Module 7. The obstacle is the way
Welcome back. How’s the curiosity practice going?
We’ve been talking a lot about pain and suffering in this course. Yes, it can be painful to be exposed to or take on so much of others' suffering. It can be painful to learn that we might have formed a few unhealthy coping habits of our own. It can be painful when we look back at our patient and colleague interactions or social media posts, flinching as we think, “did I really say that?” Yeah, those emotional contagion bugs are nasty and really infectious. And moods and attitudes become cancerous if allowed to grow unchecked–we go on autopilot, get caught up in negativity, cycle after cycle of self-judgment, worry, outrage, cynicism or whatever. Hopefully, you are starting to recognize signs of this illness so that you can get a shot of curiosity to build your mental immune system, bringing in kindness to outcompete those nasty habits. Maybe you’re already good at spreading curiosity and kindness to your patients, colleagues, families and communities. Ready for some more pain?
Going back to the first module, we explored how pain is painful, both for our patients–and if we are really empathizing with them–for us as well. We also saw how this can be a catch-22. We have to feel their pain to help them heal. But if we feel it too much, we get burned out. In the second module, we explored how compassion helps us not take on other’s stories of suffering. We can be right there, beside them in the flames, without getting burned. Today we’ll explore some important elements of how our brains perceive pain–both ours and others–and how these can affect how we treat pain. This is really important because if we don’t know how this works, it can lead to misdiagnosis and mistreatment. This just adds to the pain, both for our patients and ourselves. Let’s dive in.
Before we begin, an important aside, I am going to have you imagine a professor. I would much rather that you imagine a female professor given our long outdated notions of gender roles, especially in medicine. But I am terrible at vocal impressions. For this next part, think of a female physician with a unique-sounding voice. Ok, let’s go.
Imagine being a medical student or resident physician or in some stage of your healthcare training. Your team is discussing how to treat a patient who is reporting post-operative pain. Your attending physician seizes the moment to attend to her duties as a professor and teach you about pain. She starts by giving you the following definition of pain: “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described regarding such damage.” Thank you very much professor. Sounds like you read that out of a textbook. That didn’t tell me much more than what I already know. And what about emotional pain? Doesn’t that hurt too? Looking a little pained that this definition wasn’t enough, the professor adds, “Pain is not only a sign of damage, but the result of complex interactions between biological, psychological, and socio-cultural factors.” You think to yourself, I already know this. Teach me something useful.
You check in with yourself and notice how you might be coming down with an impatience bug–who did I catch that from?–you wonder. You remember from somewhere that curiosity is an antidote to impatience. You pause and lighten your tone of voice before asking, “Hmmm, can you explain the clinical relevance of what you just told me?” Perhaps you are even a bit surprised that genuine curiosity can actually be triggered by that silly vocal trick of hmmming that you learned somewhere.
Perhaps catching a little of your curiosity, the professor gets a glint in her eye. Right! This science stuff only matters if we can translate it into understandable language and show why it matters. She starts asking you questions, “Did you know that pain can be influenced by mood or emotional state both by the patient’s and our own?” Before continuing, she looks to see if you have that “tell me more” look on your face. Tell me more, your expression tells her. She smiles. “Oh, she’s a smart one,” you think. “But I’m on to her. She’s spreading happiness via emotional contagion, which also helps learning.” You note that intrusive thought and it disappears. “Damn this noting stuff works!,” you think to yourself. You note that and it disappears, leaving you more focused. “So how does mood or emotional state affect pain?” She asks. You give her an “I don’t know look.”
She continues, “studies have shown” –oh Gawd, a lecture as you feel yourself closing down. You curiously note “Cynicism” to yourself, and open back up, ready to learn. “Studies have shown that negative emotions increase the unpleasantness of pain, while positive emotions do the opposite. Did you also know that pain can be enhanced by cognitive fatigue or sleep deprivation?” You think back to how painful it was to try to stay awake in grand rounds after being on call.
