Putting a human face on chronic pain

“Forty-two-year old male, chronic pain syndrome,” the chart reads.

I’m a third-year medical student doing an elective at a physical medicine and rehabilitation clinic, and this is my first time seeing Joe.

Sitting expectantly in the exam-room chair, he’s a gaunt man with a long face and dark tattoos down his arms. Wire-rimmed glasses, stringy ponytail, faded jeans and leather jacket complete the look.

“Nice to meet you,” I say. “I’m Angela, a medical student. I’m doing a couple of weeks here with Dr. Ross, the chief physician.”

“Thank you, doc. I’m Joe.” He smiles, dark eyes twinkling, and I glimpse yellow-stained teeth.

Probably from smoking, I think.

Joe starts talking, jiggling his leg nervously.

“My car was towed yesterday. And these past two weeks have been tough. I got kicked out of my apartment, had no money for the bus, so I had to walk here today, five miles, for my pain meds.”

He’s here for refills, I think wryly. Can I believe his story? Someone who’s walked five miles in this hot weather should look worse — especially if he’s in pain. Or am I passing judgment because of his greasy hair and tattoos?

I push these thoughts aside. “So what do you do most days? Are you working?”

“I’m a handyman. That’s all I ever knew, y’know? I graduated from high school … didn’t do so well, and I’ve been a handyman ever since. But now, with the pain in my knees, feet, back, I just can’t work the whole days. I want to, but I just can’t. And the pain is getting worse.”

He pauses, and then sits up, looking at me. “Things might get better next week, though! A friend of mine hooked me up with a house-painting job. That might be real good, turn things around.”

He sounds hopeful but wary, as if he doesn’t quite believe it could happen.

Reaching into his pocket, he pulls out a business card and offers it to me.

I hesitate.

“Please take it,” he says, a bit desperately. “You can give it to your friends or whoever.”

I take the flimsy card. It sports his name, phone number and services: “Window installations, siding, exterior and interior professional painting and much more … ”

“Very nice,” I remark, pocketing it. How do I show concern without coming across as condescending? And how could I help him find work, anyway?

I escape my unease by asking the questions I’ve been taught to ask.

“So how’s your pain doing?”

“Oh, terrible. Just terrible. Much worse since the hurricane.”

It’s been four days since Hurricane Irene struck.

I have Joe stand for the physical exam, paying particular attention to the painful areas. His back muscles feel tight, and his range of movement is slightly limited, but I observe no spasm or obvious abnormalities. Asked to walk, he limps along slowly. He tolerates the exam with only a couple of winces. Overall, his exam results don’t match his description of “awful pain,” but that’s not uncommon.

“Thanks, Joe,” I say. “Hope that didn’t hurt too badly … So tell me more about yourself.”

“Well, I’ll tell you, it’s been tough. Really tough. My wife left, and she took the kids. The young ones. There’s two of ‘em. Then there’s Bill, my son … he’s on dialysis. He failed a kidney transplant … ”

“How old is Bill? What happened?”

“Bill’s only twenty-two. That’s too young, I know. But he failed the transplant, and now he’s had all sorts of medical complications … a lot of com-pli-ca-tions.”

Joe draws out the word slowly, as if trying to drain it of meaning.

“And now, with the pain in my back and legs, I can’t do anything for Bill. Sometimes a certified nursing assistant comes to help, but … I can’t do anything on my own. I can’t even lift him up … ”

A lump forms in my throat; tears start to roll down Joe’s scrawny face.

“I don’t want to cry … ” he falters, looking down.

“You can cry, Joe, it’s okay.”

Thankfully I have tissues on hand; I give him the box.

“Joe, are there friends nearby who could help you out, or who you can talk to?”

“No one really … nothing … a church … North Providence,” he mumbles.

To see someone you love suffer; that is true pain. Between Joe’s handyman card and his tears over Bill, I’m beginning to believe his story. I feel relieved: now I’ll be able to offer him a med refill.

What else can I do, anyhow? I imagine Joe walking the five miles home from the clinic, empty-handed except for some moist tissues.

Pain is no stranger to me. Last year, I did a research project on chronic-pain patients and narcotics. Beforehand, I’d opined, brashly, “Doctors prescribe pain medications because it’s the easy way out.”

But when I visited the patients in their homes, I saw how crippling chronic pain can be. I learned that it can arise after losing people or things you love, or not being able to do things you once could do. Chronic pain robs people of jobs, family, self-worth, identity. It can tear the heart and crush the soul.

I learned, too, that with pain comes depression. Joe’s hopeless desperation echoes that of many others.

Now, amid the third-year whirlwind, when I see the familiar drug names on a patient’s prescription sheet I feel oddly comforted.

At least the patient will get a refill, I console myself. It’s what he wants, anyhow.

But on a deeper level, I find this very unsatisfying.

Personally, I feel torn. Being pain-free myself, I find it hard to empathize with drug-seeking patients. Should I feel angry at them for blunting my compassion, or disappointed in myself?

I also believe that as care providers, and as a society, we are missing the bigger picture.

Joe needs pain meds, but he’d also benefit from occupational training to do work that he could manage. Free public transit or assistance getting his car back would help, too.

My mentors say, “The goal isn’t to eliminate pain; it’s to cope with pain.” But what if Joe wants to cope — what if he wants to work, despite his pain — and I can’t give him a job?

Joe needs a lot more help, and of a different kind, than I can provide.

As I sit here with Joe, part of me wants to care more, but another part shrinks from getting involved — it’s too messy. I feel boxed into the model of the fifteen-minute clinic visit: the doctor does the exam, listens, speaks kindly, then gives the drug; the patient walks out happy.

In this moment, all I can do is say, “I’ll prescribe your refills.”

I say it. Joe seems satisfied.

My preceptor enters, does a brief check-up on Joe, and signs off on the prescription. Joe has regained his composure, and there’s not much talk.

“Goodbye, doc,” he says warmly. On his black t-shirt, a bright yellow smiley face beams above an optimistic quote. I try to read it, but he turns away too quickly.

At home that evening, as I empty my pants pockets, Joe’s business card falls into my palm. The sight of it conjures up his face with its toothy grin.

I mentally review the friends who might need Joe’s services. If only I could call him with some good news …

No one comes to mind.

I hold the card in my fingers a second longer, then let it fall into my wastebasket.

We are ill-equipped to treat pain, I reflect. We give patients a diagnosis, but no true remedy … Our drugs never touch the heart of their pain — or our own.

Lying in bed that night, I pray to God that Joe’s house-painting job will work out.

Angela Yang is a medical student. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission. 

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  • SunriseGuidedVisual

    I agree with your article. I record MP3′s so that people can do what they can on their own — guided imagery, meditation, relaxation. Sometimes the mind can really help out the body. Thank you for sharing!

  • ninguem

    Joe also needs a cognitive-behavioral psychiatrist or psychologist, with an interest in pain management……if not arranged already

  • azmd

    If your PM&R clinic had a social worker, that person could have met with Joe and perhaps put him in touch with some community resources such as support groups for parents with chronically ill children, low-cost counseling, vocational rehabilitation, food stamps or rent/transportation assistance…

    Sometimes, the most important things we can do for our patients have nothing to do with a prescription, and everything to do with maintaining hope in a world that is pretty overwhelming for many of them.