How do you rate your pain on a scale of one to ten? The question is such a commonplace that when I complain about it to friends, they shrug and say, “They all ask that.” Why did this seemingly innocuous question annoy me?
One hurdle I had to surmount before I could be released from my hospital stay last March was a physical therapist appraisal. Two arrived together, and we got off to a bad start because almost the first words one of them uttered were the dreaded, “How do you rate your pain on a scale of one to ten?”
Nurses had asked the question each time I sought more Tylenol, which they administered through the intravenous tube hooked into my left wrist. I’d found that Tylenol took off some of the edge of the pain I was experiencing. I’d thought there were in-between pain killers, but not for someone in my condition. For me, the next leg-up was morphine, which I declined because I worried it would play games with my head. My decision suggests, correctly, that the pain I had was far from unbearable.
But the problem remains: How do we measure our own pain? I am not brave. When I get a headache, stomach pain or similar internal ailment, I retreat from the world. The more frequent pain I experience is arthritis-related. I can walk only a few blocks before my feet hurt and they stop cooperating, forcing me to seek rest. That pain merges with frustration over my restricted mobility.
Pain is like a fluid: What it does and how it feels depends on what it’s mixed with. If it prevents you from doing an activity, it matters. If it prevents you from earning a living, it’s serious. If it prevents you from being light-hearted, it’s isolating.
In short, the experience of pain is very much about context. In the hospital, circumstances limited me in several ways. I was attached by the IV tube to a tall wheeled machine that had things coming out of it in all directions. My brother-in-law Ralph, tethered to one a few years ago, calls them mobile coatracks. I couldn’t go anywhere without having to pull it along with me, and I had to ensure I didn’t trip on its floor-level wires. Also, I was in a post-anesthesia fog that focused me on discomfort. Add to that my aversion to hospitals, despite the caring of the nursing staff and doctors I experienced this time around. My focus was on getting home and catching up on the sleep of which blood pressure checkups every three hours deprived me.
In that environment, a one-to-ten pain scale was especially absurd. True, when the nurses asked the question, they were getting me to compare how I felt before and after the infusion of Tylenol. I settled on “5” for before and “3” for after. Completely arbitrary, but my answers satisfied the nurses’ requirements and earned me that Tylenol infusion every eight hours.
By contrast, I couldn’t fathom what answer would satisfy the physical therapists. I sensed they were asking it as if reading from a script, with no understanding that pain has context. Had I been at home, my experience of that pain would probably have been less. Had I not been sleep-deprived, it might well have been marginal. Had I not been restricted by the mobile coatrack, the resulting freedom might have left me more or less oblivious to the pain. Indeed, when the IV was at last removed and I was released from that ball and chain, I walked around with a blissful sense of freedom that, temporarily at least, overrode all discomfort.
I didn’t think through all those explanations at the time. Instead, I was tempted to tell the physical therapists something along the following lines. Okay, “ten” on the pain scale would be a reasonable rating for someone being burned at the stake. Applying electrodes to the genitals probably also qualifies. Other tortures come to mind, down to having your fingernails and toenails pulled out, which in that context might rate a “one.”
Once you recognize there are degrees of pain that make you beg for a quick death, all lesser pain fades into insignificance, rendering a numerical pain scale meaningless. In that light, the only genuine number I could assign to my pain was “zero.”
But getting discharged from the hospital required me to cooperate in this game of illusions. I said to the physical therapists, “I don’t know. Call it ‘5,’ or ‘6,’ or ‘7,’ or ‘ten.’ Anything you like.” Sitting next to me, my wife Laura whispered that if I kept going on like that, they’d only see me as a crotchety old codger.
After they left, a nurse appeared and announced my discharge had been approved. To their credit, the physical therapists hadn’t declared this crochety old codger unfit for life on the outside. (Or, if they had, they’d been overruled.)
The physical therapists were kind. They maintained patience in the face of my unappeased irritation. To use that damning faint praise, they meant well. I infer that someone deep in the recesses of the hospital’s administration requires staff at the nursing and physical therapy level to pester patients with this meaningless scale, even though it corrupts the hospital’s database with a phony statistic.
Aside from the fancifulness of pain scale numbers, they’re also subjective. I sometimes wonder how store employee who must stand all day tolerate sore feet. Is their pain less debilitating than mine, or am I just a spineless wussbag?
There are a variety of pain scales based on subjective experience. One originated at Montreal’s McGill University, where I spent a fondly-remembered summer session forty-seven years ago, just around the time this scale was devised. Initially, I was sorry to learn that McGill had inflicted it on the medical world, but it turns out their system was more coherent than the stripped-down question put to me during my hospital stay. For one thing, its questions focus on context. Critics who have since pointed to its flaws reinforce my conviction that context matters.
When numbers work to improve effectiveness and efficiency, great. When they don’t, abandon them because a scale that pretends to quantify something but actually measures nothing leaves a patient feeling like an empty statistic. Reason enough for the “one-to-ten” question to annoy me. But there’s more.
A subjective pain scale negates our capacity for empathy. If all you think about is yourself, a scale of one-to-ten might make sense. You summon to mind the worst pain you ever endured and assign it “ten.” As for “one,” you might think of the time you removed a Band-Aid from a hairy forearm. But for anyone with an ounce of awareness that we aren’t alone on this earth, such pain is insignificant, gone in minutes with no lasting trauma. Real pain is so overwhelming that in giving tolerable pain a number, I feel I dishonor people braver than I.
Another consideration is that we experience pain not just physically, but also emotionally and spiritually—psychically. The two kinds of pain can ameliorate or accentuate each other. Physical pain can be lessened when we’re feeling good about ourselves. But it can be a cruelly ironic outlet when we’re in despair. Stuck in an isolation cell, prisoners may bang their heads against a wall in order to give their psychic pain physical manifestation.
While drafting this essay, John Lennon’s line, “God is a concept by which we measure our pain,” has been going around my head. The song, “God,” from his first solo album, suggests that pain can cause us to turn to that unseen, unknowable entity we call God, or Allah, or Buddha, to take us outside the confines of our bodies and beyond pain. The song denies the existence of God, by whatever name, but there is something sacred about the experience of pain. It can give us the gift of empathy. If a friend is having a procedure I’ve gone through myself, I can articulate something of what they’re suffering. The difference, and it’s a big difference, is that my pain was in the past. I can no longer “feel” what that person is going through.
Empathy’s limits must be respected. When someone says, “What I’m going through is nothing like you are,” we’re claiming knowledge we can’t possibly have about another. For one thing, our backgrounds might help us manage certain kinds of pain for which others have no such defenses. I’d be upset if while walking through a park, I got hit by a thrown baseball, but baseball players accept it as part of the game. Indeed, there are notable players who appear to welcome being hit by a pitch in order to get a free pass to first base.
In addition, pain can motivate us to hurt others. Much violent crime is committed by people who endured physical and other abuse as children.
Nevertheless, pain can generate some of the emotional tissue that connects people and leads us to do right by our fellow human beings. If I owned a supermarket, my experience of foot pain would surely motivate me to give employees with a similar affliction opportunities for periodic relief.
I’m tempted to say that for this reason, I’m glad of my experiences of pain. In reality, hardly anyone would willingly seek out pain. Those prisoners in isolation cells seek one kind of pain only in order to alleviate another. Something similar might be said of self-harmers and masochists.
But pain, of one kind and to one degree or another, is universal. If it helps us feel something for our fellow human beings, it does some good.
How much good on a scale of one-to-ten? Oh, give me a break.
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