“Psychological distress” she continues, “can worsen pain. Personal health beliefs and coping strategies can make pain worse or last longer. This can be compounded by anxiety: if you can’t control your distress or start to worry that your pain isn’t getting better, is going to last a long time and so on, you get more anxious, which feeds back and makes the pain worse.” Seeing that you are making connections in your brain, she adds, “Did you know that when pain becomes chronic, brain activity actually switches away from pain circuits to circuits that process emotions? That’s why anxiety and other emotions take center stage when it comes to back pain and other chronic pain conditions. At that point, it isn’t about point tenderness or the physical sensation of pain. It’s about that protective flinch, the worry, the fear of the future. So it is critical to target the mechanism, and treat the root cause. Analgesics are only part of the story. We have to treat the whole human: body and mind. Here, for example, mindfulness-based stress reduction has also been shown to change brain activity in these circuits. This makes sense because it has been shown to help both chronic pain and anxiety.”
As an aside, hopefully you can see by now that pain is complex. Notice how inadequate and shallowly one dimensional the 1-10 pain rating scale seems. To diagnose pain effectively, you have to keep in mind the body and the mind: the physical cause is only part of the equation, and much less of the equation when pain moves from acute to chronic. To treat pain effectively, you also have to treat the whole human: the physical and the mental.
Your professor saves the best for last. “Ok, pain is subjective. Pain is influenced by mood and emotional states. Did you know that experiencing pain in the presence of others can influence your reaction to pain?” She gives you an example, telling you how in one study, women reported a lower intensity of pain when a romantic partner was holding their hand. She mentioned something about physiological synchronization, when your physiology syncs with one of the other. No wonder partners hold hands during childbirth. No wonder parents hold their kids' hands when they are undergoing painful medical procedures. Wow, another example of social contagion. Mind. Blown.
She sums it all up with this clinical pearl. She says, “Just remember this formula. Suffering equals pain times resistance. The more we resist pain by getting anxious, worrying, closing down, turning away from or otherwise trying to protect ourselves from pain, the more we suffer. What you resist persists. This goes for physical and emotional pain.” Your brain makes another connection: all of the times you have turned away from or resisted your patients' suffering, not only have they suffered, but you have suffered as well. All of the times you have ignored, turned away from or shoved your own emotional pain into the closet for another day, you have suffered, and it might have made your patients suffer as well.
The ever-patient professor sees that you’re learning. She sees that you’re open. She knows this is the time that she can bring up unpleasant and even painful subjects. She starts in gently, “So you can see that pain diagnosis and severity aren’t straightforward. The perception of pain is influenced by the patient’s genes, social conditioning and even mental state at the time. When clinicians try to diagnose pain and determine how severe it is, we are influenced by our own conditioning and our own mind states at the time. We can even be influenced by emotional contagion, whether our patient’s or anyone else in the room. All of these can bias us.” She looks at you to see if you are still open and curious, or if you flinched or closed down with that last sentence. The word bias is painful for many people. For dark-skinned individuals who have suffered from racial bias for many generations, the layers of pain are obvious and run deep. For white-skinned individuals, the feeling of fragility, the wanting to not have socially conditioned biases, and so many more factors make the subject sensitive or feeling too hot to touch.
Your wise and compassionate professor mentally holds your hand, knowing that the next thing she’s about to say hurts for a lot of people. With the tender voice of kindness, she describes a 2016 study published in The Proceedings of the National Academy of Sciences where half of a sample of white medical students and residents endorsed the belief that black people’s skin is thicker than white people’s skin. They also rated black patient’s pain as lower and made less accurate treatment recommendations. Half of them. In 2016. She described several other studies where black people are less likely to be prescribed pain medications. She then pointed out that this isn’t simply racial and ethnic bias: a number of studies have found that female patients with acute coronary syndrome are less likely to get a diagnostic workup than men. In fact, a 2018 study, also published in PNAS found that female patients who have an acute myocardial infarction and are treated by male physicians have higher mortality rates than either male or female patients treated by female physicians. What are these male physicians thinking? Well, another study showed that women are twice as likely as men to be diagnosed with a mental illness when their symptoms are consistent with heart disease. What? You have indigestion and discomfort in your neck radiating into your jaw? Lady, you’re just being hysterical. Go see your shrink.
Bringing this discussion between you and said professor to an end, unfortunately, this type of bias-based misdiagnosis and maltreatment is common enough that it is now called medical gaslighting. It probably takes the term gaslighting a bit far, but you get the idea. For example, a New York Times article written about the topic in 2022 describes a woman, Jenneh Rishe, who had intense chest pains that woke her up at night. Ms. Rishe flew from Los Angeles to a highly recommended cardiologist in the midwest. Despite a history of not one but two congenital heart conditions, the doctor told her “People who have these heart conditions aren’t this sick.” Smartly, she got a second opinion, and after a proper diagnostic workup, tests revealed that her arteries were spasming. Oh she needed open-heart surgery to correct the problem. She got the surgery and it did correct the problem. Did I mention that Ms. Rishe was black?
