Rate Your Pain
Rate your pain, on a scale of zero to ten.
It is more a demand than a request, this phrase that has been following me for the past two months — ever since I injured my knee at a nephew’s wedding. (No, I was not dancing. Or drinking. I’m just a klutz.) You would think, at some point, I would get better at responding.
Of course, this is far from my first experience with the ubiquitous “pain scale” — the system for rating pain used by doctors and hospitals. “Rate your pain,” they say, “on a scale of zero to ten. Zero being no pain and ten being the worst pain possible.”
You can see, right away, how problematic this is.
Do they want me to rate my pain sitting or standing? Stationary or walking? Do they want a measurement of my pain when I have been staying off my feet for a few days, or when I am trying to live my life normally? Knee brace or no knee brace? With pain medication or without? Here’s a weird one: barefoot or wearing shoes? For some reason, I have very little pain when I am barefoot — maybe a one to three. When I am wearing shoes, of any kind, my knee joint has a tendency to slip off its torn cartilage, shooting my pain up to a seven or eight.
I am not a person who takes questions at face value. I am always looking for the catch. The trick. I always suspect that I am being set up as the straight man if I answer a question literally. (My youngest daughter is the same way. My sister says that, if you ask my daughter does she want a glass of water, she will look at you suspiciously.)
Each doctor I see has roughly ten minutes for me. They have no time for subtleties, so it is up to me to figure out: do I tell him what my pain is at its worst, or do I give him an average? I read somewhere that you should always add two to your pain estimation because doctors tend to assume that patients are exaggerating when they talk about pain. I try to remember to do this, but I often forget because doctors make me nervous. Then I’m kicking myself after: Why did I say “two”? Now he thinks my injury is insignificant.
People like me — people who overthink everything — should probably add four to their pain scale numbers, rather than two. That’s two points for the doctor’s assumption that we are exaggerating and two points for the downplaying of pain that we do because we are trying to please the asker.
Rate your pain on a scale of zero to ten.
What do these numbers even mean? Zero equals no pain. But is there ever a moment when a person isn’t experiencing some sort of pain, however minor? A mosquito bite. A too-tight ponytail. A lingering ache from where you stepped on a lego that your child left on the floor last night. Should my baseline be absolutely no pain, or should it be that low-level buzz of minor background pain?
If like me, you suffer from chronic pain, the question of zero becomes even more complicated. My baseline of normal, day-to-day pain — my zero — may be what someone without chronic pain would consider a two. Or a five. Or a seven. I remember once taking a strong prescription pain medication and thinking: Oh my god, is this how normal people feel all the time?
Pain is an inherently subjective measurement. Your seven might be my three. Your five my eight. The urgent care doctor has no way of knowing what sort of pain I have experienced in my lifetime. She has no time to carefully judge what my zero is, based on my particular medical history.
The issue of ten is even more complicated than that of zero. Depending on who is doing the asking, it represents either the worst pain you have ever experienced or the worst pain possible. A big difference between those two.
I think that most of us — especially those with overactive imaginations — do not believe that we have experienced the worst pain possible. Maybe we have experienced some terrible pain — pain that we hope never to experience again. But the worst pain possible? Were I actually experiencing that much pain, I would not be able to answer stupid questions because I would be screaming so loudly I wouldn’t be able to hear them.
Even if you use worst pain you’ve ever experienced as your ten, subjectivity is a huge problem. Not just the obvious subjectivity of person-to-person variations in the experience of pain. Throughout our lives, our own personal pain scales are reevaluated every time we have a new injury or illness. Childbirth, I can tell you, radically recalibrates one’s personal pain scale. I use labor, before I got an epidural, as my ten. I can tell you that — compared to this new ten — my old ten was, maybe, a four or five, tops.
It turns out that the pain scale was not even created for diagnostic or treatment purposes. Like many metrics that have crept into medical diagnosis (BMI, for example), the pain scale was created for researchers and statisticians. Pain specialist Dr. John Farrar says:
Rate your pain on a scale of zero to ten.
If I am in a particularly silly mood, I imagine myself asking the doctor, “Is this scale linear or exponential? Is a five exactly fifty percent of a ten? Or is the difference between an eight and a nine much greater than the difference between a one and a seven?”
I overthink this question because I am in search of the “right” answer. Questions that don’t have a right answer — questions that seek to elicit personal thoughts and feelings — make me incredibly uncomfortable. Since I was a child, my greatest desire has been to blend in. To be normal and ordinary and not to draw attention to myself. To this day, I am reluctant to express personal opinions about things as innocuous as music or food, for fear that my preferences will be viewed as weird.
I tend to give a number that reflects, not so much my actual pain level, but what I think is an appropriate level of pain for my particular ailment.
Along with my fear of underestimating my pain, I have a fear of overestimating it. Of overplaying my hand to the point where I am not taken seriously. A couple of years ago, I was in the emergency room with my daughter, who was experiencing severe back pain to the point where she was visibly shaking. When asked to rate her pain on a scale of one to ten, she said “ten.” No, I thought (but didn’t say). You can’t say that. When you say “ten, “ they assume you are being melodramatic. You can see it in their eyes: the point where they lose all respect for you. Where they decide that you are a whiner.
Or an addict. Another very real hazard of giving too high a number is that doctors will think you are drug seeking. If you have chronic pain, you are already at greater risk of this suspicion. Because you probably already have a few prescriptions for pain medication. (I have three but, when asked, I will only admit to two. I feel like that third one puts me over the edge.) Because you may have used the less suspicious medications (the schedule IV and V drugs) for so long that they have lost effectiveness. When I tell my orthopedist that I can’t take anti-inflammatories, because they cause severe stomach pain, I know that this claim is considered a red flag for drug seeking. But what can I do? It’s also the truth.
Rate your pain, on a scale of zero to ten.
There is no “pain scale” for emotional pain, as far as I know. When you go to a therapist, she does not say, “Rate your depression on a scale of zero to ten. Zero being I am blissfully happy and ten being I plan to leave here and walk in front of a bus.” She does not ask you to assign a number to the loss of a loved one. Or to the first time you dropped your child off at college. To a broken heart. A therapist may ask you to fill out a multi-page questionnaire on various aspects of your mental health, designed to reveal the subtleties of your particular situation, but that is merely a starting point.
Physical pain interacts with psychological pain, in a way that can make it difficult to isolate what is the cause and what is the effect. Often, when you tell doctors about mental health issues, they will write off any physical pain as a symptom of depression. If you have a history of anxiety, your insistence that there is something physically wrong with you is dismissed as hypochondria. I will not deny that depression can cause physical symptoms. But, by the same token, chronic pain can cause depression. How could it not?
Rate your pain . . .
When my husband starts groaning about the tests he has to grade, for the class he teaches, I tell him (only half-joking), “Just give everyone a B-plus.” It’s a good enough grade that no one should complain, but low enough that it won’t look like he’s just handing out A’s to everyone. This is basically what I do when I’m asked to rate my pain. I give a number somewhere between four and seven. High enough to be taken seriously, but not so high that I seem like a drama queen. A number that reflects, not so much my actual pain level, but what I think is an appropriate level of pain for my particular ailment.
Because physical pain — like psychological pain — is too complex a thing to boil down to a single number between zero and ten. Maybe if it were between zero and a million. Maybe if I were allowed to use irrational numbers. . .
