Oct 29, 2009

Never Say 10! (How Doctors Interpret the Painscale)

A question from a reader:
My doctors all use that 1 to 10 pain scale. Could you explain why? It seems so crude. Is a doctor equating my "6" to someone else's "6"? I always figure that "10" should be left for when a wolverine is gnawing off my face while my lower extremities are on fire, but other people may use "10" more casually.
The painscale is one of Doctor D's biggest pet peeves! The “powers that be” in medicine prefer looking at data rather than real people. And by data I mean numbers. Academics, researchers, and bureaucrats love numbers! They add them up to make treatment or policy recommendations. I often appreciate these bean counters that help clinical doctors, but it gets problematic when we try to pull hard numbers out of subjective human experience.

Medical people are now all commanded to record a numerical pain level on each patient. 0 means no pain at all and 10 means the greatest pain humanly possible (such as fiery wolverines.) They tell us to record this number like a vital sign, but while a fever of 102° F is the same temperature in every person, 8/10 pain may be a very different experience for different people. And lots of hospitals are making policies like "No one can be sent home from the ER until their pain is less than a 5."

Doctor D sees lots of people every day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale. Doctor D suspects that some people might be exaggerating a bit when they answer “Ten” while texting and complaining about the lack of pretzels in the waiting room vending machine. I've seen a few people I was certain had 10 of 10 pain and it seems like disrespect to those people to classify bruises and upset stomachs in the same category. But pain is subjective, so who is to say a mildly sprained ankle isn't more horrific to this individual than the fires of Hell?

Obviously there are some addicts who lie about pain to get drugs, but I think more commonly people say 10 because they lack the imagination to conceptualize greater pains or they hope that a 10 will cause doctors and nurses to take their discomfort more seriously.

While the painscale is supposed to empower patients to define their own pain, it ends up tricking people into an answer that gets them nowhere. Anyone who says 10, who doctors don't think looks like a 10, is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F.

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.” Your doctor will recognize that if you understand how bad 10 is then your 7 is really horrible, so your doctor will work hard to alleviate your misery.

But trust me, never say 10! Even if it you had to set your self on fire to get the wolverines to stop eating you say 9. Ten on the painscale is a Catch-22; answer “10” and the doctor immediately thinks you are about a level 4.
What is the worst pain you every felt? Doctor D's worst pain of his life was about a 6. Did a doctor believe you went you complained of the pain? Do you think the painscale was helpful for getting your pain treated?
Follow-up post: The Purpose Of Pain: Why the painscale doesn't work



Yes a pain scale is so subjective. If the worst pain a person has ever had to make a comparison with was a stubbed toe versus a badly sprained ankle then, they may personally find a sprained ankle agony....to them.

In my case when I have been asked about pain levels, I always say to medics to put the pain in context, "I have had complete bladder removal with bowel, while experiencing a prolonged and arduous Bowel Obstruction and would call that a ten" yet I could still walk around with it.
So usually my pain hardly ever gets past a 5 in comparison.

Saying that I can honestly say that complete urinary retention with reflux into kidneys can be just as painful as the afore mentioned and be a ten.

Sharp stabbing pain can be less "painful" as a continual throbbing ache if it is intermittent sharp pain.

Exhaustion from being in pain a prolonged amount of time, can up the scale as the body and mind tires there is no resiliency to fight it any more.

So many factors..
Life experience, previous medical experiences to compare pain too, fear of the unknown upping the pain brain reaction, tolerance levels and the type of pain experienced, learned behaviour.

I personally hate bowel pain especially wave after wave of sharp stabbing, mouth-watering pain. Next would be severe headache, as you cant distract and escape from it.

We are all individuals and cope differently.
You may also find that people who were bought up by over protective parents, who over react when their kids get hurt, in turn cause a life time anxiety and fear in their kids, who then become more sensitive and don't handle pain well as adults.

Dani said...

Hm, I would say my worse was the time I slammed my finger in a heavy wooden door in my dorm a few years ago. It hurt, but I thought I was okay. When my entire hand started to turn a blue-ish black color after like 20 minutes, I decided I better see about it. Went to urgent care still with my nasty looking hand that even still bleeding. When asked by the triage nurse, I said it was like a 6/10. She actually showed me the little chart, and was like are you sure? Yeah, wasn't like I got runover by a car or something.

Anyway, they must have thought it was worse than I did because I got in to see a doctor right away when there were like 30 people there. Pretty cool.

I have never even considered saying I was in 10/10 pain for anything and I hope to never feel that much pain. Ick.

WarmSocks said...

