How much do you really care about pain?

ByJohn A. Hovanesian, MD, FACS

How important pain is depends upon whether you’re the one causing it or the one experiencing it. To our patients, all pain is important. Several years ago, we did a study on patient perceptions in cataract surgery. We used MDbackline, our patient engagement software, and we learned that patients preparing to undergo cataract surgery fear pain more than they fear going blind. As surgeons, we say we’re committed to improving our craft continuously, looking for better ways to treat patients. But how often do we really spend effort looking for ways to reduce pain?

I did a small informal study recently on my own patients undergoing routine cataract surgery. We asked 28 consecutive patients about their level of discomfort at six time points: baseline discomfort before the first incision, during capsulotomy, during phacoemulsification, at the end of irrigation/aspiration, after the lens implant was delivered, and after the patch was placed. We asked the patients to describe their pain on a scale from 0 (no discomfort) to 10 (worst pain of their life), where a 1 would be barely noticeable discomfort. When pain was present, we asked them to describe exactly when it happened.

Here’s what we found: Four (14%) reported no discomfort at any time point. Nine (32%) had discomfort of 1 or less at all time points — barely noticeable. Thirteen patients (46%) had 3 or higher at some time point, 10 (36%) had 4 or higher at some time point, and seven (25%) had 5 or higher at some time point.

If we define 5 out of 10 as “real pain,” then my own patients experienced about the same incidence of pain as seen in other studies.

Here’s the most interesting relationship we found, and this made the whole exercise worthwhile: Of the seven (25%) patients who reported pain of 5 or higher at any time point, five of them (18% of total patients) had this pain with removal of the sticky drape at the very end of surgery. (The remainder of “real pain” was spread over other time points: two (7%) with phaco and one (4%) with the marking pen used to mark the 0° and 90° axis at the limbus before surgery.)

It was quite humbling for us to learn that the majority of our patients experiencing real pain did so during a reproducible time of the procedure — drape removal. More humbling was that this finding did not surprise us. In retrospect, we had heard many patients complain about the discomfort of drape removal, and we had become desensitized to hearing this complaint. Would we have become so desensitized if we were experiencing the pain instead of the patient? Surely not; we would have addressed this friction point long ago.

Now confronted with the painful reality of drape removal, why would we allow future patients to continue to experience unnecessary discomfort? From this learning, our surgery center staff is now evaluating different drape solutions to reduce or eliminate this discomfort, and we’re committed to finding a solution.

Whether it’s the drape, the marking pens, the prep methods or something else, shouldn’t every surgeon live an “examined” surgical life, evaluating the pain points of our patients? I would encourage every colleague to spend a day or so in the operating room collecting data as I did. What you learn may be painful to you, but transformative for your patient’s experience.

Disclosure: Hovanesian reports he is the founder of MDbackline.