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The Pain Masquerade

Looks… painful, I guess?

Newly acquired knowledge is usually empowering and in theory improves patient care. However, on one occasion I learnt the hard way that no amount of theory can trump experience – when dealing with a patient I believed to be exaggerating his pain.

No Malingerers Here!

I refer a time when I was working in my first registrar role. Eager to do a good job, I read as much orthopaedic literature as I could, and came across an article describing nonorganic signs of back pain, better known as “Waddell’s signs of malingering”. Essentially, these were signs that a patient with lower back pain was exaggerating their symptoms. Such physical signs included an apparent worsening of lower back pain if the clinician applied axial load through the head, distraction tests, non-anatomic sensory changes, or weakness not consistent with myotome anatomy. Overreaction of the patient to any sort of physical exam was another indicator.

Now generally when on call, any doctor worth their salt does their very best to avoid inappropriate admissions or patients with ‘heart sink’ diagnoses. As the registrar on call one night I was no different in my approach, ensuring that only patients with genuine pathology requiring urgent orthopaedic care were admitted. Admitting patients with simple lower back pain (of which over 80% of the population will get at some point in life) was deeply disapproved of by the Orthopaedic consultants and was considered a waste of a hospital bed, nurses’ and doctors’ time. Most patients were encouraged to take simple analgesia, stay mobile and have out-patient physiotherapy.

Tear Down the Wall!

My enthusiasm for being a brick wall to admissions ended in some embarrassment one night. The case involved a young man admitted with acute, SEVERE, lower back pain which has had started suddenly 4 hours prior to arrival at the hospital. Eager to do a good job and not disappoint the boss I sat about taking a history and examination. The history was almost impossible to take however because the man was rolling around the bed in apparent agony. This I have to admit I found very frustrating as I could not get a decent answer to any of my questions. It was at this point that I started to consider my newly acquired knowledge of Waddell’s signs.

I swiftly moved onto examination. Observations were normal. His abdomen was soft with no guarding to suggest intra-abdominal pathology. After a complete neurological examination, I started to test my theory that this may be ‘non-organic’ pain. To my interest, axial pressure of his head exacerbated the pain. The numbness in this groin did not fit any anatomy either.  His pain upon being examined certainly seemed out of proportion. I had made up my mind. This was not an orthopaedic problem. It certainly was not a cauda equina syndrome requiring urgent investigation or surgery. However, the patient was in too much discomfort to be discharged.

A Traumatic Meeting

At the trauma meeting the next morning, attended by several consultants, middle grades, and junior doctors, I set about to explain my shame in admitting a patient with back pain who might, I suggested, have some malingering characteristics.  It was at this point, to my horror that time exponentially slowed. The junior doctor in charge brought up his spine radiograph just as I had finished my summary. To my utter surprise it showed a HUGE staghorn calculus. No wonder he was in so much discomfort…he had a huge kidney stone which apparently is worse than child birth!  My only saving grace is that I blurted out the new diagnosis more quickly than anyone else in the room. The admitting consultant gave me an unsympathetic grunt but nothing more, not unfairly given the lack of sympathy I had shown the patient the night before. His colleague offered a wry smile – maybe he had been in this situation as a registrar I wondered?

Looking back, I think the poor bloke would have answered yes to almost any question given his distracting pain. I learned a huge lesson that day which was to always listen to the patient and to give them the benefit of the doubt.  Sometimes the patients who don’t comply are the ones who need most help. Belligerent patients with hypoglycaemia or a significant head injury fall in to that category – easily dismissed as time wasters when they need urgent medical care. The risk of newly acquired knowledge combined with relative inexperience is that with your new hammer everything starts to look like a nail. The truth is that there is no substitute for clinical experience. I am pleased to say I haven’t repeated this type of misjudgement since. By telling this story I hope that others don’t need to learn this lesson the hard way like I did.

Words by an anonymous consultant.


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