Book Alert! The Gift of Pain

Hello, blog readers!  I'm realizing now that I never concluded the cross country road trip blog posts several weeks ago.  I must have been so excited to arrive in Connecticut to see my family, it slipped my mind.  Kristen posted about the end of our journey here for anyone who thought we fell off the face of the Earth.  I flew back cradling a container of Clorox Wipes like they were my newborn baby, extensively cleaning my whole seating area, and, because I had no alternative, an entire bathroom of the plane. I'll send you the cleaning bill, Alaska Airlines!  Now I'm back home in Seattle, and I returned to a huge stack of books and audiobook CDs waiting for me at the library pickup as the world is slowly starting to open back up!

On January 6, 2020, before we knew about the COVID-19 Global Pandemic and had masks perpetually glued to our chins, while there was still air in the lungs of Breonna Taylor, I wrote my first blog post of 2020 entitled "I'm a Book Nerd."  I outlined six books I wanted to read this year related to PT and was already underway reading "The Graded Motor Imagery Handbook" - which I highly recommend to PTs, particularly those who work with patients experiencing chronic pain.  On my list were five more books, but with the closure of the library and my decision to buy a condo during a global pandemic limiting me from spending money to buy books, I couldn't get the books I intended to read.  I've been reading A LOT of alternative books since then, and with the re-opening of the library, I finally dove into "The Gift of Pain: Why We Hurt and What We Can Do About It" by Dr. Paul Brand and Philip Yancey, previously titled "The Gift Nobody Wants." 

The introduction was written by Dr. C. Everett Koop who served as the US Surgeon General from 1982-1989.  Dr. Koop starts the book off with a quote that resonated with me - and which I whole-heartedly believe in as a clinician - "When you examine an abdomen, watch the patient's face, not his belly."  I'm not the right person to say if the eyes are truly the window to the soul, but for sure I believe that the eyes are a window of truth with regard to pain.  My patients experiencing pain show their experience with a crinkled brow or looking away, sometimes covering their eyes, and on the rarest of occasions, tears.  

I must not have read a synopsis about the book prior to adding it to my list, because I was surprised to read the first pages of the book... a heartbreaking story about a little girl who genetically could not experience pain. Dr. Paul Brand was a hand surgeon whose career focused on patients with leprosy, a condition characterized by the absence of the pain experience.  Pain, after all, is an experience.  It is interpreted differently by each person and is dependent on unique understandings of- and interactions with- the environment.  And so, a four year old girl who could not experience pain tries to find ways to interact with her environment, ultimately participating in self-mutilation of her fingers and stepping on nails without awareness and continuing to walk on them.  For so many people, we try to find ways to get rid of pain, but as I've learned working in the Seattle Children's Pain Medicine Clinic, the goal often needs to be to better understand pain and learn how to optimally function despite it.  Too many people need to learn how to embrace their pain because rejecting pain allows these negative sensations to dramatically interfere with life.  

The book is a memoir of Dr. Brand's life in parallel to his journey to understand pain.  He begins with his childhood experiences in India, watching his father serve as a Missionary who also provided medical care to the local villagers.  Later he describes his schooling and career, in London during war time, and developing into a hand surgeon ultimately devoting much of his career to patients with leprosy. There are cultural influences of different world regions and comparisons between medical and community practices in India versus the United States, interactions with nature and animals and their use in scientific research, and vivid descriptions of Dr. Brand's unique interactions with pain.  In some ways it reminded me of the book we read in PT School for Cultural Competency called "The Spirit Catches You and You Fall Down," which was also an interesting approach at looking at the American Medical Model and how it conflicts with the beliefs and practices of different cultures. 

Free photo 96827 © Chrisharvey - Dreamstime.com

This book was published in the 1990's, but it's describing Dr. Brand's understanding of pain from at least 40 years of patient care.  I was repeatedly surprised at how deeply he understood pain, and the ways he tried to apply his knowledge to various conditions such as the peripheral neuropathy commonly observed in diabetics or HIV/AIDS. The book explores fundamentals about how the brain and nervous system interact, stigmatization of people who look different than "the norm," how Dr. Brand learned to conduct surgeries by operating on cadavers because the procedures didn't yet exist to help his patients, and some incredible medical successes. The stories are simultaneously heart warming and gut-wrenching, the full spectrum of emotions.  I'm six years into my PT career and this book helped me to see how I'm really only beginning to touch the surface of learning about pain and how important the biopsychosocial model of practice truly is.  How different my patient care could have been if I had known sooner! It's no wonder groups like the Level Up Initiative have been pushing for healthcare transformation... healthcare education too frequently misses the mark on the importance of therapeutic alliance and bedside manner. Medicine and the understanding of the human body has advanced considerably since the time Dr. Brand treated patients, however we, the modern day healthcare providers, have so much to learn about these foundational concepts. 

Several stories were memorable, but one that fit closely into physical therapy was when Dr. Brand's patients had successful surgeries on their hands, restoring function previously thought to have been permanently lost, only to come back a few months later with severe wounds on their newly functioning extremities.  Dr. Brand would carefully bandage the patients and they would heal, but then they would have recurring wounds, often in similar patterns.  He took the time to observe their daily activities - noticing that one gentleman was using a hammer that had a splinter in its handle that he could not feel - so the repeated use of the hammer was breaking down his skin.  Another instance found that a man was reading in his bed at night time and would go to turn off his lamp, night after night brushing some of his knuckles against a hot piece of glass on the lamp, and that this was slowly burning his flesh.  In a third instance, one that Dr. Brand felt was most challenging to figure out, some of the patients had rats chewing on their fingers in their sleep, which through the introduction of cats into their housing fixed the problem of their hand wounds.  All of these patients - and the world at large - thought that having the diagnosis of leprosy meant that fingers and toes would spontaneously fall off, that the tissues were somehow bad, and that the disease was highly contagious.  Dr. Brand was able to solve so many problems for his patients to improve their quality of life and provide hope to this patient population.

The book goes into some detail with regard to Dr. Brand's three stages of the pain system - how first a "danger" message must be received from the environment, then this signal is transmitted to the spinal cord and lower portion of the brain to be filtered and assessed - ultimately reaching the higher portion of the brain where a response is decided upon.  Pain occurs when "the entire cycle of signal, message, response has been completed."  He provides examples of how pain can be "stopped" by interrupting the cycle at each stage, and how much the mind and learned experiences can impact the third stage and  recovery from pain.  

I think reading this book will certainly improve my understanding of pain, though some of the newer materials I have read go into some different detail, this is a much simpler read with memorable anecdotes.  I can't recommend it highly enough for newer physical therapists to emphasize a different way of thinking than our classical training likely provided. If you have any interest in science, medical stories, pain, and human compassion - check it out.  Brand includes the definition of Compassion early in the book: latin roots are com + pati meaning "to suffer with."  A compassionate healthcare provider truly does suffer with their patients. We may not feel your physical pain, but our hearts connect to your experience, and we care about you.  To some degree, suffering has an element of choice. I hope to help reduce the suffering of my patients, and I'm so glad this book was recommended to me!