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It’s July, and that means new housestaff, students, and fellows.  Interns, fresh from medical school, and newly minted residents.  Medical students starting the wards.  Fellows brimming with enthusiasm.

July is also the time when these early trainees are taught the “basics.”  I have the pleasure of giving the introductory lecture this week about pain management, a very GeriPal bread and butter topic.

I’m hoping to inject a little bit of humanism, in the form of poetry into the lecture.  One poem I’ve selected is called Pain Work-up, by Jeremy Nobel (thanks to Guy Micco!).  See what you think:

Tell me about the pain.

Is it sharp or dull?

What brings it on?

What makes it go away?

Does aspirin seem to help?

Does it feel better after eating?

Can you tolerate greasy foods?

Does it get relieved when you lie down?

Is it worse in the morning or evening?

Put your finger on the spot that hurts most.

Does it come and go or is the pain constant? 

Does it radiate through to your back or shoulder?

Do you feel like a small animal is nibbling inside you?

Do you wake in the morning crowned with a halo of pain?

Have you come to depend on the pain to keep you alive?

Do you remember a time before birth when the rhythm of the universe was your second heartbeat?

Do you remember how green the grass used to be?

Do you remember a time when you remembered no pain?

When you were young did you torture animals?

Were you faithful to your first lover?

Are you afraid of the darkness?

Tell me about the pain.

Is it sharp or dull?

I like this poem because it moves beyond the dry, formulaic questions about pain to address psychological and existential dimensions of pain.  But this clinician-narrator goes too far – injecting his/her own personal conception, fears, and mythology of pain into the interview. We learn more about the clinician than the patient from this series of questions.   I like the flow of the poem too – the gradual build up, peeling back layers of complexity about the pain, before ultimately retreating from dark psychological aspects of pain to more familiar and professional ground.  The poem is both a recognition of the richness and complexity of the pain experience, and a caution against inserting our own selves too much into the interview.

Does anyone else have a poem about pain they would suggest for this introductory teaching session for new students, interns, residents, and fellows?

Thanks, Alex Smith

This Post Has 11 Comments

  1. Here is a poem generously shared by a friend with fibromyalgia:

    Pain Time

    Pain time
    is extended time
    it's expanded time
    and I have lived for ages

    I am older than
    dinosaur bones
    Deeper than
    the grand canyon
    cut by the constant drip
    of blood on stone

    Pain is a stopwatch
    caught between seconds
    An egg-timer sand stream
    caught in a black hole
    flowing ever more slowly
    until it stops
    when space and time
    become intertwined

    I am both
    observer and observed
    I watch from the outside
    and sense agony within
    I reach from the inside
    and grasp at nothing

    Pain time
    is elapsed time
    it's erased time
    and I am almost gone

    By M. Jennifer Markus

  2. When the Patient is a Poet

    (In memory of Michael Donaghy)

    Describe your pain:
    A foolish command.
    He says he can't, too difficult.
    Words are your life, I joke.
    Try sharp, dull, stabbing, pressured..
    Try burning, squeezing, aching…
    Try gnawing, boring, piercing…
    Just try.

    Try to capture pain, which it is,
    beyond language, phantom words,
    beyond reason,
    like love, only, not love,
    but suffering: solitary, mute.

    Try a lifetime of similes and metaphors,
    try iambic pentameter.
    A sonnet, an ode?
    An elegy?

    No, just call it pain.
    Across the gap of understanding,
    I hear your need
    to heal

    Bonnie Salomon, MD
    Lake Forest Hospital
    Lake Forest, IL 60045

    Still Life With OPen Window

    "Pain, fatigue, hunger give time
    the color of the infinite" -Simone Weil

    I went to sleep as one woman -silken, magic, strong-
    My life full of intelligence, bravura episodes
    And turns of phrase. I woke up all stitching and sorrow,
    With a silence around me like the endless quiet
    At the edges of a late Rembrandt self-portrait.

    Time spent in pain exists absolutely, without structure,
    Demarcation of relief, it is all one color,
    like winter's rainy sfumato inscriptions on gray.
    Meanwhile, the other, inner life goes on, unwitnessed,
    The shadow a tree makes on the wall, rippling like water.

