Historically, one of the main reasons for anybody to seek medical assistance from a healthcare professional is the experience of pain, the state or condition of consciousness arising from mental or physical suffering (OED).
Pain is universal, but extremely challenging to convey. The question of “How would you describe your pain?” is one of the most puzzling questions for a patient to answer. The main reason is the intrinsic difficulty that the question involves. How do we describe our pain? Well, “it hurts” is usually the immediate and utmost common answer.
It hurts, yes, and it is because of that that patients seek medical help; to improve or remove altogether this sensation, an abnormal feeling signaling that something in our body is not quite right, the biological function of which is to provoke reactive patterns directed towards avoidance of the nervous stimulus presenting a threat to the individual (Zborowski, 1952). Although generically called pain, there are different types of pain (Beth Israel Medical Center): (a) nociceptive pain, caused by ongoing activation of pain receptors that can be somatic (localized) or visceral (not localized); (b) neuropathic pain, caused by changes in the nervous system; and (c) psychogenic pain, explained by psychological issues. Relief from it comes not just by killing the sensation, but also for healthcare providers to dig deeper into its causes, the causes that triggered that signal to switch on. Prototypical answers such as ‘it hurts” or “it hurts a lot” do not take us far. To that end, we need a more detailed explanation and a description of the minutest sensations. We know it hurts, and that hurts to an abnormal degree (otherwise we would not be in need of aid), where it hurts, and under which conditions, but still, how would we describe it?
The description of the sensation of pain is challenging enough for the patient to such an extreme that to help on that effort, several methodologies and charts have been devised. Maybe the simplest, and thus, the most used, are the ‘Universal Pain Scale Tool’ and the ‘Wong-Baker Faces Chart’. Known as the ‘pain scales’ they are initially very useful, especially with limited language expression people such as children or limited English proficiency (LEP) patients; a limitation usually aggravated while in pain and in an unfamiliar environment (clinical or hospital setting).
Most clinicians acknowledge that all these numbers are subjective; thus, by using them what they are really looking for is simply to assess pain over time. Even though, there are clinics that provide patients with additional descriptors to accompany the scale numbers in an attempt to quantify pain more objectively (see below an example from the Michigan Medicine Occupational Hand Therapy Clinic at Burlington Building; reproduced by permission):
0. Absolute no pain or sense of anything wrong
1. No pain but feeling that something is wrong. Just does not feel right. Could be a feeling of “stiffness”.
2. Very light whispering soreness
3. Mild dull discomfort
4. Between mild discomfort and moderate pain; begin to frown
5. Moderate pain – considering pain meds – about 50% of the worst pain possible; begin to wince.
6. More than moderate pain; can hardly think of anything else.
7. “I want to use swear words or moan” but still able to talk with people – burning pain – between moderate and severe pain, approaching severe pain – about 70% of the worst pain.
8. Severe pain – difficulty focusing on tasks or talking to others.
9. Very severe, throbbing pain, crying – 90% of the worst pain. Unable to talk to others.
10. “HELP ME” I’M IN AGONY” – EXCRUCIATING PAIN – LABOR PAIN! PAIN FROM PASSING A KIDNEY STONE! THE WORST PAIN! SHARP TWINGES THAT “TAKE YOUR BREATH AWAY” I’VE GOTTA GO TO THE EMERGENCY ROOM NOW!
If this usually works under certain circumstances it does not offer, however, enough detail for providers to discern amid the multiple possible causes of a patient’s chief complain; it merely hints to the intensity of pain. Consequently, a more comprehensive and elaborate description is often needed. The classic McGill Pain Questionnaire (Melzack, 1975) aims to fulfill that endeavor; it contains a large palette of pain descriptors, organized in multiple categories, for patients to pinpoint their sensations in a meaningful way for the provider.
But if the McGill questionnaire can be useful in ambulatory care or in any other circumstances where there is time for the patient to think about, and recapitulate on the nature of his/her pain, in cases of emergency or under extreme manifestations, even the completion of the short version of such questionnaire (Melzak, 1987) may still be too challenging.
In a recent book: “The Language of Pain”, Dr. David Biro, himself a bone marrow transplant patient, prompted by his own past difficulties to communicate accurately the intensive nature of his sufferings, discusses thoroughly the whereabouts of such a particular and deeply personal sensation. As he explains, pain is all-consuming; it actively swallows up language as it does everything else. At its most intense, there is no time to think, let alone try to represent how one feels. (…) As a practical matter, we need language to alleviate pain. Physicians rely on the stories of patients. (…) When language is lacking, it becomes increasingly difficult for them to do their job and much more likely that pain will not be adequately treated. (…) Pain challenges us and challenges language, like no other experience we have. Because of its problematic nature, we can’t express pain directly or literally; we can’t point to it like we point to a bird in the sky and describe its features. The only way to talk of pain is indirectly or metaphorically. Right up front we need to be more imaginative and creative than usual. We need to think more literarily. (…) [The underlined is mine.]
