Three. It’s always been my favorite number – the one I’d write with neat curls on my elementary school fun fact questionnaires. The number I’d rely on in my paintings for the perfect balance of asymmetry.The number of people my friend circles tended to feel most comfortable in. Yet, I never anticipated becoming it.
“3 out of 10.” I flinch as the EMT says those words to describe my pain in the trauma bay. I’m lying on my stomach, and my rear is on fire. A thin sheet is all that hides the tire tracks on my body from view. I am hyperventilating. My mind replays seeing the car door to my right slamming open on me, feeling a large mass rolling over my rear, and looking up to see the bus that had been to my left only a second ago now driving away ahead of me. My bike sits collapsed in the bike lane beside me. In the ambulance, the EMTs ask me: “From a 1 to a 10, how do you rate your pain?” I struggle to answer. There is a lot of blood. I’m feeling pain like I’ve never felt before, and I fear that my pelvis is fractured. But in my mind, a 10 means that I am dying, and in that moment all I can think to calm myself is that there is no way I am dying. I tell myself that worst-case scenario, I could be in a wheelchair for the rest of my life, but I will live.
And so in the ambulance, I say something about imagining a 10 as being mauled by a tiger, and that while this is probably the worst pain of my life, there’s no way I’m a 10. The EMTs chuckle. Yet I didn’t expect my (unintentionally) somewhat-comical non-answer to be construed as “3 out of 10” when presented to the trauma team at Mass General. Hearing that number, I felt 3-times smaller. Did I really appear to be in so little pain? I thought to myself. I had become a number I didn’t identify with.
One year later, I am standing on the other side of the trauma bay as a medical student. A gunshot victim is wheeled in, and the team goes through the ABCDEs of the trauma response primary survey. Airway, breathing, and circulation are assessed. Clothing is systematically cut away. Two large-bore peripheral IVs are inserted. It is a dance, rehearsed to perfection, and one that I see many times during my Emergency Medicine rotation. Almost every time, I note the random number used to identify the patient; this one might be “Unknown #0001029390”. While I had been extremely lucky after my accident, many of these trauma victims are not so fortunate. Unidentified, they leave the world as a number.
“From a 1 to a 10, how do you rate your pain?” It’s the same question the EMTs asked me, but as a medical student seeing a patient, it’s now my turn to ask. I use the number he gives in my presentation on rounds: “Today, Mr. X’s pain is a 3, much improved from 7 out of 10 on admission.” Numbers run through the rest of my presentation as well, as I list the number of pack-years Mr. X has smoked, trend his vitals and labs, and specify a target O2 saturation in my assessment and plan.
Experiencing the hospital from the perspective of both a patient and a medical student has provoked me to think deeply about what we as healthcare workers can do to make the experience of the hospital, with all its beeping noises and whirlwind of people and devices, less alienating and more personal. As a patient being asked to rate my pain, I remember how minimized I felt to have my pain reduced to a 3, and how that number had failed to capture the complex emotions of fear and self-reassurance influencing my answer. But as a medical student asking patients to rate their pain, I also appreciate how useful numbers can be in summarizing a patient’s progress and subjective experience. A pain rating, despite its subjectivity, is a useful benchmark for a patient’s progress day-to-day. And beyond numbers, I appreciate how the ways we summarize patients in general, from one-liners to SOAP notes, emphasize the most relevant details that enable us to better manage their care.
At the same time, my experiences have made me more acutely aware of the shortcomings in how we reduce patients to short summaries. A provider once remarked to me that her Chinese patients tended to go to the ED for problems that were much more severe than average, yet they described their pain more benignly. As a Chinese American, I suspect this discrepancy is largely cultural; Chinese culture praises endurance of pain without emotion as a virtue. Yet distilled patient summaries leave out aspects, like cultural values, that could be just as valuable as pain severity ratings in understanding a patient’s experience of their illness.
Our window into a patient’s experience of healthcare is considerably limited in other ways as well. As providers, we may see little of what happens to a patient once they leave the hospital. For example, we don’t see the bills that follow a patient after they leave and how confusing they are to navigate. After my accident, I was flooded with medical bills that kept changing in sum and in insurance coverage. I debated whether to discontinue physical therapy after my much-higher-than-expected first bill arrived, only to be reassured that it would be covered by the driver’s insurance after a frantic phone call to the hospital. When I see patients in the hospital having to stay extra nights due to inefficiencies in the healthcare system, like unavailable rehab beds, my mind flashes to the $50,000 bill I received for my short stay in a hospital bed – never mind the extra services and procedures. Even now, nearly four years after my accident, I am still sorting out bills and a future settlement with my personal injury lawyer. I recognize that if not for my own experience as a hospital patient, I would have never known about these hidden costs nor about the new challenges that a patient must face long after discharge.
These problems are big, and as a medical student, I don’t purport to know how to solve them. However, I do my best to remember the broader contexts of patients’ situations even as I summarize them. When a patient expresses resistance to extra blood draws or nights in the hospital, I stop, listen to their concerns, and adjust our plan accordingly. I pay attention to cultural backgrounds that may influence their approach to healthcare. I practice patient-centered care by considering individuals’ unique circumstances, such as financial and social situations, and asking for their input when making plans. When I ask a patient to rate their pain from 1 to 10, I also ask them to describe how they are feeling in their own words. Recalling my own experience when showing empathy for patients, I recognize patients’ fears and concerns. I will always strive as a future physician to make patients feel comfortable, cared for, and understood.
Kimberley Yu is an MS4 at the Perelman School of Medicine.
Image by Tracy Du, an MS2 at the Perelman School of Medicine.
