Summer 2010 - The British Pain Society

PROFESSIONAL PERSPECTIVES
Teaching your
grandmother to suck eggs:
the pain history (101)
Professor Henry McQuay
Oxford
Teaching your grandmother to
suck eggs means that a person
is giving advice to someone else
about a subject that they already
know about (and probably more
than the first person). Wikipedia
suggests the origin was a Punch
cartoon in the 1890s; "You see,
Grandmama, before you extract
the contents of this bird's egg
by suction, you must make an
incision at one extremity, and a
corresponding orifice at the other."
Grandmama's response is to the
effect, "Dearie me! And we used
to just make a hole at each end."
Which sums up my trepidation
at writing about the pain history.
There seems to me no harm and
a lot of potential good in revisiting
the basics. If any of these are
useful to you that’s terrific - if
there are better questions then
that would be a bonus.
How much of the useful
information in a new patient
pain consultation comes from
the history? Most of the time we
work from the patient’s story and
the referral letter, with no other
records available. This may be an
advantage, because you have to
listen. If you can’t get an accurate
story, because of language,
special needs, deafness or speech
difficulties, then you will really
struggle, which just goes to show
how important is the history.
The questions you ask and the
way you ask them change over
time. You accrue questions you’ve
heard your colleagues use. You
drop things which don’t help,
and grow those which help you
distinguish. So why focus precious
ink and paper on this topic, taking
a pain history? Because of the
way in which we are increasingly
required to work, paid bum-onseat
with minimal overlap with
colleagues’ sessions and hence
less interaction and conversation.
This means that we have less of a
professional memory on which to
draw, with the threat that you ask
the same questions thirty years on
as you did at the beginning. My
questions draw heavily on those
instilled by our mentor John Lloyd,
on my colleagues Chris Glynn and
Tim Jack, and on the consultants
from different specialties with
whom we did joint clinics. Debt
duly acknowledged.
No matter how long you’ve been
doing this job you can still have
the consultation which runs away
from you. Some of my worst
have been with doctors and their
families, where the plunge into
the details of the most recent
intervention for their problem, or
the quest for the next, derails the
consultation, and gives you the
salutary warning that the structure
of the history is really important.
A blob of drug history, adverse
effects and previous surgeries
can otherwise leave you fifteen
minutes in and none the wiser.
The structure of the history is so
crucial, and often the examination
so peripheral, that we gently have
to steer it back.
Some logistic stuff first
How should one arrange the
room?
This always going to be tricky with
the need for wheelchair access,
but should we be learning from
others about desk and chair
positions? Certainly at appraiser
training it was apparent that
there is a wealth of sociological
information on this which I'd
never heard before.
Who else is present makes a
difference
The necessity for translation and
the presence of translators which
I alluded to above can create
difficulties. With sons or daughters
translating I'm sometimes unsure
of whose agenda I'm dealing
with. With outsiders translating
a different set of queries arise.
One Chinese patient crept back in
when the translator left and said
“I no come with her anymore.
She no tell the truth.” With patient
advocates the troubles may be
different - hostile anti-doctor
feelings can produce a runaway
consultation. A third party in the
room, a student or a trainee, can
alter the conversation, with the
patient directing remarks to the
third party; for me this has been
more of an issue with followups
than with new consultations,
perhaps because the dynamics
change from the original
one-on-one to a more diffuse
arrangement.
Going out to collect the
patient
John Lloyd used to watch the
patients leaving the clinic from the
window in his office. By walking
with them from the waiting room
to the office you can garner the
same feel for disabilities. Always
invite the accompanying person
(but beware if it is simply the
chauffeur), and beware too asking
the older male (or female) patient
if they’d like their daughter (son)
to come too (yes I've done it).
Where is the pain?
Asking the patient to colour in
which bit(s) hurt on a body
sketch provides a baseline. The
affected area can shrink over
time (c.f. postherpetic neuralgia),
so the serial chart can provide
some reassurance that things are
improving. In our old notes it’s
common to see Chris Glynn’s
turquoise ink just circling the entire
body - the original ‘widespread’
pain graphic. Important too is to
remember the corollary “Where
doesn’t hurt?”
If I've not asked it anywhere else
then “Is it numb in the affected
area?” should be included,
and the necessary “Does it go
anywhere else?” If the pain does
go somewhere else then what
provokes it to move?
Another way of tracking change
over time is to photograph the
affected parts. Data protection
gets in the way, but getting the
patient to photograph the area on
their mobile phone is an informal
work-around.
What sort of pain is it?
Everybody struggles to describe
their pain. Classically we are taught
to ascribe burning and shooting
descriptors to neuropathic rather
than nociceptive pain, and that’s
probably fair, but neither 100%
specific nor 100% sensitive.
It‘s common for there to be
background pain (which may be
dull) and flare (which may be
sharp) [see below on background
and flare], so one adjective is
unlikely to suffice. Some feel for
intensity is helpful too - “on a
scale of 0 to 10 it’s a 12”. Again
these numbers can be used in
subsequent appointments to
monitor progress.
If it’s not already clear by this
stage in the history then once
again a primary focus of these
questions is to help you decide
if the pain is nociceptive or
neuropathic, because this is such a
huge distinction when it comes to
treatment, one pharmacopeia for
one and one for the other (well
nearly).
PAI N N E W S S U M M E R 2010 45