It is clear that due to the very particular nature of pain, we will have to rely on the descriptions provided by the world literature and its metaphors, along global imagination, for assistance on this endeavor. Is the author, then, suggesting here that poorly read individuals, by the lack of extended language and literary resources, are going to face serious disadvantages in conveying their suffering? He might, but what is undeniable is that the task will be somewhat easier for people more articulated, with a higher level of education, no matter which background culture they are coming from; the further their own culture from the mainstream culture of medicine, the more challenging will this be for them. Accordingly, the cultural responsiveness during an interpreter’s performance, if needed, will have to go beyond expectations.
This book contains as well a couple of ideas that from the point of view of a healthcare interpreter need special consideration:
(1) Pain, either quantitatively or qualitatively, having a strong subjective component, is lived distinctively by different people.
A notion already presented in terms of its manifestation or patients’ response to it. Physiologically speaking, it is considered that the threshold of pain is similar for all individuals regardless of age, sex, or nationality (Zborowski, 1952), but not the patients’ response to it, which besides including pathological aspects, physiological characteristics, and the personality of the individual relates directly to the concept that:
(2) People of different cultures don’t feel pain equivalently.
Every society expects for every of its members to live up to what the society establishes as correct behavioral standards, among them the responses to pain and processes of suffering (Zborowski, 1969). Therefore, it is not surprising there the presence of a strong ethno-specific component (Moore and Brodsgaard, 1999). Moreover, if it is safe to say that the higher the level of acculturation of the individual (further from the immigrant generation) the more American (closer to the culture of medicine) is his/her behavior going to be, this is not quite exactly so regarding the attitudes towards pain (Zborowski, 1952).
According to Diller (1980), we should also keep in mind that:
• Lexical differentiation of pain terms might not correlate with physiological or psychological conditions.
• When differences in perceived pain experience are involved, there may be semantic processes working beyond simple quantitative or qualitative distinctions.
• Language-specific dissimilarities in pain reporting may be partly an effect, but somewhat also a cause of culturally modulated differences in pain perception. Language can exert a powerful influence on conscious attention, but probably also on semiconscious and unconscious aspects of our species cognitive abilities to deal with meaning.
The cultural background of a patient, the language used, and the expression of such language are highly responsible for the way a patient is going to communicate pain. All those interacting parameters increase the challenges faced by the healthcare interpreter in transmitting high sensitive information such is the pain experience. Hence, it will be very important not just to master the language of interpretation (with all its nuances, local expressions, idioms, sayings), but to gather, without being intrusive or disrespectful, as much information as possible about the patient’s specific culture or cultures and the way they use language. Only then, is the interpreter going to be able to provide the patient’s deserved service in helping with communication as accurately as anticipated.
1. Beth Israel Medical Center, Department of Pain Medicine and Palliative Care. Definitions and Types of Pain; http://www.healingchronicpain.org/introduction/definitions [Accessed Feb 2017]
2. Biro, David. 2010. The Language of Pain: Finding Words, Compassion, and Relief. W. W. Norton and Company, New York and London.
3. Diller, A. 1980. Cross-Cultural Pain Semantics. Pain 9(1):9-26.
4. Melzak, R. 1975. The McGill pain questionnaire: major properties and scoring methods. Pain 1:275-299.
5. Melzak, R. 1987. The short-form McGill pain questionnaire. pain 30:191-197.
6. Moore, R. and Brodsgaard, I. 1999. Cross-Cultural Investigations of Pain. In: Epidemiology of Pain (I.K. Crombie, ed.) IASP Press, Seattle. pp.53-80.
7. OED (Oxford English Dictionary); http://www.oed.com
8. Pixabay: free high quality images; https://pixabay.com/
9. Wong-Baker Faces Foundation; http://wongbakerfaces.org/instructions-use/
10. XKCD: a webcomic of romance, sarcasm, math, and language; https://xkcd.com
11. Zborowski, M. 1952. Cultural Components in Responses to Pain. Journal of Social Issues 8(4):16-30.
12. Zborowski, M. 1969. People in Pain. Jossey-Bass, San Francisco.