 100,000 Americans and land 1.5 million more in the hospital every year, and these are only the extreme reactions, the severe but not life threatening reactions account for tens of millions more, and the moderate but unpleasant enough to make a reasonable person discontinue the meds millions more still. It is little wonder so many people are dying every year when doctors either dismiss complaints of adverse reactions out of hand, deny them, or accuse anyone reporting them of being drug seekers.

9. People who claim they have a “high pain tolerance” usually don’t. Individuals who can genuinely tolerate large amounts of pain have never had to consider pain enough to conclude that they have high pain tolerances–and hence, would never need to make this claim. On the other hand, people who who are so exquisitely sensitive to pain that they notice it in all of its subtle variations–and seek relief for the most annoying of these–are usually the ones to make this claim.

More annoying still are ignorant physicians who don't know the difference between "pain threshold" and "pain tolerance," have no objective way of telling how much pain a particular person is in but are deluded into thinking they know better than the patient does, and are full of judgement and condemnation of anyone who doesn't meet the arbitrary and frivolous criteria they use to judge whether someone is "worthy" of pain relief or not. Doctors who use terms like "exquisitely sensitive" to describe their patient's pain reactions are pretty damned annoying as well. Actually, they are more than damned annoying.

The term pain threshold refers to the minimum intensity or duration of a sensory stimulus at which it becomes interpreted as painful. In scientific literature the term is clearly differentiated from the term pain tolerance. Pain threshold is the minimum stimulus which elicits pain and involves measurement of stimulus intensity, whereas pain tolerance is the degree of pain which a subject can tolerate, and involves a measurement of a subject's response to pain.
Pain tolerance is the amount of pain that a person can withstand before breaking down emotionally and/or physically.

Pain tolerance is distinct from a pain threshold. The minimum stimulus necessary to produce pain is the pain threshold. One's pain tolerance is the level of pain needed to force a person to 'give up'.

So pain threshold refers to the amount of stimulus needed to elicit pain in a given person, and pain tolerance refers to the ability to "take the pain." Studies have shown that women have a lower pain threshold than men do, yet they also have a higher pain tolerance. So an average woman will both feel pain sooner yet be able to take that pain better than the average man. There are conditions, most notably fibromyalgia, that can radically increase one's pain threshold to where even mild stimulus can be extremely painful. Allodynia is common with other neurological disorders as well, and is a reflection of problems with the nervous system, and not a character defect. The fact that a person is ultra-sensitive to pain does not mean they are wimps who can't take pain. If anything, they fact that they are often able to bear pain that is for them more severe than a normal person would experience suggests the opposite.

Most of us with chronic pain and any degree of humility can readily admit there are limits to just how much pain we can take, because we have learned this fact the hard way. Those still exhibiting the adolescent macho posturing most of us left behind at age 15 either haven't experienced real pain or have pain that is relatively mild, or they're still trapped in that mindset. Then there are of course those who do have very severe pain but like to play the good patient and put on an "I can take the pain" performance to please their doctors, who are in fact expecting exactly just such a performance from their patients when they should be encouraging an honest and thorough reporting of all symptoms, particularly pain. If you wish to torture yourself to please your doctors, knock yourself out. Most of us who have experienced real pain know just how stupid and self-defeating that is, because while you may get a pat on your back from your doctor, you will not get the treatment you need, and it could cost you your life. If your doctor insists you "suffer in silence," find another doctor.

In either case, it is not a competition to see who is the toughest, and a doctor's only concern should be to alleviate the patient's suffering, regardless of individual pain threshold or tolerance. That so many doctors feel the need to minimize their patients suffering or to mock and ridicule them when they can't handle pain says more about their character than it does about their patients'.

10. Even the most well-intentioned ER physicians fall prey to dealing with patients according to categories and stereotypes from time to time.

Do tell, although I fail to detect anything that could be construed as "well-intentioned" from this article.


Anonymous said...

i hate to even validate this gals perception of people with a reply, but i just cant stand it. She is coming from a nice comfy place of "integrity" and "professionalism". I daresay subject her to a good week of a CPP's serious flare--you know the kind----where getting to the bathroom requires a tremendous act of faith and courage, where eating is out of the question unless someone feeds you, and the only sound that comes out of you is a short low moan that comes with every labored breath. Let her lose her job because she is unable to think, much less work, let all her "buddies" walk away like she never even existed or worked side by side with them, let her utilities be shut off because there simply IS. NO. MONEY. Let her mris and emgs come back "clean" (they ARE, after all, INFALLIBLE tests), let her have her car repoed from her driveway, maybe lose her 1/4 to 3/4 million dollar house, and have some equally pompous, arrogant, undereducated, and jaded "practitioner" tell her its all in her head, and completely decimate whatever shred of self respect she may have left label her as a distraught drug addict/seeker with a personality disorder. I think a good healthy dose of their own "medicine" is certainly in order.

Anonymous said...

