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Academic Medicine:
doi: 10.1097/ACM.0b013e3182127813
Other Features: Teaching and Learning Moments

What I Know About Excruciating Physical Pain

Possner, Adam B. MD

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Dr. Possner is assistant professor, Division of General Internal Medicine, Medical Faculty Associates, George Washington University, Washington, DC; e-mail: apossner@mfa.gwu.edu.

The page reads, “DR. POSSNER, PATIENT IN ROOM 506 IS IN SEVERE PAIN. PLEASE EVALUATE.” Walking from the call room, blinking the sleep out of my eyes, I consult my binder of sign-outs. The patient in room 506, I remember, is Mr. M, a 60-year-old man admitted earlier in the day with metastatic prostate cancer. “The tumor has literally grown to the surface of his back,” the intern had told me.

When I arrive in his room, I find a man, more bones than flesh, lying in bed, clutching each bedrail. The nurse is at his side trying to comfort him, which includes saying, when she sees me, “The doctor is here.” He's moaning, eyes shut tight, the blood blanched out of his fingers. After a few questions, it's clear that this is his usual cancer pain. I adjust his patient-controlled anesthesia pump and lay a hand on his shoulder.

As I stand there, waiting for the medication to take effect, I think, “What do I know about excruciating physical pain? I mean, what do I really know about it?” I've never broken a bone or had surgery. Probably the worst pain I've ever known was from a car wreck in college when the seatbelt bruised my spleen. Certainly it was nothing more than a 6 out of 10 or a moderately sad face without tears. Certainly it was nothing like the scene in front of me.

That being said, as a physician—as someone who witnesses pain regularly—there are some things that I think I know about it. Excruciating physical pain simultaneously brings people together and drives them apart—the former in how it invites concern, such as with Mr. M, and the latter in how it is fundamentally subjective and all-encompassing. Empathize as one may, no one can truly feel another's physical pain. Pain quite literally forces people to close their eyes to the world. It reduces people to a single experience dominated by a single desire—for it to stop.

Childbirth aside, severe physical pain is by no means guaranteed in life. I recall other elderly patients of mine who never had a broken bone, surgery, cancer, etc., and then died suddenly and seemingly comfortably. It raises that age-old question—Why one person and not the other? I'm convinced that this uncertainty, this not knowing if we'll make it through life without experiencing it, is why many people fear excruciating physical suffering more than death. At least death is a given.

Above all, the potential for experiencing intense pain exists within each of us. When you've never been in pain, it's hard to believe that you ever could be. And yet this potential is real, like the action potential by which nerves function or the energy stored in our mass. Maybe the ability to feel pain is the price of ecstasy, like being able to choose poorly is the price of being able to choose well. More than the uncertainty of not knowing if I'll ever experience excruciating pain, I fear the certainty of knowing that, if I were in a predicament like Mr. M, I would experience it.

By now Mr. M has drifted asleep. His hands are relaxed by his sides, but his face remains tense, even in sleep, betraying an uneasy truce. It's his face that makes me realize that I can wax poetic all night, but I really don't know anything about excruciating physical pain. Perhaps this is an example of where, for me, not knowing is more powerful than knowing. And I lean over and shut off the light above his bed.

Adam B. Possner, MD

Dr. Possner is assistant professor, Division of General Internal Medicine, Medical Faculty Associates, George Washington University, Washington, DC; e-mail: apossner@mfa.gwu.edu.

© 2011 Association of American Medical Colleges

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