Unfortunately, no matter what our skin color is, no matter what our gender identity is, we’re all susceptible to social conditioning. There’s one more thing that is important to know, because it affects how much we are influenced by our biases. Ready?
A study done at the Veterans Affairs Healthcare System looked to see how much high cognitive loads–when we’re juggling a lot, feeling rushed, stressed, anxious and so on–can influence their medical decision making. They had docs read patient vignettes and found that high cognitive load affected the likelihood of prescribing opioids for pain in Black vs. White patients. Female physicians had a much narrower gap than male physicians, but the signal was pretty clear and fits with known science: when we’re stressed, our prefrontal cortex goes offline making it harder to think and reason. That’s when we fall back on habits or conditioning. You can do your own experiment, no matter who your patients are: when are you at your best in diagnosing and treating your patients? When you’ve got a million things running through your head? When you’re stressed or anxious? When your clinic is running way behind and you’re wondering how you will possibly get back on schedule? We’ve all already replicated this experiment. Unfortunately, too many times. All of these have direct impact on how we treat, and how well we treat our patients. If we don’t take care of ourselves, we can’t take care of our patients.
I’m guessing that whether gender, racial and ethic or some other type of bias can affect pain perception and medical decision making, this topic may have gotten under your skin. Perhaps take a moment to feel the suffering of those who have experienced bias. Perhaps it was even you. Focus on the fact of suffering, not the story. Does it move you to want to relieve that suffering? Here’s the good news. You already know how. Since bias is conditioned, since it is learned, you can un-condition, un-learn it. Simply being aware of this is already a step forward. Bringing curiosity in so that you can be on the lookout for any little bias that you might have picked up through social conditioning can help you stop looking through any tinted glasses of what your patients look like. It can also help make sure you aren’t acting based on what your own mental state is at the moment.
How about another pearl, a tip you can take to your clinic? Let’s start with treating your patient’s pain. For example, you can learn to notice when you flinch, jump to a conclusion, prejudge, make an assumption, dismiss or do something else that makes it harder for you to listen carefully, rush to a treatment recommendation or otherwise get in the way of proper diagnosis and treatment. Noticing these habit loops helps you step out of them. It can be as quick as recognizing the mental pattern, and taking a single deep breath. Here’s a way to turbo charge this: because your stress or rushed feeling is contagious, you can bet that your patients will feel this when you are with them. So when you notice you are feeling rushed and so on, you can play with saying something like, “Hey I’m noticing that this is a lot. I’m going to take a deep breath to let this all settle in. Join me if you’d like.” And like a little mental joining of the hands, you both take a breath together. If you really want to “throw caution to the wind and approach the bedside” as one of my surgery professors used to joke, you can play with admitting what you’re feeling at the moment. “Wow, I’m feeling a little anxious, stressed, rushed, overwhelmed or whatever you’re feeling. I’m going to take a deep breath. Care to join me?” Vulnerability is strength as Brene Brown says. If you’re a little nervous about trying this with your patients, practice opening up or being vulnerable with your spouse or partner first. Go ahead, throw caution to the wind. You might be surprised by the results.
Now let’s extend this to your pain. Hopefully you got a sense of how treating pain is anything but formulaic. This is true for the medical field in general. Medicine is complicated. Medicine is messy. Yet, when we learn to accept, even embrace the uncertainty, when we turn toward the pain instead of running away from it, when we admit that we’re stressed out, something amazing happens: the obstacle becomes the way. We learn how our minds work. And we learn that we can work with our minds instead of fighting against them. And this opens us to what we love about our jobs and our profession: helping people. When we set the healthy habits of curiosity and kindness, we open to our patients, ourselves, our families and our lives. This is when our patients, our families and we thrive.
So take a moment to take a moment today when you’re getting caught. It could be an empathy protection habit loop, it could be anxiety or fear, it could be pain -physical or emotional. Whatever it is, take a deep breath, maybe even take a breath together with your patient so you both can get grounded. See how much you can step out of the old loop and into compassionate action.
In the next module I’ll briefly review each of these modules so that you can practice putting all of the pieces together. You can also download a summary document with each of the practices here.
Onward! We will see in the next module.
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