Although it is probably the most common problem for which medical advice is sought, pain remains one of the least understood and, as a result, the most undertreated of medical complaints. That undertreatment persists despite an unprecedented tempo in drug development and breakthroughs in our understanding of basic mechanisms speaks to the need for clinicians to keep themselves informed about new advances pertaining to pain treatment and to continue to explore innovative ways to integrate them into their practices.
This issue of Pediatrie Armáis describes new tools and approaches that have been developed to manage childhood pain problems. While a thorough understanding of these interventions is a requisite for the provision of optimal pain management, there is something more that is required. Careful reading will disclose that the common theme underlying each of these excellent articles relates to mastering certain requisite skills and behavior, that unfortunately, are too often neglected in contemporary practice.
The management of pain demands a great deal more of the practitioner than just up-to-date knowledge and technical expertise. Obtaining a clear understanding of the overtones of meaning that accompany a complaint of acute or chronic pain, and instituting effective management requires time, effort, skillfial interpersonal relations, and a great deal of insight. Unfortunately, these attributes are difficult to quantify, and even harder to bill for. Fortunately for children and their families, these attributes are fundamental to the practice of pediatrics.
There is now widespread consensus that the best means of assessing pain, when it is available, is a patient's self-report. Changes in behavior and vital signs are our best alternative in preverbal children and serve as valuable adjuncts later in childhood. However, even after primitive communication is established, neither observations of behavior, whether conducted by physicians, nurses, spouses, or parents, nor alterations in vital signs or endocrine function are as accurate as the patient's self-report.
Incorporating this principle into clinical practice requires the establishment of a trusting relationship among the practioner, patient, and family. The environment needs to be unhurried, safe, and supportive for the patient and his or her family to verbalize pain complaints, report related observations, and ultimately to explore the private, sometimes obscure issues that are often relevant to the pain.
The interested physician can readily master the art of a good pain history and family interview. Just as critical, though, and more difficult to achieve, is the creation of an environment where physician and staff are able to fully engage in the dialogue that is necessary to encourage a relationship of trust and that facilitates eliciting the information needed to intervene effectively. A focus on how patient and doctor relate is important in all medical practice, but even more so in pediatrics. That the pediatrician deals with patients who, by definition, possess developing or imperfect communication skills, requires that his or her own skills be carefully honed. Attentive communication is required not only to obtain an optimal history, but also to elicit and listen for the complaint of pain that is a metaphor for hurts the child is even less able to articulate. The pediatrician is further challenged by the fact that the child's difficulties can never be fully understood in the absence of insight into how . the child's family functions.
Contemporary medicine has failed to legitimize or codify a means to recognize and reward physicians for being insightful and caring. There is no formula for compensating the physician who, by means of applying his or her skills, reduces inappropriate utilization of health care, keeps normal development on track, or simply enhances his or her patients' quality of life.
The pressures, pace, and implied values of today's medical practice tempt, and even reward the physician for responding to persistent complaints with a prescription pad or quick referral. Although medications and specialist consultation have unquestioned roles in the management of most acute and chronic pain problems, they are best prescribed in the context of a meaningful relationship between the patient and his or her doctor. The real conundrum for today's doctors and health-care policy makers involves engineering the maintenance of the traditional skills and values fundamental to the practice of pediatrics that so strongly influence the efficacy of our more mundane technical interventions.