A scale of one to ten

I don’t know how many times a patient has told me that their pain is a 10/10. We joke about in the residents’ lounge, because, well, you shouldn’t be able to tell me that your pain is that bad. According to the folks who designed the 10-point pain scale, a 10/10 is the moment before you lose consciousness from pain alone. 8/10 is a strong labor contraction like women experience when they are almost fully dilated and most women have had an epidural for several hours already. In OB/GYN we tell women that they will unable to walk or talk through the pain of these contractions (I’ve been there and done that, and it’s absolutely true). Chances are, you have never experienced even 8/10 pain. If you have, the idea that there are two more points in the pain scale will either blow your mind or terrify you – maybe both.

But it isn’t a linear scale. A 3/10 isn’t three times as much pain as 1/10, and the difference between a 1/10 and a 2/10 is less than the difference between a 7/10 and an 8/10. I think this is why so many patients find it so confusing. For quick reference, here are a few benchmarks that I use with my patients:

1 – present, but so slight that you are easily distracted from the pain

4 – definitely present, but you could “sleep it off”

5 – the pain keeps you awake at night

6 – a migraine headache

8 – unmediated transition labor (the final hour or so before pushing), the pain is so severe that you can no longer walk or talk

10 – the moment before you physically pass out from pain alone (not from shock, or blood loss, or hypothermia)

Why is this important? Because this is the scale your doctor is thinking of in their mind (or should be). If you calmly tell me that your pain is a 9/10, I frankly just don’t believe you. You can tell me that it was a 9/10 an hour ago and is now a 7/10 and I might believe you, but as you can see, at 9/10 pain you shouldn’t be able to talk to me at all. When patients inflate their pain ratings, you lose your credibility with your care provider. If I can’t trust you to give me a realistic rating of your pain, it’s hard not to think that you are just looking for me to give you a big bottle of narcotics. Before you leap up to insist that you aren’t a drug addict, let me remind you that your doctor has probably seen at least one dealer or addict in their office this week, and that person was probably just as articulate and well-dressed as anyone else to sit in that chair.

The other risk is that we will under-treat your pain. I had a patient once who kept saying his pain was a 4/10 after a major abdominal surgery. He hadn’t been getting very much pain medicine because when his nurse asked him how much pain he was in, he said 4/10, which is what we usually consider to be a manageable level of pain that does not require additional pain medication. But despite his pain being “well controlled,” he wasn’t getting out of bed with the physical therapists, or sitting up to eat his meals, both of which are important parts of preventing hospital-acquired pneumonia. After a day or two I sat down with him and explained the pain scale, and he immediately said “Oh, in that case it’s a 6-7/10. I haven’t slept since the surgery, and I feel like I can’t breathe when the pain gets bad.” We increased his pain regimen and he started doing much better – he sat up in bed, worked with physical therapy, and walked the halls. It was all a misunderstanding – we thought we were speaking the same language, but clearly we weren’t.

So the next time you go to your doctor with pain, make sure you’re speaking the same language, and be honest. Don’t try to inflate the ratings so we take you more seriously. We can usually tell when you’re “rounding up” and you’ll lose a lot of credibility in the process.

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