Our psychiatry consult team had been called to the bedside of a man who, after a grueling lumbar spinal surgery, was refusing to partake in physical therapy on account of severe pain.
We understand that he's in a lot of pain, but there's great evidence that early PT leads to faster recovery, the aggrieved surgical intern told us. Psychiatry was consulted to see whether there was a component of anxiety that could explain his reluctance to participate.
We found him groggy and barely awake, slurring his words, so numbed was he from the amount of narcotics he needed to stay sane from the pain. Still, he tried his hardest to focus on our questions and answer them appropriately, sometimes speaking in circles and frequently trailing away into unrelated topics. But that was understandable.
I asked him if he felt anxious about taking part in PT, and he said yes.
"I've never been in this much pain," he said, eyes meeting mine.
I asked him whether he was anxious about the pain or whether he thought that the surgery had gone wrong. He was equivocal. I asked him whether he thought himself an anxious person at baseline. He denied that.
My resident said, "Your primary team has asked us to see whether we can't help you feel more confident about PT. I know it seems like we're asking too much from you, but PT is really imperative right now."
At the mention of his primary team, the patient's face fell. He mumbled something.
"What?" I said.
"I feel like Dr. M -- is disappointed in me," he said. "I feel like I'm letting them down by --"
"-- because I'm not progressing quickly enough."
My heart lurched a little; I averted my eyes. Empathy rose unbidden. His words had such weight, his simple confession such emotional heft. Here he was, not behaving like a model patient (and aware of it), and here we were, called to adjudicate whether this represented a psychiatric abnormality.
An interesting aside: On the internal medicine floors, when patients hang out, slowly improving but without any hospital-level interventions, we call what we're doing "watchful waiting." In surgery, it's "expectant management." I think the difference in terminology for what is essentially the same thing, is rather non-trivial. Surgeons don't like to watch and wait; they're more active, more vigorous, see.
I've been thinking a great deal about pain lately, and its role in the human psyche, given that on our tableau of consults, we have a great number of patients who are "drug-seeking" for narcotics. We ask all of our patients to quantify their pain, from a scale of 1 to 10, 10 being childbirth-without-an-epidural level pain. Then we collate this number with our observations for points of disagreement.
The young woman with an 11/10 who was comfortably sitting up in her bed, playing Candy Crush. The trucker with an epidural abscess pressing down hard on his cervical spine, rigid and wrynecked in his Miami collar, only finding a modicum of peace on level of morphine so high that his nurse felt compelled check in on him every 10 minutes to make sure he was still breathing. The young man with something called cyclic vomiting syndrome, pleading for dilaudid for his abdominal pain -- which would perhaps numb the pain but would slow down his gut and worsen the vomiting.
I sometimes wonder whether pain carries a sense of nobility or just plain degradation. Whether it brings about clarity through an expansion of experience, or diminishes by blotting out everything inessential. Artists seem conflicted on this point.
Kelly Clarkson sings that what doesn't kill you makes you stronger. But Frida Kahlo, braced lifelong after enduring poliomyelitis and then a near-fatal collision with a streetcar, struggled much more in living with chronic pain, painting her fear of being hospitalized, her fear of isolation, her depression into a series of stark self-portraits. Meanwhile, Joan Didion, dealing with a more emotional torment after the premature death of her husband, unwittingly continues to summon her late spouse's entreaty that she "once in [her] life, just let it go." It wouldn't do for her to keep dwelling in this loss, in her damage.
I just don't know.
My resident paused for a long moment and then genuflected to get at eye level with our patient.
"I don't think the surgical team is disappointed in you," he said gently. "I think they're wracking their minds about how best to support you, knowing of course that your pain is not a numbered average with everyone else who's gotten your kind of surgery. We understand that."
He was doing what New York Times critic Anatole Broyard invited physicians to do for him -- "for perhaps five minutes... give me his whole mind just once, be bonded with me for a brief space, survey my soul as well as my flesh, to get at my illness, for each man is ill in his own way."
I think that this is what our patient needed more than anything. To be heard.
At the end of it, we wrote these recommendations to the primary team: Please offer patient options and constant encouragement to give him a sense of agency and control. No medications on our end.