Accepting as we (at least tacitly) do, the professional obligation of physicians to relieve human suffering, including that which is engendered by severe, persistent pain, this well-recognized failure of healthcare profes sionals to make it a priority in their care of patients verges on the inexplicable. There is a "chicken and egg'' conundrum about the first two barriers to effective pain management. Do clinicians fail to identify pain relief as a priority because they have not been taught how to provide it? Or is it rather the case that medical schools and residency training programs do not emphasize training in pain management because clinicians, including medical educators, do not consider pain relief to be a priority in patient care? There may be a synergy between the forces that have erected these two barriers that confounds the search for a satisfactory answer to these questions.
Some insight into the problem can be gained by noting that it appears to have been exacerbated by the advent of modern, scientifically based, high-technology medicine that has shaped what we have previously noted to be the curative model of medical practice. As the term suggests, the curative model focuses primarily, if not exclusively, upon the goal of cure, i.e. the eradication or radical reversal of a disease process. Particularly to the extent that curative interventions themselves cause pain, discomfort, temporary dysfunction, or risk of death, the relief of pain and suffering can be interpreted as a conflicting goal, and hence one that must be abandoned during the pursuit of a cure. One commentator suggests that the pain experienced by the patient is subjected to two kinds of forgetting: one psychologic and the other conceptual.28 The psychologic component arises from a need of the clinician to distance him- or herself from the patient's pain, as well as to convince the patient that the pain is not really as bad as it seems, or that it is a regrettable byproduct of the necessary means to a desirable clinical outcome. The conceptual component treats pain as a symptom of the underlying disease process, something to be observed but not managed or eliminated. This is particularly the case given the widely held (mis)perception that relieving pain impedes the process of cure. The patient's reports of pain are noted, if at all, as information about the progression of the disease, not as cries of distress giving rise to a duty to provide relief. To the extent that this perspective is accurate, it may call into question the ultimate effectiveness of one proposal by pain specialists to improve pain management in the inpatient setting - charting pain as the "fifth vital sign.''29 The implicit assumption is that pain is more likely to be treated if it is measured and recorded. However, if pain continues to be conceptualized as nothing more than an indicator of the progression of disease, noting its presence and severity in the chart will not necessarily result in interventions to relieve it. For insight into why that might be the case, we need to explore further the nature of the prevailing model of medical practice.
It has been persuasively argued that the pervasiveness and the overemphasis of the curative model in medical education not only results in a particular style of medical practice but also engenders a set of assumptions, attitudes, and values which are inherent in the model.12 Among these are the focus on the disease process rather than the patient's experience of illness. Such a focus privileges the objective and scientifically verifiable, and discounts the subjective and unverifiable. This focus, of course, has significant implications for the care of patients with chronic, nonmalignant pain. The implicit message of the curative model is that there is no compelling need to know the patient as a person as long as the professional has a firm grasp upon the pathophysiology of their disease and an interventional strategy for reversing it. While the curative model may not pose any significant problems for patients whose pain is of the acute variety and limited in its severity and duration, it has itself been the cause of considerable unnecessary suffering for patients with chronic malignant or nonmalignant pain. The predominance of the curative model of medical education and its obsession with the pathophysiology of disease rather than the patient's subjective experience of illness is "disastrous," according to Arthur Kleinman, to the care of the chronically ill.30 Indeed, the curative model, in conjunction with rampant opiophobia and an ethic of undertreatment of pain, has resulted in numerous instances of pseudoaddiction among chronic pain patients. Pseudoaddiction is an iatrogenic condition caused by the failure of physicians to provide adequate pain relief that forces the patient to employ (legitimate) drug-seeking behaviors to obtain analgesics they are entitled to.
Kleinman's work with chronic pain patients, as physician, psychiatrist, and medical anthropologist, provides a number of important maxims for those who seek to provide compassionate care to such individuals.
• One of the core tasks in the effective clinical care of the chronically ill is to affirm the patient's experience of illness as constituted by their explanatory models and to use those models in the development of an acceptable therapeutic approach.
• Chronic illness is as distinctive as the lived experience of different individuals because in the end it is the lived experience of different individuals.
• One half of all patients with chronic pain syndrome, like many others afflicted with chronic illness, meet the official criteria for major depressive disorder. More than anything else, the depressive mood represents demoralization from the life of pain and the persistent questioning by others, including healthcare professionals, of the authenticity of the patient's experience of pain.
• The science of pain medicine must include social science interpretations together with biomedical explanations. It must bring to bear knowledge of the economic, political, and social psychologic sides of pain.
The maxims I have gleaned from Kleinman's work describe what he characterizes as a "meaning-centered'' model of chronic illness that he deems essential to the compassionate and effective care of such patients. It is a biocultural model that places the emphasis upon the patient's illness experience, as does the palliative model, and in doing so stands in stark contrast to the biomedical model whose exclusive focus is the disease process - its diagnosis and its cure or remediation.31 While it may be much too simplistic to suggest that restoring some proportionality between the curative and palliative (or biomedical and biocultural) models of medicine in the education and training of physicians would eliminate this and related barriers to effective pain relief, it is also the case that it is naive and unrealistic to suggest that continuing professional education programs on pain management alone can overcome the assumptions, attitudes, and values that have been instilled in physicians by the curative model of medical education. Physician practice styles and patterns are acquired early and thereafter are highly resistant to change. Part of the solution goes not only to the substantive content of medical education but also to the venue. While most physicians practice in settings that would be hospitable to a balance between the curative and palliative approach to patient care, by far most medical education and residency training takes place in the acute, tertiary care setting where the hegemony of the curative model is most complete.32
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