The big problem with the pain scale is that people seldom ask for your frame of reference.

My worst pain: regaining consciousness face-down in the water (perfect dead-man's float) after cracking my head open on a diving board.

The pain of childbirth is bad, but mitigated because 1) you know the cause, 2) you know there's a purpose, and 3) you know that it will end and everything will be good again. Unmedicated childbirth with my first two kids I'd put around 8-9. The other three times I'd say 7-8.

Gallstones, probably an 8 or 9. Laying on the floor unable to move, finally feeling enough better to start puking. Scarier than childbirth because you don't know what's wrong.

My MVA: 7-8 This was the only time someone has ever asked for a frame of reference - the EMT asked me if I've ever given birth; apparently that qualified me to know what pain is. Arriving at the hospital on a backboard in an ambulance gets you quick treatment, but it was the situation, not the pain scale, that was addressed.

I think the pain scale is worthless.

Slatsette said...

Hehehe... When asked my pain scale I say "Oh. It's a 7 or 8(tears streaming down my face, red and splotchy all over from pain). Where 10 is the kidney stones I had a couple years ago, and the childbirth I had two days after the kidney stones."

Helen said...

I hate the pain scale! There is absolutely no point, and I always wonder what a ten is - is it the worst pain ever, in the history of the world, or is it MY worst pain ever? (You've answered that question here, so thank you). In the past I've even occasionally understated my pain and said 1 or 2 for something that really seriously hurt, because I didn't want my doctor to think I was an idiot.

Stupid, stupid.

Ella said...

Ok, I'm definitely a newbie I guess because I have never seen a patient describe pain as a 10. In fact, I have always had patients underestimate their pain... maybe cause I'm a girl and they want to act tough? I don't know?

And I disagree that pain is subjective. Perception of pain might be subjective... but there is certainly a quantifiable difference between a compound fracture and a hangnail.... and these differences are extremely useful for docs to interpret whats going on.

I personally have always asked a patient to describe the worst pain they have ever felt... then I make that the 10 and ask them to describe their current pain with that frame of reference. Works great actually.

As for my pain story... I bled 2.2 units of blood into my peritoneal cavity... that's my 10. I'd describe it, but I actually passed out from pain.

Doctor D said...

Wow, it sounds like all of you have been through worse pain than Doctor D. The people who read this blog never cease to amaze me! You are some tough folks!

I should clarify that I don't think that the painscale is totally useless, just mostly useless. It is good that the scale allows patients to define their own pain and say what is more or less painful. This is helpful. It is just useless for doing "pain math" where we treat it as an objective number and make policy and treatment decisions based on these numbers.

Patient numbers vary widely. The fact that WarmSocks could call childbirth without anesthesia a 7 and a fibromyalgia patient could tell me that all day everyday she is a 10, show that these numbers just don't equate across patients.

I think I have a pretty good idea why. I'll most again on the painscale next week...

Anonymous said...

I wonder if one of the biggest challenges with classifying pain is the fact that there are 2 types, transitory & chronic. Transitory pain can be excruciatingly awful, such as a broken bone, or a migraine, or childbirth... but it goes away. A few days of medication, and there is a resolution. It is clear that it can be "fixed" by drugs, breathing techniques, meditation or distraction techniques.

Chronic pain is a trickier beast. If you have a rock in your shoe, it is not a pain worth metioning. It is a 1 maybe a 2. The assumption is that the rock can be shaken loose, that the foot will soon be comfortable again, since it is a small pain. It isn’t much, really, just a little thing. An aggravation in your shoe.

But it isn't a little thing at all.

At first, it is an annoyance, really. An aggravation, if you tend towards anger. But after a while, the pain dominates your thinking. All you can think about is how long until I can take the pebble out of my shoe.

You start trying to walk differently, trying to avoid the thing that causes pain, but then other parts of you start to ache because you aren’t using your body the way it is supposed to be used. So you go back to walking normally, pretending the pain doesn’t exist. You walk slower. When that doesn’t work, you walk faster.

You buy better shoes. You buy a cane. You take Tylenol, and Advil, but the pebble is still there.

You try hopping. You try crawling. Still a pebble.

Mind over matter, you tell yourself. Meditation. Breathing. Hypnosis. And a pebble, still in your shoe.

“You don’t have acute pain, you don’t need strong drugs,” the doctor tells you, and you can see him thinking don’t you know there are people who are in serious pain out there? Stop whining.

“What’s the matter with you?” your boss asks, “Your mistakes are costing me money!” and you want to scream can’t you see the pebble? I can barely think past the constant background noise of the pebble! How am I supposed to work as well as I used to?

