Monday, February 14, 2011

Henny Penny in the Hospital

As much as I am not a fan of many of the studies that clutter medical journals --- poorly designed studies or those that display extreme bias --- I am occasionally delighted to find an article that is a bit out of the ordinary. It helps when it confirms my own biases (I admit it, I like to say "toldya so"), and there's an extra bonus for teaching me a new word. Such is the case for an article from the January edition of the American Journal of Surgery --- Catastrophizing: a predictive factor for postoperative pain.


What the heck is catastrophizing? Well, it's listed in Dorland's medical dictionary (not in my prehistoric version, but in their online version), but I haven't been able to find it elsewhere. Put simply, catastrophizing is an irrational belief that something is far worse than it actually is. In the realm of pain research, pain catastrophizing is defined in the article as:
...an exaggerated negative mental set brought to bear during an actual or anticipated painful experience (defined in simple words as expectation or worry about major negative consequences, even one of minor importance).
OK, that means that some people worry excessively about pain associated with medical care, either during or before the actual care event. So? I worry about lots of things --- whether my kids will be alright when they are adults, whether or not I'll be able to bike to the top of the next hill without hacking up a lung, or whether SWIMBO will wake up one day and realize that she was duped into marrying me 23 years ago. I lay awake at night worrying about patients in the hospital, knowing that there is little I can do but wait. Well, in this situation, it's the degree of worry involved --- hence the provocative name for the problem. Once again from the article,
High levels of catastrophizing have been reported to be associated with a heightened pain experience and can result in the development of chronic pain.
The authors reviewed a large number of pain studies in surgical patients, and came up with a few general findings:
  • Pain catastrophizing is becoming recognized as a key predictor of the severity of acute post-surgical pain and its progression to chronic post-surgical pain. That's a big deal, because the severity of a patient's pain perception significantly alters their recovery and postoperative mobility, which can lead to other problems (DVT, atalectasis, etc.).
  • There are screening tools available (the Coping Strategies Questionnaire and the Pain Catastrophizing Scale) to identify patients with a tendency to catasrophize, which could potentially allow us to tailor postoperative pain management for them.
Hmm. I am a surgeon. Basically, that means that everything I do hurts. It's important for me to make sure patients know and fully understand that before we go to the OR, because otherwise I would be a lying SOB. But, it is also important for them to know that we try to mitigate their pain ---- but we are unable to take it completely away --- and that it will gradually improve with time and eventually pass. I am definitely not a fan of the current pain management fads such as identifying pain as a "5th vital sign," and really think this sort of pain scale is a poor substitute for patient assessment:
I suspect that those who have pain catastrophizing issues would routinely self-assess their pain levels as "above 10" on such a scale.

So what should we do? Should we try to identify patients who have a tendency to catastrophize their pain levels preoperatively? That would involve yet another set of screening questions that already take up way too much of the preop nurses' time, and would probably cast such a wide net that many patients would needlessly be labeled (as almost every patient entering the hospital is now labeled as having the potential sleep apnea; that's a rant for another day). Or should we add this as a diagnosis to those who exhibit these tendencies, which will hopefully allow a more aggressive approach at working with these patients during subsequent hospitalizations?

I'm not sure. I just know that we all see patients with this issue, and now at least I have a name with which to identify them.

Perhaps until some regulatory body passes a decree mandating some new pain management rule, passing out these bumper stickers might be of some benefit, especially in the ED: