On a scale from one to ten

An early lesson taught in medical school is about pain: ask patients to quantify their pain on a numerical scale, usually one to ten. One is mild pain. Ten is the worst pain they have ever felt. After patients give me a number, I like to ask them what a ten would be for them. Some answers I have heard include a dislocated shoulder, kidney stones, shingles, and childbirth.

When I was working as an oncology scribe, my patient “Oscar” said his ten-out-of-ten pain was “when Martha, my ex-wife, told me she wanted a divorce.” Oscar, a Vietnam war veteran with a strong New Jersey accent, was always quick with a joke. I said, “If that's a ten, then where are you at right now, Oscar?” He laughed and said, “Oh, not too bad.”

The rest of Oscar's appointment was a routine follow-up. He was several years in remission from lung cancer. As he stood up to leave, he winced and sat back down. The doctor and I looked at each other. She opened her mouth. Oscar gave her a rueful grin and spoke before she could.

“I know, doc. I've been meaning to bring this up but, honestly … I'm kind of embarrassed. I'm having a lot of pain. My neuropathy's pretty bad now, and I'm feeling more tired than before.”

Oscar asked about a referral to palliative care that the oncologist had mentioned almost a decade ago. He said, “at the time I wasn't interested because it just sounded like giving up. I thought it was basically sending me to hospice. It wasn't until recently that a friend of mine got a palliative care doc. I felt awful. I wasn't sure what to say. Then she told me it was for symptom control, for relief from the pain she's been having — she wasn't dying.”

He laughed and added, “At least, she said she wasn't planning on it anytime soon.”

Oscar said this misunderstanding about the role of palliative care had been the main reason he originally turned down the referral. He did not want to consider his own mortality. The way he saw it, now cured for almost a decade, he was satisfied with the decision he made then. But he was interested now.

I nodded. His reasoning made sense to me. I turned toward the doctor and caught the barest hint of a frown before it was spirited away. She sat back down and faced Oscar. “How long have you been feeling this pain?”

“Oh, not too long.”

For a moment the room was silent. I recognized what the doctor was doing.

“Okay, you're right. Maybe a few months. Could be a year by now.”

“I'm so sorry, Oscar. Thank you for telling us. I have to ask — why were you trying to hide it? As your doctor I want you to feel comfortable telling me anything.”

“Honestly, doc, I hate asking for help.”

I sat at my desk afterward and thought about Oscar's visit. His words, “I hate asking for help,” tumbled around my head like rocks in a washing machine. I thought about the oncologist sitting across from me, skipping yet another lunch to finish her notes. I wish she would ask me to warm up her lunch for her. I thought about how long I put off talking with a social worker to debrief after my first patient death. Why had I waited? I thought about what suffering and pain people in my life might be fighting alone, in the dark and silence of the night, too afraid or embarrassed to seek help and hope in the light.

After work, I got into my car and started the engine. I shifted into Reverse. Then I shifted back to Park and turned the car off. I walked over to a bench next to the parking lot and watched some leaves fall from the trees, pirouetting in the breeze on their way down. I called a friend I was worried about and asked how he was doing.

“I'm alright. Or at least, I'm getting there. Thanks for asking. How are you doing?”

“I'm feeling sad, to be honest. I had a patient today who's been suffering in silence for a long time and my heart really hurts for him right now.”

“I can only imagine. How bad are you feeling, on a scale from one to ten?”