August 10, 1999, Tuesday
A Munch Moment By SHERWIN B. NULAND
FOR a brief period during my years of surgical training in the late 1 950's, I worked under a tough-minded senior resident who conducted what he called "narcotic rounds" every evening just before midnight. The purpose of the former Army medic's solitary nocturnal perambulations through the wards was to decrease, or sometimes cancel, the dosages of post-operative pain medication junior members of his team had ordered during the day. Should any of us have the temerity to reinstate those dosages the following morning, the miscreant was sure to be subjected to a string of invective, "lily livered" being the least indelicate of the terms he used. The ax-sergeant's message to us was that all complaints of pain were exaggerated, if not phony.
One day, 20 years later, a nurse refused to administer the Demerol I had ordered for a patient with advanced cancer, pointing out that the dosage was significantly higher than usual and the frequency approximately twice what was recommended in the hospital drug manual. She and the head nurse who supported her decision could not be persuaded to relent, even when I remonstrated that the prescribed amount was standard in our local hospice. It took the intervention of their supervisor to convince them that the patient's pain could not otherwise be brought under control.
More than a decade would pass before an increasing body of literature on symptom relief made it clear that pain is commonly undertreated in American hospitals. Recently, two scientists at the New York State University in Albany were granted a patent for a computerized system of measuring pain. Whether or not it is effective remains to be seen.
The two reasons most often cited for patients suffering pain unnecessarily involve the patients themselves and the professionals who care for them. It must have come as a disagreeable surprise to my obdurate former resident when he read in one journal after another that many sick people are too stoic for their own good, or at least reluctant to ask for sufficient relief lest they be thought not stoic enough. Physicians and nurses underestimate the severity of pain, particularly when it is at its most intense. Comprehending the magnitude of pain that accompanies some medical conditions is very difficult for those who have not themselves suffered. Samuel Johnson, a man accustomed to discomforts of all sorts, said 250 years ago, "Those who do not feel pain seldom think that it is felt."
AMONG the several difficulties inherent in the misapprehensions about the treatment of pain is the troublesome fact that there has never been any accurate way to measure its severity. Neurologists and researchers depend on rather simplistic pain intensity scales based on patients' verbal reports or the choice they make from a graded sequence such as 1 to 10 or its equivalent. The situation is far from ideal.
But all of this is said to be changing with the new method developed by Dr. A. Vania Apkarian, a neuroscientist at SUNY's Upstate Medical University in Syracuse, and Dr. Nikolaus Szeverenyi, a radiological physicist at SUNY in Albany. Volunteers in their studies are subjected to varying degrees of discomfort, and their brains' responses are recorded on an electroencephalogram or imaged by a C.T. scan or M.R.I. But even with such a complex assortment of electronic gadgetry, results depend ultimately on the subjects' description of the degree of pain they feel, which is signaled by how far they separate their opposed thumb and forefinger. The researchers believe that they can correlate the characteristics of the brain patterns with the quantity of pain the patient reports in such a way that the images or electroencephalographic tracings can then be used as an unbiased and therefore; accurate indicator of a patient's discomfort. Interpretations made in this way, the patent document states, create a "quantitative analysis to characterize the brain's representation of pain."
Sounds good, doesn't it? The trouble is that the more experience physicians have with the diagnosis and treatment of pain, the more skeptical they are likely to be about the usefulness of the newly developed technology. There is a reason for the present lack of objectivity in pain measurement: The quality measured is in itself not objective. For example, a pinprick delivered with a measurable amount of pressure will produce widely differing perceptions among a group of subjects of differing personality characteristics, or even when applied at different times in the same individual, as surrounding conditions change or even as mood alters. We feel pain in various ways at various times, depending on who we are and the circumstances under which it occurs. Not only that, but even were it possible to make the perceptions exactly the same among a diverse group of people, the ability of each to tolerate similar degrees of perceived pain would vary considerably. In other words, both the amount of pain one feels and the ability to tolerate it are the result of a mix of factors, the subjective or intangible among which are at least as significant as the physical or chemical.
THE symptom of pain has multiple dimensions. Its diagnosis, measurement and treatment are so complex that scientists and clinicians in vast numbers have turned their attention to its many aspects, and organized themselves in the International Association for the Study of Pain. Even the meaning of the word is entangled with uncertainty, and the group has constructed a working definition: "an unpleasant sensation and emotional experience associated with either actual or potential tissue damage, or described in terms of such damage." This means that those most qualified to study pain recognize it not only as a "sensation" but also as an "emotional experience," including the realization that even the "sensation" part of it is to a large extent determined by the emotional circumstances in which it occurs. Patent or no patent, it will be decades before the technology is developed that can reliably quantify emotion and measure its contribution to the calculus of-a sick person's pain.
The old sergeant died about 10 years ago. I am told that he bore
a difficult final illness with forebearance and a determination
not to show outward signs of suffering. I hope his doctors and nurses
were more sensitive than he had been. I hope they went to great
lengths to relieve the anguish of body and mind that he was never
able to acknowledge, whether in himself or others.