On a Scale from 1 to 10: How My Perception of Pain Changed as a Medical Student

“Little pinch and burn now,” the nurse muttered, focusing intently on injecting lidocaine into my hand. I breathed deeply, feeling the needle and the subsequent uncomfortable heat seep into my skin. She then quickly pushed in the IV, applied a bandage, and stood, collecting her used supplies with a smile. “All done!” she said brightly as she tossed the pile of refuse in the trash. I smiled tentatively back, then looked down at my hand and the bruise that was already starting to form. However, there was no pain thanks to the lidocaine. I remember marveling at the power of the local anesthetic to prevent my discomfort.

I was, at that moment, a surgical patient for the first time. The operation was a meniscus repair and ACL reconstruction after a dance injury at the end of my first year of medical school. I was so excited to finally have the surgery and to begin physical therapy and recovery.

Then, I woke up from anesthesia in the worst pain I had ever experienced. I had encountered my 10/10 on the pain scale. I always thought I had a high pain tolerance, but nothing compared to surgical pain. I’d had a nerve block, opioids, and over-the-counter analgesics, but the burning aching stabbing pain in my leg was so terrible that I immediately vomited on emergence from the anesthesia. I had mobility issues from the start, making physical therapy torturous. Nobody could tell me why I was in such terrible pain compared to the average ACL patient, which contributed to my constant frustration.

It is now 1.5 years since my injury. I continue to have daily pain and soreness in my knee and thigh, but the most lasting impact has been that I no longer understand my pain.

Pain is a signal, notifying our brain of a noxious stimulus. It travels along our nociceptors and nerves, telling us that something ‘wrong’ is happening. We often try to get away from the stimulus in order to avoid damage to our tissues. In life, with both physical and emotional pain, we use pain as a signal to stop. It is valuable feedback, an indication that we are going too far or doing too much. I had depended on that feedback in my life, using it to dance and exercise and even to sort through my relationships.

Deciphering that feedback became increasingly difficult after my injury. I was in the worst pain after the operation, but the operation was…good. It meant recovery. Enduring the pain in physical therapy was supposedly normal. I wasn’t going to cause damage, even pushing myself to tears. My pain signals had become scrambled. I had relied on them to tell me that I was close to an injury, and then they were muddled. Often, there was no concrete answer to the cause of my pain besides generic ‘surgical pain’. I could no longer tell the difference between acceptable discomfort and painful warning signals.

As I dealt with this increasingly confusing relationship with my own pain, I entered the clinical phase of medical school. Especially during my surgery clerkship, I was constantly confronted with patients in pain. I saw how surgery causes pain to address a deeper problem. While the patient’s pain is a true signal of injury since they’d just been cut open, this pain is expected and accepted. Often it is even dismissed, with a casual remark of “You’re fine”. This means that the pain isn’t worrisome, but the patient hears that the pain isn’t real.

This miscommunication often led to frustrated patients and irritated providers. Didn’t the providers understand that patients were just listening to their pain signals? Did they understand the overwhelming sense that ‘something is wrong’ that pain elicits? Didn’t they see that the patient was dealing with conflicting signals, being told everything was alright but feeling like everything was all wrong? I was sometimes bewildered at the dismissal from the doctors, at the inability to comprehend.

However, the medical perspective on pain was also prominent in my mind. As a medical student, I was learning that in almost every field of medicine there is a certain amount of comfort with causing pain. Innumerous aspects of medicine involve pain; eliciting pain in physical exam maneuvers to localize the issue, vaccines, surgical procedures, medications with muscle aches as a side effect, physical therapy requiring painful movements, and drawing blood to get labs. I also was learning to see pain as a sign, a key part of the ‘subjective’ part of a patient’s history. Medically, pain can be a clue. The patient’s description of pain indicates how much pain relief to give them, whether to advance their diet, how much activity restriction to place them on, whether intervention is indicated, and more. Importantly, changes to pain can indicate drastic health changes, pending complications, or disaster. Horrible abdominal pain may mean a medical emergency in the case of a perforated bowel. Or, it may just mean the patient is very constipated. Deciphering pain signals is difficult for the patient, and even more difficult for the physician.

I simultaneously felt immense empathy for my patients and their reactions to pain, while understanding the necessity of pain in medicine. This contradiction plagued me. I didn’t find it easy to watch patients in pain. Sometimes, it seemed as if every doctor was jaded. Discomfort was seen as normal; even I sometimes rolled my eyes at a patient’s complaints. Yet I also remembered my own difficulty with understanding my pain. I had wanted answers and acknowledgement; surely that was all my patients wanted too.

Pain can be useful. It can tell us a lot about a patient, their diagnosis, and their progress. But pain can be emotionally difficult for a patient. It can be confusing in the setting of a treatment that is supposed to improve health and wellbeing. The discomfort may be sensed as a contradiction to the ‘goodness’ of a medical intervention. Communicating this contradiction, acknowledging it, and setting boundaries for patients within the subjectivity of pain allows pain to exist. It allows it to be accepted and used as the useful diagnostic tool it is. And acknowledging that something causes pain doesn’t negate the good that the intervention may provide. As a medical student, I’ve seen the necessity of pain in testing, getting a diagnosis, and treatment. And as a patient, I am once learning how to understand my pain signals. Sitting at the junction of these two identities is the realization that how we talk about pain influences a patient’s experience, and that is something I hope to remember as I continue my medical education.