Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Diagnosing And Treating Pain


Always listen to your patients and make sure that they understand that you believe their experience of pain.

Pain can be a difficult symptom to diagnose and treat. In medical school, we learn scripts for presentations of pain to ideally allow for easier management, but often those generalizations come from only subsets of the population. For example, while birth-assigned males have higher rates of heart attacks, birth-assigned females are at increased risk of death after a heart attack. One major reason for this disparity is that traditional descriptions of heart attack pain don’t reflect women’s experiences. 


Pain can also be difficult for patients to discuss. They may worry that it will be dismissed or misunderstood. Black patients’ pain is systematically underrecognized and undertreated compared to white patients. Patients at higher weights report missed diagnoses because their health concerns are seen as a consequence of their weight. We need to find a better way to talk to all patients about pain. Here are five things that have helped me: 


1. Listen.  

On average, a clinician interrupts a patient’s history after only 11 seconds. Let patients speak and tell their story. Take mental notes of follow-up questions to ask. 


2. Affirm patients’ experience.  

Try saying, “I want you to know that I believe you and that your pain is real. Only you can let me know what you’re feeling. It’s my job to help determine the source of your pain and what to do next. It may take some time, but we’ll work together to investigate it. Like a detective, I’m putting the clues you give me together.” 


3. Remember the mind-body connection.  

Try saying, “There can be different sources of pain. Sometimes, they come from an injury or illness in our body and other times they can come from our mind, or a combination of both. It may be the way our body is managing stress, trauma, depression, or anxiety. It doesn’t mean ‘it’s all in your head.’ Our nerves feel real pain. Our plan may include assessing and addressing these types of conditions.” 


4. Discuss appropriate work-up.  

Have a conversation about your conclusions from history, exam findings, diagnostic steps, and/or management with your patient. Talk about goals for improvement.


5. Share the limitations of medical understanding.  

I remember seeing several children in the ED with abdominal pain and their parents’ disappointment when the ultrasound showed no appendicitis or other abnormalities. “Then why did this happen?” they’d ask.  

“Unfortunately, we don’t always know,” I’d say. “We try to rule out any life-threatening causes and sometimes we don’t find a specific answer. I can’t imagine how frustrating it is to not have a specific cause, but this happens a lot. The good news is your child doesn’t need surgery today and my hope is they get better in the next few days. If they get worse, please bring them back because sometimes, problems take time for us to recognize them.” 






This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.