I hate to say it, but I'm not surprised. Another ignorant doc..this is the kind of crap that cp'ers have to deal with everyday. Your blog is's not often that you come across someone so articulate and to the point. Excellent..

Payne Hertz said...

Well said, anon. Your comment wraps up the chronic pain experience in a nutshell: the destruction of our lives and livelihood, the monumental struggle to regain some control over our lives and the ordeal of dealing with ruthless doctors and their often prodigious ignorance and cant. Sometimes the little details say a lot, and I can definitely relate to having to psych myself up as though preparing for battle just to go to the supermarket, or do something simple like take a shower.

It is a sad reality of our culture that many feel the need to dehumanize people who suffer; sadder still, is that so many people like this find their way into positions where they have control over our lives.

Anonymous said...

ER doc here.

I feel for patients in pain. I want to treat all of you. However, I have to prioritize. The heart attack, the appendicitis, the pneumonia all come first because if I don't treat them, disability or death will result.

So yes, you might wait longer than they do. I'm sorry for that, but that's the system we work with.

Sadly, the privilege of having an ER is abused on a daily basis by drug-seekers, attention-seekers, and people who refuse to wait to see their primary physician. The person with a heart attack shouldn't have to wait longer because these selfish people think that their headache is more important other people with more acute disease.

I suffered through a chronic pain syndrome myself for years. I didn't use drugs, I didn't scream at the nurses in the ER, I didn't give up my life and I got through it. There are lots of us with serious pain issues out there that don't burden the system. I have nothing but contempt for the ones that do.

Pain is a subjective experience. You have control over your life. Use it. I'll try to help you but ultimately you have to help yourself. And if you're in the ER, you'll have to wait like everyone else.

Payne Hertz said...

"I feel for patients in pain. I want to treat all of you. However, I have to prioritize. The heart attack, the appendicitis, the pneumonia all come first because if I don't treat them, disability or death will result."

I have never heard a single person in chronic pain suggest otherwise in my entire life. It is understandable some people in agonizing pain are impatient to be seen, especially when they have to wait for hours with no guarantee they will actually be treated after waiting. treating them like scum because they don't want to wit weeks too see their PC is just ridiculous.

You can't expect people to know whether you are having a busy night or not unless you tell them, and if there is going to be a wait, you should send a nurse in to inform people and tell them the reason why, as well as keep them updated. If it's that bad, the hospital should have a staff doctor come by and help out, or hire more doctors.

"I suffered through a chronic pain syndrome myself for years. I didn't use drugs, I didn't scream at the nurses in the ER, I didn't give up my life and I got through it. There are lots of us with serious pain issues out there that don't burden the system. I have nothing but contempt for the ones that do."

So much for feeling for chronic pain patients. Your post drips with contempt for the people you claim to care for. What do you want, a medal for not taking meds? Maybe your pain wasn't that bad, which is why you "got through it." You obviously think you're better and tougher than other people, I have yet to meet a doctor who didn't, but what gives you the right to judge what someone else is going through?

In my experience, the majority of people who have experienced severe pain don't have the dismissive mentality you show here, because it is a very humbling experience. If someone claimed getting kicked in the nuts was no big deal, most guys would laugh at him knowing that either the guy was a lying braggart or had never experienced that pain. I say the same to anyone who claims to have experienced "severe pain" but acts like it was no big deal, just some "subjective experience" you can choose to get over.

Anonymous said...

none of the posts any of you make on here indicate anything to me other than you needing a good dose of "shut-the-hell-up-and-get-over-it" and that, more than a pain specialist, you need to see a shrink.

the ER doc said what she did because experience has taught her those things. it's SO true that the more energy somebody has to bitch and complain and obstruct the process of care for everybody else in the ER, the less sick they really are.

Payne Hertz said...

"none of the posts any of you make on here indicate anything to me other than you needing a good dose of "shut-the-hell-up-and-get-over-it" and that, more than a pain specialist, you need to see a shrink."

Hit a nerve, eh? Maybe you should follow your own advice and shut up, get over it and see a shrink. Anyone with this much hostility to the people who pay him for medical attention needs more than a little attention himself.

"the ER doc said what she did because experience has taught her those things. it's SO true that the more energy somebody has to bitch and complain and obstruct the process of care for everybody else in the ER, the less sick they really are."

Whatever. Experience has taught me and far too many people with CP that there is a surfeit of arrogant, cold-hearted, pathologically self-absorbed doctors who whine and complain about trivia while telling people whose lives have been destroyed by the endless torture of chronic pain to "shut up and get over it." And of course, they are so full of themselves they think everyone who doesn't worship the ground they walk on needs a shrink.

What a load of sorry bastard little children you are. Grow up.

Tonja Matthews said...

I'm in search for other's that have not received proper medical care because the Physician, E.R. or other Specialist saw Fibromyalgia in their chart and treated them negligently ignoring serious injuries. Injuries such as broken bones, head injuries or torn ligaments.