    Since nothing outward remains to signify or to connect
    One moment with nother, no more achieved life
    For the moments to be part of, they will have to be connected
    By what can flower within the moment themselves.
    Each moment must expand to hold my infinite, singing joy.

    Karen Fiser

  3. Check out comedian Brian Regan's stand up routine on his visit to the emergency room (on you tube). He does a very funny bit about pain rating scales – fun to use for a teaching tool.

  4. Most of my poetry is about illness, death and pain. These two poems about pain were both published recently. "Pain Scale" is at the Yale Journal for Humanities in Medicine site,

    and "I first saw Cancer" is at YB Poetry,

    Pain Scale

    “Describe your pain on a scale of 0-10, with 0 being no pain at all and 10 being the worst pain you can imagine.”

    Zero is a sundrenched day in August at the shore,
    where you lounge, occasionally glancing at waves
    that wave back and demand nothing.

    One is a sun-break on an otherwise drizzly morn
    Just as the radio serendipitously begins to play
    Here Comes the Sun.

    Two is a phone call from a friend seeking advice,
    which you dispense cheerfully while vigorously
    kneading the knots in your neck.

    Three is a workhorse drenched with extreme
    coffee. After rummaging for Percocet to no avail,
    gulp down 800 mg of ibuprofen and chase with vodka.

    Four is unbearable and you verge on being unkind,
    but instead you just don’t speak.

    Five is an incessant round of electric shocks delivered with a branding iron.

    Six is a curtain rod impaled within your spinal column.

    Seven is a dead baby lodged in your chest.

    Eight is like nothing you can imagine.

    Nine eliminates personhood.

    Ten is.

    I first saw Cancer

    I first saw Cancer rocking gently,
    as if to mollify a small child by keening
    a lullaby. She murmured a promise,
    a truss of blossoms.
    After winter, in the thaw of Spring
    wisps of hair returned, a limp corkscrew crown,
    while pain knifed open bones and gnawed
    them into lacy stalks.
    Cancer rocked gently again, smothering
    the lumpish body with a thin coating of saltpeter.
    And when it was dried out like a codfish,
    she proffered her caress.

  5. Alex,
    Great poem. What is more interesting to me is that so many people were able to se easily identify an additional poem dealing with pain. The extremely odd and meaningful nature of pain appears to drive many people to poetry. I think that says even more than an individual poem.


  6. Thanks for a lovely post, both the poem you shared, and those it prompted. All of us — patients and doctors — could use more poems, read and written and shared. As another doctor, William Carlos Williams, reminded us –"It is difficult/to get the news from poems/yet men die miserabley every day/for lack of what is found there."

    Janice Bressler
    VA Staff Attorney
    The Law and Poetry Project

  7. Thanks to all for your poetry. This is like a blog poetry slam! I shared these poems with the UCSF medical students and residents who attended my lecture on pain yesterday. Much appreciated.

  8. Hi- I didn't know where to post this frustration until I found this blog. Amazing! I am a 4th year medical student on my final 4 rotations until graduation. I can't help but feel discouraged and angry about the oblivious nature that medicine has when it comes to palliative care. I bring up the "p" word- and I am automatically marked down on my evaluation or literally shunned from entering the ICU. I can't help but wonder why are ICUs must be infested with delirium and sick souls who really just want peace and comfort. I was told today, by a cardiologist, that I was too compassionate and my approach to palliation was naive. He reassured me that "this world isn't perfect" (does he even know what I have seen or what I have personally experienced?!) He tried to convince me that the patient would just "end up back in the ER"- and my response was: "not if you consult the right people- hospice". So here is to a repeat in cardiology- too bad the 93 yo woman I was fighting for wouldn't get a repeat in her last few days of life. A death without dignity and certainly without pain relief and comfort. Another day in the life of an "overly" compassionate medical student who oversteps her boundaries to fight for what she believes in- good patient care from birth to death. Such a frustrating world!

  9. Thank you for your post Jenn. It sounds like you are coming across a common barrier to increasing hospice access in the united states, which is the discomfort that many health care providers who care for the majority of patients at the end of life have regarding hospice use. It can be frustrating but as a soon to be physician, you can make a big change in how health care is provided.

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