But of course no one else can see the pebble. Most don’t even believe it is there, not all the time. It couldn’t possibly be. Pain is a transient thing, after all. No one could REALLY be in pain ALL the time.

Those who do believe don’t understand why you don’t just take a Tylenol and make it go away, like they do with a headache. Pain is conquerable, after all. We have the technology, they say.

Because the alternative is too scary to contemplate: What if the pain never goes away? What if I’ll always have a pebble?

Chronic pain doesn't have to be a strong pain to have a strong effect on your quality of life. Even a chronic pain of 2 or 3 should be taken as seriously as a chronic pain of 7 or 8, because your life changes in so many ways.

And it doesn't just affect the person with the pain. My kids are 6 & 8 and my daughter has never known me when I wasn’t in pain, and my son was too young to remember it.

My pain affects their life every day, and I hate that. I find it so hard to live with that knowledge.

It doesn't have to be a 10 on the pain scale to be a 10 on the "negatively affects quality of life" scale. If a doctor can give me back my quality of life by medicating my pain, even if my pain isn't a 5 or higher, then why on earth would they choose to not medicate it? Why would one force my kids to make sacrifices in the richness of their life experiences just because one thinks my pain isn't strong enough to warrant treating with anything more than over the counter meds? If OTC meds were working for me, I wouldn't be in the doctor's office saying I'm in pain and please help me do something about it. I'd be out there doing fun stuff with my kids and enjoying my life to the fullest. Yet, being young, and female, and diagnosed with fibromyalgia among other things, I find it next to impossible to get adequate pain control, and our lives are the poorer for it.

Doctor D said...

Excellent point Anonymous. The numerically scaling pain misses the reason the body uses pain! More on that in my upcoming painscale post next week...

It was not at all my intention to imply that chronic pain isn't as serious as acute pain. Chronic pain very real, but is much more difficult to treat.

Particularly with Fibromyalgia there isn't any data showing that narcotics help and some indications that they may cause more harm than good. I have often turned down narcotics for Fibromyalgia pains--not because I don't believe they hurt (I have friends with fibro, I know how miserable it is) but because I suspect those medications could harm them.

RSDS said...

The way that I use the pain scale, is that 10 is the worst pain that I can imagine. I have NEVER had a level 10 pain. I believe that some of the POWs in Viet Nam probably reached that level of pain during their interrogations in torture cells.

I use pain level 9 to describe the worst pains that I have ever experienced. I have had level 9 (or high eights, very near level 9) pain, maybe half a dozen times in 50+ years of life.

Over thirty years ago (before use of the pain scale), as a young adult in the millitary, I had severe peritonsillar abscesses (quinsy), necessitateing first an I&D, and then, when that proved ineffective, a tonsillectomy a month later. To control the pain afterwards, I was perscribed Tylenol elixir since I am unable to swallow pills. This was during the time when Tylenol liquid still contained about 8% alcohol. When the alcohol in it hit the raw areas, where my tonsills had been, the referred pain in my ears was sufficient to cause my knees to buckle, and set me to writhing uncontrolably on my barracks room floor. Fortunately my room door was closed, so no one could see me, but I was embarassed anyway. I had never really completely believed in writhing pain, until it happened to me. It was not sufficient to send me to sick-call, since there was nothing to be done for it anyway; except to wait for the Tylenol to take effect.

The statement "I can't stand this pain", has some basis in fact. I have found, that if the pain is severe enough, there is a point at which I literaly, not just figuratively, can not stand, or can only do so through exerting extreme will power. Knee buckling is one of the hallmarks of level 9 pain.

My most recent experience of knee buckling, due to pain, occured about 2¼ years ago. I fractured my distal radius when I took a misstep on rough ground in my yard and fell over. After I got x-rayed at the local ED a young girl there (she looked like she was barely out of high school, if that) applied a spica thumb-splint. She had never done one before, in fact, the person ahead of me got the first cast that she had ever applied. No one supervised her or showed her how to do it properly. She applied it much too tight, so that there was no room for the swelling. My exposed fingers swelled up like sausages. After several days, the base of my thumb felt like it was being jabbed repeatedly with a red-hot poker. One day at the grocery store the pain in my left thumb was so bad that my knees started to bend and not support me. I still managed to stagger home by using great will power. At home, I took a dose of generic for Vicoden liquid. A week later, when the spica thumb-splint was removed at a different hospital, to be replaced by a cast, it was discovered that I had developed a pressure ulcer under the splint. I did not get a good look at it, but suspect that it went clear to the bone. This led to the complication of Reflex Sympathetic Dystrophy Syndrome.

