Doctor, I am in pain

Roger Ladouceur

Not a day goes by when family physicians aren’t privy to the full range of human suffering. Acute pain associated with diseases, infections, ischemia, seizures, and physical trauma resulting in severe, sometimes horrible, pain that typically passes given time and treatment. Chronic cancer or noncancer pain that is persistent, prolonged, and exhausting, for which time provides no relief and treatment effectiveness is limited. Psychological suffering often related to anxiety, depression, or cognitive disorders manifesting themselves in many ways: insomnia, fatigue, burnout, anhedonia, worries, and preoccupations. Moral or existential suffering frequently associated with aging and change: loss (of ability, independence, memory, status), fear (of aging, suffering, dying), abandonment (lovesickness, breakups, family conflict), and all other forms of human suffering, great and small.

I often tell myself that the uniqueness of family medicine rests not only upon continuity of care—as we so often hear—but also upon our proximity to our patients’ (of all ages, sexes, statuses, or conditions) suffering. There are few other professions, even among the other specialities, that deal so closely and so frequently with human pain.

But are we well prepared to accommodate and manage all types of pain?

Certainly, we have all been trained to provide high-quality care to sick patients. We have all been trained to be active listeners. We have become proficient in the Calgary-Cambridge guide. We use a rigorous hypothetical-deductive method to formulate appropriate diagnoses. We possess an impressive therapeutic armamentarium. We practise evidence-based medicine. We use valid scientific methods to prescribe recommended treatments. We are competent in most psychotherapeutic techniques, especially cognitive-behavioural therapy, to help patients who are suffering.

But is that enough? Does this allow us to genuinely understand the people who consult us about their pain?

A few years ago, I participated in a conference for Canadian family physicians at Mont-Sainte-Anne in Quebec. That day, an Anglophone physician invited us to a workshop on using literature as a family medicine reflection tool. To do this, he gave us a text by Hubert Aquin, a renowned Québécois author. This impressed me greatly, as we all know that Canada is inhabited by 2 (or maybe more?) solitudes who do not know each other well. Alas! Family medicine is not immune. This text, entitled “Back on April 11,”¹ told the story of a husband whose wife had left on a trip to Europe, and who had, over the course of her absence, fallen into a deep depression. He decides to end his life. To do so, he steals a prescription pad from an old physician friend, allowing him to amass an impressive supply of barbiturates to ensure his death. The husband gives a detailed description of his journey to the end in a letter he addresses to his wife, who meanwhile has sent him a telegram telling him that she will return on April 11. The man writes, “Someone has to tell you, so I’m telling you frankly. I’m bothering to show you that I am still alive, alas, to let you know that I have tried to take my life.”¹

The story might seem banal—a lovesick person describing a pain we have all experienced at some point in life. And yet it certainly is not. I still recall the indignation of workshop participants unnerved by the story. This story is about the suffering experienced by a person in pain. Truly, this story is absolutely not banal. It has contemporary relevance when some opt for medical assistance in dying while others prefer to take their own lives. Liberating suicide. Death over suffering. This is understandable.

Which brings me to the following question: What do we do when someone’s suffering becomes too great, the distress too immense, and when the pain cannot be relieved? When everything has been tried, prescribed, administered? When everything possible has been done? What more can we do? Nothing?

Nothing beyond being present, listening, respecting, and keeping hope alive.

Which is certainly not nothing!