Early in my first year as a physician assistant in primary care, I was reminded of the importance of the patient's perspective when I developed my own abdominal pain. Pain is something we assess no matter what type of medicine we practice; and most of us assess it every day, often relying on patient descriptions in order to make our assessments. I learned a lot when roles were reversed and I became the patient.
I didn't feel right at work that morning, but I pushed through and saw all of my patients. That afternoon, while on call at home, I began experiencing nausea, chills, and abdominal discomfort. I took my temperature. No fever. Soon after, I vomited and immediately felt better. Unfortunately, not much time passed before I keeled over and curled into the fetal position. I continued to answer calls until my pager went off and, ironically, “stomach pain” flashed on the screen. Enough was enough. I decided to call the doctor on call to ask for coverage.
At first, I thought that I might have picked up a GI bug at the office. This was the first time I had vomited in 10 years. I decided to call a friend and fellow PA. She recommended that I go to the ER. Of course, I didn't want to go, and I definitely didn't want the radiation of a CT scan. I told my friend, “I know that if a patient with these symptoms called me, I would tell them to go … I just don't want to go!”
Could I really have appendicitis? I had just recently diagnosed my first case of appendicitis, and a friend from PA school had also just had appendicitis. Perhaps it was just on our minds. Nonetheless, I became convinced that appendicitis was a possible diagnosis. I decided to go to the ER. On the way there, I tried to tell whether going over bumps in the road made the pain worse. When I reached the ER my pain had subsided, and I no longer felt like I had to twist into a pretzel to feel better.
In the ER, the triage nurse asked me the typical questions, including, “What does the pain feel like?” That's when I realized, I wasn't really sure what the pain felt like. The best I could come up with was that it was “burning,” but I wasn't really sure that that was what I was feeling. “Rate it on a scale from 1 to 10.”
“Hmm … right now, I guess about a 2?” As soon as I said that, I knew the triage nurse was wondering why I was there. And earlier, when I was keeled over on the floor … maybe a 6? Now they must really think I'm crazy.
I was taken to an examination room, and an IV was started. I was feeling pretty comfortable at that point, so I declined pain medications and antiemetics. The nurse reassured me, “You don't have appendicitis; you're not in enough pain.” During the physical examination, I felt no tenderness when the attending pushed on my abdomen. She didn't seem convinced that I had appendicitis either but wanted to be sure. I was sent for a rectal CT scan—which is very uncomfortable by the way. Afterward, the CT tech told me she did not think I had appendicitis either because I didn't have “the walk.” I felt much better after the scan. I settled back in my room, lay down in bed, and watched TV comfortably, waiting for the doctor to come and tell me I could go home.
When the doctor returned, she said, “You were right—it looks like early appendicitis. You'll be the next case.” Just when I was starting to feel better!
Looking back at the experience, a few things stand out in my mind. In the past, I had become frustrated when patients couldn't describe their pain. “I don't know … it's just pain!” they would say. Now I understand. Asking someone to describe a physical sensation in one or two words may be too demanding. If nothing else, my experience reminds me to go easy on the patient. Furthermore, as we all know, everyone experiences, describes, and tolerates pain differently. These differences are worth considering. Even though I was curled up on the floor with abdominal pain, I still didn't think that the pain was very bad or that it was what I thought of as “acute abdominal pain.”
Since my experience, I try to remember not only how I perceived my pain but also how my discomfort was almost written off simply because my description and presentation of symptoms did not meet certain expectations. I try not to let my own expectations interfere in my assessments, and I try to remember what it was like to be on the other side of all the questions. I believe that some valuable lessons can be learned from living the experience. JAAPA
Pamela Gervais practices at Newton Wellesley Primary Care, Newton, Massachusetts. The author has indicated no relationships to disclose relating to the content of this article.