Because there is no objective test for pain, and because each patient's experience of his or her painful condition is subjective and unique, physicians who treat these patients must process a variety of symptoms, signs, and cues to determine whether they can trust their patient's narrative.
Participants at the 2014 annual clinical meeting of the American Academy of Pain Management, in Phoenix, AZ, got a reprieve from science and medicine and a chance to consider the ethical implications of trust and mistrust. Should doctors trust their patients? This was the dilemma posited in a keynote address by Peter A. Moskovitz, MD, Clinical Professor of Orthopedic Surgery and Neurology Surgery, George Washington University, Washington, DC.
On one hand, it is well known that patients can mislead doctors, whether intentionally or not.On the other hand, while an objective diagnosis can sometimes verify a patient’s account of symptoms, it cannot verify the patient’s experience of the condition. “The apparent paradox is more troublesome for the pain practitioner who endeavors to understand the patient’s experience of pain,” explained Moskovitz.
Moskovitz said neuroscience saw the “Decade of Pain Control and Research” from 1990-2000, the “Decade of the Brain” from 2000-2010, and is currently in the “Decade of the Mind.” The mind is subjective and cannot be measured. It is fleeting and chaotic. It does not exist in a specific location. He said, “An identity between a measureable objective state of the brain and a subjective experience of the mind remains elusive.” Yet, neuroscience respects the mind.
The health care system, however, does not respect the mind. Moskovitz claimed there is a backlash against this “ascendancy of the subjective; a backlash born of the paradox that we study and treat an experience whose very existence we cannot prove or disprove.” This backlash values objectivity, quantification, and quality improvement. This backlash requires checklists, spreadsheets and algorithms. Perhaps most influential, this backlash requires an objective diagnosis and a code for reimbursement.
But what is health care? Is health care “the prevention and control of disease, injury, and deformity” or “improvement of life quality”? This is central to the paradox that practitioners face, especially those involved in the management of pain. Moskovitz contends that these definitions are not mutually exclusive and proposed a compromise: “Health care is as much about the patient’s experience of the condition as it is about the condition itself.”
Practitioners, and especially those who treat pain, are at the center of this paradox; they must constantly balance respect for the mind and the requirement for objective proof, which brings us back to the question of trust. It is difficult for practitioners to trust a patient’s subjective report, especially if deceit or fraud is suspected. In these cases, physicians can become angry, or worse, blame the patient for their condition.
“The struggle between trust and mistrust,” explained Moskovitz, “is intrinsic to the human condition, is the first conflict of neonatal development, and dominates every stage of life, every relationship.” However, he urged physicians to realize that “trust and mistrust are equally irrational, and neutrality is not an option.” The only ethical solution to the paradox, therefore, is to choose trust, “to honor and respect the patient’s narrative of pain, the patient’s story of suffering.”