14 July 2009

Confusing 'ameliorating' with 'obliterating'

I've seen several authors make this point, but in an email to me, reader SV put it in a very nice way:
"We physicians are called upon to "ameliorate" pain, which often is considered synonymous with "obliterating" pain."

This is a very important flip-side to the incredible advances that have been made in pain medicine and public expectations about treatment.

The way 'ameliorate' and 'obliterate' have gotten run together in the public's (and even in many physicians') expectations has a significant downside: In addition to being annoying and disappointing to all involved, there's a case to be made that this sometimes (often?) leads to worse treatment outcomes.

For example, if a patient expects complete relief from her pain, partial relief might leave her depressed, frustrated, and resigned. Attitudes like those can be some of the biggest factors in determining how bad a pain is.* This is especially the case with many chronic pain conditions.

Of course, we've come a long way from seeing pain as an inevitable concomitant of disease and treatment, and thus not a direct concern for the physician.

And, we've to a large degree gotten over the invidious tendency to heap moral condemnation upon those who don't suffer in silence, and to see all pains, including medical pains, as deserved (the words 'pain' and 'punishment' both have their roots in 'poena').

On that note, this story in the Boston Globe is important: The Day Pain Died: What Really Happened During the Most Famous Moment in Boston Medicine

So, I suppose its worth keeping some perspective on how much attitudes and expectations have come in a very short amount of time. Still, there's still a long way left to go.


*As always: These attitudes are not merely responses to the pain, they can become part of the pain itself.

It is a serious conceptual mistake to think of a patient who feels helpless and resigned in the face of her pain as (necessarily) being in two bad states:
(a) Her pain is bad to degree x
(b) Feeling helpless and resigned is bad to degree y.

Rather, these feelings are themselves parts of the pain. Their treatment is just as much a treatment of the pain itself as is the administration of morphine.