Extreme pain without knee buckling, is level 8. I have been there with migraines. My current migraine, though, is at about a 5.5 level.

Cervical Spondylosis keeps me at a level 2 or 3 most of the time, when I am not at a higher pain level.

Level 1 is pain free, which is not very often.

My personal scale, also, includes a level 0; which is a sense of wellness beyond just being pain free. It is excedingly rare, and usually of very short duration, hours at the longest, but more often less.

kitrona said...

Yes, anonymous, yes! "It doesn't have to be a 10 on the pain scale to be a 10 on the "negatively affects quality of life" scale."

I wish more doctors would realize this. I hate the pain scale; my brain doesn't work that way, so I have to think about it and it feels very artificial. I suspect doctors pick up on that and think I'm lying, because it doesn't seem to matter what number I say, I never get painkillers that take away all the pain; at best, the painkillers take the edge off, and I want more than that, I want to be able to live better.

Sarah G said...

Worst pains: dry sockets and ear infections. Both can go to 9s. Getting Novacaine shots in the top front of the mouth might be my 10, since it makes my eyes water, limbs shake, and I sometimes even scream. Sorry for the dentist-phobes reading this.

That 'pebble' business, though, is the type of pain that really kills me. At least the severe pain goes away. That chronic stuff can mess your life up.

Sassenach said...

I agree that pain scales only work in comparison to the personal experience of the patient, skewed by their perception of how that rating will affect their care. It's clearly a pro forma question, like asking for your name, that has to be asked before getting to the real business of diagnosis.

My husband had lumbar fusion surgery in July; he woke up screaming in the recovery room and screamed -- full throated, uncontrollable, wake up the other patients type screaming -- for the next hour. They gave him combinations of pain killers that I did not think were possible and managed to get him quiet enough to send to his room, to agonize for three days. I'd say that was a 10. In comparison, I have to knock the acute part of childbirth back down to a 7.

Comparing the acute 10 to the months of chronic pain at a 5 that he lived with is tough. It's like asking if you want the train to hit you all at once or in slow motion. And I'm just a bystander.

Anonymous said...

i am an orthopaedic surgeon and hear "10" from people in the office with a pain they've had for a month. can't really trust this number.
had a laparoscopic surgery and had intermittent freakin' severe pain that would quickly subside. most of the time, pain of 2, occaisional 8, Toradol helped, i walked a lot and recovered quickly.
put up with pain as best you can, don't ignore pain that persists, doctor want to help you but it helps if you're honest

Anonymous said...

I find the pain scale confusing. I am now a chronic pain sufferer, which I think distorts my pain perception. I am always in pain, it just how much pain I am in at this time during the day. I have never had a 10, but I have come close to it with an 8.

There are meausable attributes to support a high pain level. They include blood pressure (higher), extremity temperature (cold) and pupil size (larger).

I have had a gall bladder attack that I would rate as a 10. It took my breathe away and stopped me in my tracks. It was far more painful than any labor pain I ever had. I was lucky that it only lasted a few minutes.

Diane U. said...

Yeah, it's the chronic, day in and day out, 5-9 level fibro pain that will kill you. I can't remember not being in pain but I circled a day in June of 2003 when I was painless. I grade my pain by which of the 1-5 star sudoku puzzles I can do. Too much pain to do puzzles, read or watch TV is 8+, 9 means I am thinking of the easiest way to kill myself and 10 means I would kill myself if I could get out of bed. A beer and 1/2 works as good as anything when the pain starts to wear me down. Don't drink often as it's the family disease.

Anonymous said...

This is a great blog entry on the pain scale. I had to share!

Doctor D said...

Excellent post. Hyperbole's pain scale chart is far superior to the one we currently use. I suggest we get it printed out and placed in every hospital and clinic in the country.

Anonymous said...

It's a problem whenever you try to objectify a subjective "anything". My pain, your pain. The only way I could do a comparative study on that is, really, if we could just switch bodies for a day or so...

But the suits want things in black and white, they want numbers, because without those numbers, they can't spin what they need to spin as far as policy; etc.....

Maybe people have a wide variation in the sensitivity of their nerves, maybe the same injury feels completely different from one person to another. One thing that erks me, though, is when it becomes an "I'm tougher than you" contest. I want to say, "So maybe the nerves in your toes are just dead, that's why you can suck it up and keep truckin in that triathlon you're in the middle of...".

Anonymous said...

