I’ve been thinking a lot about clinical reasoning recently. There’s been a lot written about clinical reasoning, but not as often applied to pain management, which is a shame. One definition of clinical reasoning is that it is a “complex process that uses cognition, metacognition, and discipline-specific knowledge to gather and analyse patient information, evaluate its significance, and weigh alternative actions” (Simmons, 2009). It’s often used synonymously with with decision-making and clinical judgment. It’s not diagnosis alone, although it includes diagnostic reasoning, and it includes decisions made how to assemble the information collected into a form that can be used to make decisions. Got that?!
OK, so why do I think that managing pain is an experiment? Is it just trial and error?
Let me unpack some of this for you.
For something to be an experiment, we need to “perform a series of actions and carefully observe their effects in order to learn about something”, according to the Merriam Dictionary. It usually involves manipulating one or more variables, with the intention of influencing another dependent variable. There are often a number of unknowns, and other variables that need to be controlled to ensure that only the one variable is influencing the outcome. Of course, in people and in the real world, this is nigh on impossible. But the principles apply.
In chronic pain management, there are many factors involved – this is why we often work in interdisciplinary teams, because no single discipline can possibly attend to all the factors that may be present. Some of the variables are known. We know, for instance, that women are more often affected by chronic pain than men. Some of these are less well-known: we may not realise that some clinicians treat women with chronic pain differently from men with the same problems (Hirsh, Hollingshead, Bair, Matthias, Wu & Kroenke, 2013).
We arrive at a problem with ideas in our heads based on our training, our knowledge base, recent patients we’ve seen, new information from journals or conferences or blogs, striking experiences such as a person who reacted badly to a treatment, or someone who responded really well. We also bring our ideas of what matters in a clinical presentation in the form of a model. Models are simply representations of the relationships between variables thought to be important. We all carry them, whether we’re aware of them or not. This means that some variables are therefore thought to be less important, and are perhaps disregarded.
There are some certainties when working in acute pain management: we know, for example, that if we remove nociceptive or inflammatory input as soon as possible, most of the experience of pain reduces, leaving the person with memories and beliefs about what should happen if they ever have that kind of pain again. So, if a bone is broken, we know that if it’s aligned and stabilised, most of the pain disappears. If there’s an infection in a finger, we remove the splinter, get rid of the pus and the finger heals with pain subsiding. And person experiencing pain processes what has happened and assembles information about what should go on if a similar event happens again. People around that person also understand basically what is going on, and what to expect. And their idea of what they should do is also developed.
But chronic pain is different. Chronic pain doesn’t follow the rules of acute pain, and although there have been some strides forward in understanding it, we don’t have a simple mechanism-based approach to get rid of the pain and allow the person to get on with life, in most instances.
Instead we have a person who is experiencing something mysterious, something that doesn’t make sense, and doesn’t follow the rules. Additional variables become far more important than they are in acute pain, while some variables that are vital in acute pain become less significant.
What’s different and why does it matter?
Apart from the less clear-cut underlying neurobiological mechanisms involved in the pain experience, chronic pain affects people as they engage in normal occupation (see this wikipedia entry for more information about why occupation is important). Occupation, or the normal daily activities we do within the context of our lives, informs and is informed by our sense of self identity. When we can’t do the things we need or want to do in daily life, we become aware of losing something important: our sense of self. People experiencing chronic pain encounter challenges and threats to self identity as they do the normal things of daily life. They may find it hard to sit to read or watch TV, they find it hard to clean their teeth, they may have trouble attending work, they can have difficulty sleeping, or going out socially – all those things that people do that reinforce a sense of self and purpose in life.
While “taking the pain away” may help a person return to many of their usual occupations, it fails to address the underlying problem of loss of identity. Can this person trust that this threat to identity has really gone? How has this person changed as a result of this experience? What meaning has this person made of their experience?
This is far more complex than simply abolishing nociception and inflammation. It’s much more about considering the factors that help a person make sense of their pain, weave that meaning into their sense of self identity, abandon aspects of self that can no longer be sustained, generate new understanding of capabilities and purpose and go on to engage in what is important in their lives.
Because (a) there are so many variables, (b) each individual’s past learning is different, (c) each person’s sense-making is unique and (d) each person’s future and the way they express their sense of self is distinctive and particular to them, we as clinicians can never just apply the same reasoning as we have to another person.
This means we need to generate models that allow us to gather information across many different domains that may influence why this person is presenting in this way at this time, and then carefully tease out the relevant factors that will allow us to collaborate with that person to become less distressed and less disabled – and much more themselves. We need to carefully monitor “what happens” when we suggest an intervention. We can’t assume that the end point achieved for one person is the same as the end point for another. We need to travel from information collection right through to culmination of the experiment which isn’t just when we stop treating the person.
Managing pain is an experiment for everyone. We, clinicians and patients alike, DO NOT KNOW what will “work”. Being honest and transparent about this might help both to collaborate and avoid dogmatism.
Some interesting readings on gender, ethnicity, and depression on clinical judgement:
Bernardes, Sonia F., Costa, Margarida, & Carvalho, Helena. (2013). Engendering pain management practices: The role of physician sex on chronic low-back pain assessment and treatment prescriptions. The Journal of Pain, 14(9), 931-940.
Parsons, S., Harding, G., Breen, A., Foster, N., Pincus, T., Vogel, S., & Underwood, M. (2012). Will shared decision making between patients with chronic musculoskeletal pain and physiotherapists, osteopaths and chiropractors improve patient care? Family Practice, 29(2), 203-212.
Hirsh, A., Hollingshead, N., Bair, M., Matthias, M., Wu, J., & Kroenke, K. (2013). The influence of patient’s sex, race and depression on clinician pain treatment decisions. European Journal of Pain, 17(10), 1569-1579.
MacNeela, Padraig, Gibbons, Andrea, McGuire, Brian, & Murphy, Andrew. (2010). “We need to get you focused”: General practitioners’ representations of chronic low back pain patients. Qualitative Health Research, 20(7), 977-986.
Scott, N., Moga, Carmen, & Harstall, Christa. (2010). Managing low back pain in the primary care setting: The know-do gap. Pain Research & Management, 15(6), 392-400.