Why doesn’t my doctor believe I’m in pain?

The challenges of treating pain

Doctors evaluate so many changes in our health through measurements, like a thermometer for fever or a blood count for anaemia. But there is no comparable instrument to measure someone’s else’s pain.

Healthcare providers often ask patients to describe what they’re feeling in relative terms. If I asked you to rate your pain when you stub your toe or the pain of breaking a leg, I bet you could give me an answer on a scale of one to 10 – with 10 being the worst pain you’ve ever felt.

That kind of report about your own experience is similar to others doctors use: “Can you read line three” during an eye exam or “Do you feel this sensation on both feet equally?” during a neurology exam. In those cases, they generally take your word for it.

Yet something about pain differentiates it from other symptoms and becomes something we need others to “believe” is happening. Why?

How pain works

To understand why medical interactions like these are so fraught, we need to explore the difference between nociception and pain.

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Nociception is the medical term for when your nerves detect a harmful stimulus – such as a burn on your skin or chemicals inside your gut – and relay that information through the spinal cord and up to the brain. This can be somewhat reliably reproduced in scientific experiments, and many medical diagnoses hinge on identifying a cause of nociception.

But pain is not merely the final product of nociception. Pain is a complex sensory and emotional experience that makes receiving those signals so unpleasant. The agony of pain is controlled by several parts of the brain – notably, the amygdala – that regulate each individual’s perception of the same stimulus and can permanently alter how they behave afterward.

Neurotransmitters, such as norepinephrine amp up the experience of pain while endorphins dampen it. And how we perceive and express pain is unique, shaped by our own experiences, traumas, genetics and disease exposures.

To complicate matters more, sometimes pain occurs as a result of damage to nerve fibres (called neuropathic pain) that send distress signals to the brain because of triggers that would otherwise feel harmless to healthy people.

As a neuro-gastroenterologist, I treat chronic pain patients who have been through dozens of standard tests that come back negative. Although highly specialised tests do in fact identify profound problems – microinflammation in irritable bowel syndrome or unique neural alterations and neurochemical imbalances in fibromyalgia – you may never uncover that pathology in a standard evaluation.

What I want my patients to know

Trust should run both ways in a patient-doctor relationship. A doctor who thinks they know how a patient feels better than the patient themselves goes beyond not believing them – it implies an omniscience we don’t possess. If you feel this is happening, bring a support person to your next visit to help you advocate for yourself. But if you’re not being heard, get a second opinion.

Washington Post

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