Subjective Experience vs Objective Perception

Recently, a colleague described an experience with a patient who said his pain was “horrible” and rated it a “20 out of 10.” My colleague said, “Of course, they are going to have pain. It’s normal after that type of procedure.” My colleague felt the patient had unrealistic expectations and was not prepared for what to expect. The amount of pain this patient prescribed to the procedure and my colleague’s feeling did not match.

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The patient’s care team was uncomfortable increasing his opioid regimen in today’s changing climate. They felt the patient’s report was abnormal, and were certain this case would show up on the survey and they would hear about it in their weekly HCAHPS meeting.

After talking with my colleague, I worried about 2 things: How we contextualize normal in regard to pain, and that the HCAHPS is not meant to drive individual clinician pain-management decisions, but be a tool for organizational use.5

Years ago I underwent an aortic arch replacement. My surgical team described the procedure and explained that I would have pain. Despite this, I was still surprised at the level of pain I felt the first time the medication wore off after surgery. However, the fact that they warned me allowed me to anticipate the pain. Much like I can try to imagine the pain my patients suffer even though I have never experienced it.

My colleague was right: the patient could have been better prepared for what to expect regarding pain.

Studies have shown that patients who are better prepared for what to expect regarding pain management have better outcomes.6,7,8 However, what happens when we delegitimize the patient’s pain report? My normal is not everyone’s normal. This goes back to a report by Margo McCaffery, MS, RN-BC, FAAN, an internationally recognized specialist in the nursing care of patients with pain, who said pain is “Whatever the experiencing person says it is, existing whenever the experiencing person says it does.”9

When we discuss patient-centered care, pain management should be seen as the epitome of doing this. We create an additional barrier to building trust when we create competing priorities to accomplishing this.

Published in 2006 yet still topical, an article titled, Is pain ever “normal”?, discussed pain and normalcy, the idea being that clinicians feel something about the validity of pain.10 We then compare our experiences with our patients’, and this colors our encounters. My colleague may have had competing priorities: the pressure of meeting the HCAHPS domain for pain management vs the clinician’s own ideas about pain. The HCAHPs domain for pain management was never meant to influence clinical decisions on pain management.11