The Role of the Clinician in Palliative Medicine
Authors: J. L. Abrahm
Journal: JAMA (2000)

EVERY DOCTOR WHO TREATS PATIENTS WILL CONFRONT THEIR PAIN AND suffering.Yet for each individual patient the experience of pain will be private and largely unique.This creates difficulty not only for the clinician but for anyone who tries to grasp the meaning of someone else's pain.The sensory component of pain, the neuronal capacity to localize and identify noxious stimuli, is largely consistent both within an individual and between populations. 1 But the meaning of pain becomes much more than the ability simply to localize or discern it.For the affective component of pain-the subjective sense of suffering that accompanies its perception-is multifactorial.Myriad factors underlie our ability to conceptualize our own pain, or to comprehend that of another: the meaning of the pain within one's larger life context, the intensity and location of the pain, the particular illness associated with the pain, the rituals of medicine around pain, and the social understanding of suffering.The pain that results from this multiplicity of factors is uniquely defined for each individual; pain becomes framed in the clinical encounter by the interplay between the physician's gaze into the patient and the patient's gaze into himself or herself.This exercise of framing is at the center of every patient-physician encounter, but most particularly so for pain.For pain is not an objective and visible clinical finding in the manner of a fractured femur or purulent sputum.Rather, pain is a perception communicated through both language and nonverbal behaviors such as tears or agitation.As such, pain is intrinsically subjective and inaccessible, "that which cannot be denied, and that which cannot be confirmed." 2 This intangibility contributes to misunderstanding and undertreatment of pain in the clinical setting.As discussed by Kathleen Foley in this issue, pain remains a serious public health problem.Many patients are inadequately palliated, especially at the end of life.This need not be so.Janet Abrahm describes how we can make palliative care itself a goal of medicine.Even when cure of the underlying disease is not possible, there is still much we can do to relieve physical and psychosocial suffering.Jane Loitman recounts that many patients seek pain relief from complementary therapies.Often they feel that these methods offer a holistic approach that is lacking in the traditional allopathic model.As we grapple for solutions to these problems within our current clinical context, we might do well to realize that none of these experiences are entirely new.Schuyler Henderson describes the expressions and definitions of pain as a function of not only personal but social, cultural, and historical influences as well.To treat pain adequately therefore requires not just that we understand its pathophysiology, solicit patient reporting, and follow practice guidelines, but that we also reflect on its meanings and thoughtfully incorporate them into our clinical interactions.We hope that this issue of MSJAMA will encourage further thought about current issues in pain management and its significance within the clinical encounter.