We were seated around the dining table in my office break room, two attorneys, a court reporter and I. A patient of mine was suing someone for injuries sustained in a car accident and that someone’s attorney had subpoenaed me regarding the case. It was a relatively straightforward disagreement. The patient said he had been injured and was experiencing ongoing pain, the defense was arguing there was no way he could have been hurt that badly in the accident.
The defense attorney showed me photos of the cars (there was almost no visible damage) and asked me about my findings and diagnoses for each patient visit after the accident. The patient had no physical findings consistent with an injury at any of the visits, did not consistently follow up with a physical therapist as requested, and had ultimately undergone an MRI of his spine that was perfectly normal. It was clear from his questions he believed this meant that there was no way the patient could be having pain. Brimming with confidence, he proceeded to ask me a stupid question.
“The normal MRI means the patient does not have a radiculopathic pain, correct?”
“No,” I replied.
“But doesn’t a radiculopathy mean that there is something compressing a nerve?”
“No, it means that the patient is experiencing pain in the area supplied by a specific branch of a spinal nerve. There are other causes of such pain.”
“What else could cause the pain?”
“I can give you an answer, but it is going to be a long one,” I replied. As i did I saw the confidence drain from his face.
I went on to give him the long answer. I explained there are many causes of pain that do not show up on an MRI or other imaging scans. I summarized the nature of pain fibers and how they could be activated without physical trauma, how once triggered even normal stimuli could lead to these nerve fibers firing and a patient experiencing severe pain.
In a resigned tone he verbalized the realization that he would have been better off not asking me that question. “I opened a can of worms,” he said.
The mistake he made is a common one. Most people do not understand pain. They understand pain after surgery, when a kidney stone gets stuck, or when a bone gets broken, but when there is no visible cause, they doubt it. If it can’t be seen it with the eyes or in a medical image it can’t be real.
This was the teaching I received when I was in medical school and residency. Patients who complained of pain in the absence of physical findings were filed into one of two categories. They were either crazy or they were “drug-seeking.” They were often treated with scorn instead of compassion.
It took years for me to understand how wrong this teaching was. My first inkling that there was more to pain than I had been told came after I had a knee operation in 1992. Several weeks after the surgery I was standing in the clinic when I had the sensation of something like a hot drop of oil running down my leg. So intense and real was the feeling that I turned and looked to see what was on my leg. The only thing touching my skin was the fabric of my pants. There was nothing there. The sensation was the result of a rogue nerve misfiring and sending inaccurate signals to my brain. There was “nothing” there, but the sensation was real.
My understanding expanded further 17 years ago when I suddenly began to have excruciating, burning pain in my right shoulder and arm. Over a period of weeks I saw 5 different doctors in search of an explanation. MRI scans and nerve tests were all normal. It was the fifth doctor who finally gave me the diagnosis of an inflamed spinal nerve, possibly from a virus. He gave me a diagnosis but could not promise a cure. The pain gradually faded to a persistent tingling but never passed. The pain returned a few years ago, this time deciding to stay, but MRI scans and nerve tests were again normal. The only evidence I can give others for the pain is a description of how it feels. It is “undetectable” but it is definitely real.
Pain of this nature is more common that many realize. Fibromyalgia, a pain condition that impacts as many as 10 million Americans, falls into this category. No visible damage can be detected and no blood tests are abnormal, but the pain can be debilitating. Many patients suffer for years while being told by doctors and others that they shouldn’t have pain. They shouldn’t, but they do.
The current theory is that these unfortunate patients have pain nerves that are overly sensitive. In the same way that some people are always cold, even on a warm day, fibromyalgia patients always hurt. Unlike those who feel cold, fibromyalgia can’t be helped by putting on a sweater. Medications can sometimes lessen the pain but there is no cure.
I cannot cure many of my pain patients, but that does not mean that I do not, or cannot care. I can listen to them and pray for them. Most importantly I have learned to avoid the mistake made by the attorney. When someone says they hurt, I believe them.
- Bart