Why do Doctors seem to have such difficulty with trusting their patients?
Everyone is vulnerable to pain and illness, it's part of being human. We all get sick and we all feel pain throughout our life
My 10 was sitting at my Dads bedside watching him take his last breath, worse than any physical pain I have ever experienced
If his Dr had taken his pain more seriously, maybe he'd still be here today

Anonymous said...

Well, It's good to know that along with many other things they don't take seriously,dummy doctors don't take a patient's assesment of pain seriously either? If breathing or moving causes sharp pain throughout the body, that's a ten,but they will give you the equivalent of an extra strength asprin if you don't have the right insurance,if you have gov. insurance, they don't like to give you any kind of real care because states are slow to pay. people who pay for their insurance get real care, people who don't get pushed out

eulogos said...

I am glad to hear a doctor say this. I always thought the pain scale made no sense. "Where 10 is the worst pain you can imagine..." and then the person sitting there calmly without a grimace tells you her pain is a 10. Poor imagination? Sometimes they say 10 is like being tortured. Sometimes they compare it to childbirth. I have had 7 of my 9 kids with absolutely no medication, and while I had some rough contractions, there is no way this was anything like being tortured. The pain after my C section with baby #1 was pretty bad right after the surgery, whenever my demerol wore off; in my opinion worse than labor. If I had had to go through the 9 hours that lasted without the demerol I might call that an 8. I have had a lot of dental abscesses, and think they are worse than labor (different, you can tell they indicate dysfunction, while you can always feel the purposefullness of labor.) -maybe a 7/8. I think there must be not two steps but a hundred between that sort of pain and torture. Maybe those women whose doctors went right on with their C sections even though their epidurals weren't working (have heard a number of these stories) could give us a little better understanding of where 10 is. But I think basically no one knows where ten is because such pain is unimaginable-it cannot be represented in the mind, it always exceeds what we can imagine. Thank God, I have never felt that degree of pain. And if we can't know where the top is, what sense does the scale make? The only way it can be used is to measure for one patient over a period of time whether his pain is getting better or worse. If the patient came in saying the pain was a 10, and after the medication he says it is a 7, you know you accomplished something, even if you suspect from the patient's demeanor that more reasonable numbers would be 6 and 3.

And what is this nonsense about using the pain scale in labor and delivery? When you should be trying to get the woman to think about contractions as something doing the work of getting her baby out, trying to get her not to fight them, helping her walk, or get into the shower, pressing on her back, whatever she needs, you are instead asking her, "Think hard, put a number on how bad this pain is. " I can't think of a better way of increasing the perception of pain.

Susan Peterson

Anonymous said...

Level 10! I gave birth naturally no pain relief at all. I almost passed our during contractions and I cried and begged the nurse to take my baby out cuz I thought I was going to die. The cramping was intense the birth was painful and it burnt when she was delivered. But I wouldn't change a thing. She is my greatest joy. A level 10 pain that was worth every second of agony.

Veronica Lodge said...

I've been through quite a lot of painful injuries from grand mal seizures, only knowing it hurts after awakening, not the actual incident. My worst painful incidents:

1) Recurrent right-shoulder dislocations
2) Childbirth x2 (2nd epidural only worked on my right side)
3) Migraines (the REAL migraines, seemingly aggravated by aspartame-containing consumables...that are indescribable as a "migraine" bc you can't think, talk or stand up)
4) Post-surgery on broken ankle
5) All shots in toes, ankle (anesthetic, steroid)
6) Tongue bites (once literally bitten half-across it)

I'm sure there are a few more, but those stand out. I would rate my #1 as a 9. I couldn't move & was literally crying out loud in the ER until they got me in the treatment area & knocked me out to put it back in the socket.

A 10 may be the worst ever I've felt, but I wouldn't be able to call it a 10 if I wanted to. The pain would be so horrendous, there wouldn't be the ability to even speak.

In other words, I 100% agree with the author. If you say 10, you're most likely full of it. I also found the reply regarding chronic pain with the pebble example, EXTREMELY correct.

The pain scale is crap, although I truly think it's a way of weeding out the haves & have-nots, of pain that is. Too many seekers have diluted the system for those of us with honest, physical pain.

Good article. Thank you.

Anonymous said...

I must also agree with DoctorD. In 15 years of practice, I've perhaps seen 2 dozen people who, in my opinion, and likely anyone else who visualized them, would categorize their pain as a 10/10. Skeptical/malingerer, are words that come to mind. I've found that the QVAS forms work fairly well, however I generally rely upon the QVAS in conjunction with disability forms such as Roland Morris, NDI, Headache, TMD, DASH, etc.

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