I am not advising that people should put themselves in potential harms way (e.g. administering to themselves a chemotherapeutic drug without indications for use) but I think that when some bodily or emotional discomfort arises in ones otherwise healthy life that the first thought should not be to jump to some narcotic or tranquilizer for relief. Or, in the case of physicians, I think that if a physician becomes ill, the doctor should not insist on or agree to VIP ("very important person") treatment by the medical care providers but instead experience the common treatments that ordinary patients receive. ..Maurice.

Maxwell, therefore my original questions "Should every human taste some individual pain and suffering so as to gain a better perspective of their own good life? If so, what is the role of the physician in supporting this process?" really should be subjected to a scientific/statistical study with regard to the value or benefit of such a "taste" to the healthy and to what extent physicians should be complicit. I haven't done any investigation as to whether any work has been done in this area of psychology/sociology/spirituality. Are you aware of any? ..Maurice.

Payne Hertz, as I responded to your comment on my Bioethics Discussion Blog
( http://bioethicsdiscussion.blogspot.com/2010/09/taste-of-pain-and-suffering-and-role-of.html#comments ) dealing with the same question as here on Medpedia, I wrote:

"while your talking to the patient does provide you with one side of the story between the patient and the doctor, you must also talk with the doctor to make a fair and balanced interpretation of the actions which had occurred within that relationship.

You wrote 'If I told you that I sincerely doubt a husband would ever abuse his wife, because he nothing to gain and everything to lose, including the trust of his wife, would you find that argument convincing?'

Do you really think that the relationship between a physician and a patient is the same as that of a husband and a wife? Is the professional oath, the professional standards to maintain a physician license and the laws regulating physician behavior and actions and the potential of a malpractice action by the patient are the same as a husband and wife simply taking marriage vows? Notwithstanding the question I posed initially to this thread, I still doubt that most physicians would allow their patients to suffer simply to demonstrate some power of the physician or to teach their patient a lesson." ..Maurice.

I would assume that Payne Hertz is not intending to paint every doctor with the same troubled brush. Certainly, there are some doctors who are humanistic, non-sociopathic, open-minded with regard to the patient's complaint of pain and not working to make a buck at the expense of the patient's health and well being. Maybe there are not enough like that to satisfy Payne Hertz but I doubt there is any statistics that are not generalized simply from the general public. But certainly those behaviors which Payne Hertz is writing about should certainly be kept in mind as we teach (and as I teach) our medical students and as we have medical standards set.

For example, the identification of a 5th vital sign, current pain on a scale of intensity, has been too long in coming. I think it only has been applied so late because the symptom of pain has been for generations misunderstood and under-considered and under-treated. In recent years, along with the 5th vital sign there has been the introduction of hospice and more recently the concept and specialty of palliative care, the latter irrespective of whether or not the patient is terminally ill. But it takes the education of physicians to cone down on the symptom of pain such as with the 12 hour California course requirement. I and my fellow instructors who teach history taking and physical examination to first and second year medical students are trying to do our part in emphasizing to the students, for example, that the 5th vital sign is not a number representing pain which the patient has experienced sometime in their history of the present illness but should be representing the pain that the patient is experiencing NOW. We teach the significance is the NOW and that means that the student understands to notify the nurses who are currently caring for the patient to provide NOW treatment for the pain.

But after the second year, the students leave our teaching curriculum and supervision and go into a ward environment that is rushed and busy with frustrating demands and being supervised by physicians who provide a "hidden curriculum" which may include less in the way of need for treatment of pain NOW and more concern about the diagnosis and other matters.

I appreciate Payne Hertz providing us with the possible mechanisms which lead to behaviors of physicians either denying or inadequately treating patient pain. I want to express my disagreement, though, that all physicians must be or can be painted with the same unhumanistic brush. ..Maurice.

Maurice,


In one of his lecture which I attended, the Nobelist Eric R. Kandel said that pain was associated with memory, to teach us a lesson and not to forget that experience. The results of a trial in advanced osteoarthritis patients with a new analgesic monoclonal antibody Tanezumab from Pfizer which blocks nerve growth factor in advanced osteoarthritis patients, show that without pain, patients damaged their knees by putting more stress. Thus having some pain may be a protective factor?


NEJM Paper : Lane, NE. Schnitzer, TJ. Birbara, CA., Mokhtarani, M. Shelton, DL. Smith, MD. Brown, MT. Tanezumab for the Treatment of Pain from Osteoarthritis of the Knee.
September 29, 2010 (10.1056/NEJMoa0901510)

Wood, JN. Nerve Growth Factor and Pain.September 29, 2010 (10.1056/NEJMe1004416)

Treatment with tanezumab was associated with significant reduction of joint pain and improvements in functions. The most common drug related ADRs were headache, upper respiratory infections and paresthesia. Tanezumab seems to be free from traditional analgesic side effects like ulcers, GI toxicity, hepatotoxicity, increased cardiovascular risk and provides sustained pain relief for upto 2 months with a single injection. Significant pain reduction may have contributed to the overuse of joints in some patients leading to accelerated knee replacement. Thus Chronic pain may have a protective role in joint protection? As most of the advanced OA patients are likely to progress to joint replacement surgery, the paradox of a drug providing pain relief and accelerated OA and knee replacement surgery requires open debate to define a way forward in the best interests of patients.

It is in the best interest of patients to live pain free and have the inevitable knee/hip replacement surgery done earlier. It seems that tanezumab is not causing the accelerated joint destruction but the pain free patients putting more stress on joints.

http://knol.google.com/k/krishan-maggon/tanezumab-pfizer-review-chronic-pain/3fy5eowy8suq3/121#

Kim,

Kim once again your insight and experience brings new perspectives.

Kandle in his Nobel lecture described the importance of pain in human evolution. It was described as a defensive and survival mechanism. We all have different pain perception and threshold for different stimuli. Some persons can walk on burning charcoal without any pain, others have chronic pain for a variety of conditions. Latest research on nerve growth factor blockers in clinical testing is raising expectations that we can reduce, eliminate or overcome chronic pain. The NGF drugs in R&D offer us pain control without opioid addiction or GI, renal. cardiac or hepatic toxicity of current analgesics. As reported with the Tanezumab NEJM study, humans without pain take greater risks and cause unwanted self damage. So it is better to develop drugs which aim at reducing the pain by say 90-95% rather than 100%.

So the point Maurice was making is right, the pain free world is not going to be a new heaven but more risky and accident prone.