Fixing the Modern Pain Scale

Other famous bloggers have handled the idea of how inaccurate the typical doctor's "pain scale" is on multiple occasions.  I think Allie Brosh, writer of Hyperbole And A Half may have done it best in her hilarious piece "A Better Pain Scale" (which you should all check out).  I think, however, that I too have something worthwhile to bring to this heavily-blogged discussion.

This past week, I had kidney stones.  I don't really know for sure how many.  I know I passed two pieces of stone, but that might have been just one that broke up on its way out of my system.  On the other hand, after I passed the big stones, I wasn't paying much attention. If a smaller stone followed up, I wouldn't have noticed.  So, 'somewhere between 1 and a billion kidney stones' is about as specific as I can get. 

My first and only other kidney stone experience happened almost exactly a year ago.  At the time I thought I had appendicitis.  I went through the terribly common ordeal for first-time kidney stone patients of going to the hospital only to be sent home with pain meds and the charming advice, "It's just a kidney stone.  Prepare for hell when it passes. Good luck!"

Because of my previous experience with kidney stones, this time I knew what was happening.  I didn't need to go to the hospital in fear that it was something more sinister. I had the luxury of knowing exactly what the problem was.  I went to my normal doctor, scheduled a normal appointment, and went into the office to get checked out when it was convenient. When I managed to get in to see my doctor a day later, I had a conversation that went something like this:

Doctor: "On a scale of 1-10, how would you rate your pain, assuming ten is the highest?"
Me:  "I guess a four or five? So, extremely painful but not the worst pain I can imagine?"
Doctor: "Oh, that can't be a kidney stone! A kidney stone is almost always a 10!"

Now, I'll skip the next twenty minutes of silly questions trying to rule out other possible causes ("Have you recently eaten any raw whale meat?") and skip back to when the doctor had a realization about why he and I weren't on the same page.

Doctor: "Have you ever broken a bone?"
Me: "I think some fingers and toes, maybe?  I'm not positive, I never really went and got them checked out at the time."
Doctor: "If you rated the pain of breaking a finger on a scale of 1-10, what would you call it?"
Me: "About a 4?  I don't know, if it was a really bad break, maybe a 5, or a 6?"
Doctor: "Oh...that's...that's just wrong."

Therein lies the problem with the modern pain scale.  Wrong?  You're telling me my subjective conception of pain is wrong? How can it be wrong when the pain scale isn't the same for every person. My first kidney stone was close to what I'd call an 8 in terms of pain.  In my opinion, being stabbed by a spork covered in salt by your least favorite childhood nemesis would also be an 8. THAT was the equivalent comparison to me.  It hurt, a lot, and then it kept on hurting. Oh, and once I thought it was done hurting, IT KEPT ON HURTING. MORE. AND IN A VERY BAD PLACE.  So when I say it was an 8, realize that it's about as terrible of pain as I can ever remember experiencing.

At my doctor's office this past week, once we realized that we weren't dealing with the same pain scale we changed how we talked about pain.  We tried to 'calibrate' the scale. In doing so, we discovered I have a very different outlook on the relative strength of pain than my doctor does.

The doctor, for example, called 'stubbing your toe hard enough to hurt but not hard enough to take the toenail off' a 6.  I'd call that a 3. He said that having a really painful stomach ache was a 5.  I'd call it a three again. He said that breaking a finger was an 8, or even a 9.  As mentioned above, I call that about a 5. And he said that a kidney stone is nearly always a ten.

Now, maybe I'm crazy, but I can conceive of FAR worse pain than kidney stones. When I was young, I fell off my bike and gutted my leg, blood everywhere and pain for days.  When I worked on an island in California, I got bit by an elephant seal, and was convinced it had broken my bones.  I've had painful experiences aplenty, and to me, so long as there is a MORE painful possibility, then it's not a 10.  A scale of 1-10 means '10 is the most extreme value conceivable'.  So, if it isn't basically the worst pain possible, it's not a 10 in my eyes.

In the end, my doctor and I managed to use other comparisons to explain my pain. I started to give common examples of painful mistakes, and I used those as a reference to explain my pain.

Doctor: "So, what sort of pain would you compare this kidney stone to?"
Me: "It's sort of like slamming your hand in a car door, except it keeps happening over and over.  So, like the intense pain of slamming your hand in a heavy car door?"

This seemed to help my doctor understand.  So, we continued, and recalibrated as we went.

Doctor: "Is that more or less painful than, say, burning your hand on the oven?"
Me: "WAY more painful than that."
Doctor: "So, like getting kicked in the nuts by someone wearing steel toed boots?"
Me: "Actually...yeah, that's a perfect comparison."
Doctor: "We call that a 7.5 or an 8."

And there we had it!  My pain wasn't a 4 or 5, it was an 8.  I was just trying to compare my pain to the hypothetical extremes I could imagine, while he was assuming that anything that hurts extremely badly will be called a 10.

Maybe this is why doctors don't always believe patients that say they are experiencing a '10' on the pain scale.  After all, when one person calls a burned hand on a hot oven an 8 and another person calls it a 3, it's pretty hard to tell what the hell a 10 is.  If doctors REALLY wanted to understand pain better, they'd take an approach like my doctor did. 

Instead of asking, "On a scale of 1-10" they should be asking, "On a scale from "meh, not that bad" to "DEAR GOD my testicles! Who kicks a man in the applebag while wearing steel toed boots covered in fire ants?", how would you rate your pain?"

I'm pretty sure that would be easier.

Thanks for reading! I hope it didn't gross anybody out, and I hope it made most of you laugh!  Have a great day,
-Brian.