Thread by @JillPiggott

The "perceived ambiguity of #pain" colors how clinicians see patients & how they see themselves, say anthropologists Megan Crowley-Matoka & Gala True in a thought-provoking 2012 paper based on ethnographic research in VA clinics. /thread

Behind the scenes, doctors characterize people w/ #pain as "demanding, desiring, disruptive" without acknowledging that patients show up w/ "maddening frequency," because fed policy limits scripts to 30 days.

Doctors often wonder if they're treating illness or playing dealer.

A senior PCP described a patient as a "pain player." Others physicians "nodded knowingly but without comment at the term."

For the anthropologists, the phrase "neatly captured the skeptical attitude & adversarial aura often surrounding pain in U.S. medicine."

The image "constitutes not just patient as 'player' but also physician as potentially 'played'—an intertwined
image that implicitly threatens the typical power dynamics of the doctor–patient relationship."

#Pain "simultaneously produces crushing certainty in the sufferer, who cannot escape the all-absorbing fact of her pain, & ineradicable uncertainty in the observer, for whom not just the extent but the very existence of the other’s pain is always in question" per Elaine Scarry.

#Pain is "ubiquitous, because it can emerge in
virtually every area of the body--and thus cuts across virtually every specialty in the fractured practice of medicine, & elusive" because it frequently resists efforts to render it "objective, observable, & reliably measurable."

Researchers "were struck by how merely noting a research interest in #pain (in the most general of terms) often elicited powerfully charged emotion, prompting clinicians to offer up expressions of frustration, anger, and even disgust in vivid terms."

"Some version of this sense of frustration & unease" about treating people with #pain "was—if not shared by all the clinicians in the study—at least recognizable to them as a frequent feature of the relations surrounding pain management in U.S. medicine."

When asked about #pain, the "clinician's 'go to' stories were about "getting burned" by patients who abused opioids ("which, critically, are really nonpain tales"), despite admitting they represent a "tiny proportion" of patients.

The "loss of control entailed in being fooled by a patient—infrequent though they admit these cases to be—becomes the experience-based justification for reasserting power and control more insistently in subsequent interactions involving #pain."

Why is the mention of #pain "so likely to provoke stories that are so pointedly not about patients in pain"?

Doubts about pain disappear when doctors take the focus off the patient's pain & replace it with metaphorical pain of their own (being burned).

Researchers observed the "gravitational pull of #opioids on clinical expectation & imagination, the way in
which virtually any mention of #pain can provoke projections to the dreaded worst case of having to deal with these drugs."

Doctors' focus on #opioids "was frequent & unmistakable" & reflected "anticipatory defensiveness that the dread of #opioids produces, the adamant assertion that this patient was not going to get any narcs."

Anthropologists noted patients aren't "only allowed but also frequently encouraged, not to believe in #pain medication. Imagine a patient announcing that he 'doesn’t believe' in antihypertensives or 'doesn’t like' to take her insulin; the response would be entirely different."

Doctors' attitudes toward #opioids put patients in "a very odd position indeed; not wanting opioids is often precisely what makes clinicians more willing to prescribe
them. Equally askew is the position of clinicians," writing rx's they hope patients will underuse or never use.

"In a biomedical culture generally fixated on pharmaceutical compliance, this attitude seems remarkable in part because of the way it renders #opioids as essentially optional & thus categorically questionable" & calls into question the importance of treating #pain itself.

"So often in medicine it is therapeutic response to a medication that confirms a diagnosis." In #pain med, "it is perhaps something nearly opposite. The fear w/ #opioids is always that the patient will respond too well, will want them too much."

Doctors often describe themselves as "strong" for refusing to prescribe #opioids, "gesturing toward the clinician weakness that prescribing opioids is thought to invite or expose." The "candy man–drug dealer" is the "boogeyman" who haunts doctors when they treat & talk pain.

An influential 2005 paper urged doctors to treat #pain patients as if they had a contagious disease like AIDS: you can't predict who might "pose a threat," so "treat all patients as potentially dangerous," a view expressing a sense of "exposure, entanglement, & vulnerability."

"In tracking clinician discomfort in the context of pain we
hope to contribute to taking seriously both the #pain of patients seeking care & the distress of clinicians often uncertain about how best to provide it." d1wqtxts1xzle7.cloudfront.net/43459271/C_A_N…

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