Painkillers won't replace a conversation

Not that kind of shot...

Acknowledging the pain of women, particularly with clinic or minor procedures, is a big talking point these days. Much is written about how our pain has been minimized by those of us in the medical profession, instead of recognizing and validating it. You see my dual role here--I also hate the "big squeeze" of a mammogram. The confines and sounds of the MRI. The "bee sting" of an injection of lidocaine. The cramp of a pap or "big cramp" of a tenaculum or "breathe through this" of the IUD insertion. "Almost done". Yes, I know all of these from both sides of the table.

I have the advantage of knowing that the discomfort is temporary, necessary, and unlikely to be a sign of something harmful or dangerous. That relaxing techniques are very helpful--visualization, muscle relaxation as much as possible, music, focusing on something else.

I'm also aware that the injection of a local anesthetic (like lidocaine) isn't pain free or instantly effective.

The discussion of what happens (or could happen or would almost never happen) during a procedure is the process of informed consent. Officially, a piece of paper, signed by both the provider and the patient. In reality, it's the conversation, not the paper that matters.

My consent conversations grew with my years in practice. My early training consents were brief: bleeding, infection, injury to surrounding organs--usually bowel, bladder, etc. okay let's go. As a learner, I was the first line, not the final word. Ultimately not responsible for the outcomes. As I saw more bizarre, sometimes unthinkable complications: what if we do nothing and watch your baby's heartbeat on the monitor as it dies; or you decline treatment and the cancer grows through your skin or bladder; what if we do the procedure and everything goes right, but you have long term pain from nerves or infections or whatever--these crept into the dialogue. The reality is that consent includes the risk of doing nothing. Not performing the c-section. Not doing the biopsy. Not treating the cancer. Not providing birth control.

We were also taught in my medical school and residency years that "Pain is the fifth vital sign". Yes, give the percocet; we cannot ignore the pain. Now we know the risks with that. (BTW, I was always skeptical of tossing narcotics at our problems, particularly over the phone. I feel a little smug in hindsight).

Nothing is risk free, or pain free. Nothing. I'll keep saying it.

Having the conversation means taking extra time that providers often are not allotted in a clinic day. It means asking the questions, recognizing that our patients' understanding of what we mean may not align with their expectations. That the woman requesting the pain medication may not know that it involves a needle. Yes, that has happened to me as a provider. I felt terrible that she didn't realize she was getting a shot.

Often, what I want to say is already out there, more eloquently or more precise or both. The following is a quote from Dr. Christine Henneberg's guest essay for the NYT this week:

The truth is: Some people will feel almost nothing with IUD insertion, and some will feel excruciating pain. It is hard to know who will have what experience and whether lidocaine — or even stronger medications — will help. (Like many areas of women’s health, more research might go a long way toward answering some of these questions.) In the meantime, as the C.D.C. reminded us, the bare minimum of informed consent requires that every woman hears transparent counseling and has a chance to ask questions. But this takes time — a lot more than the 30 seconds required to inject lidocaine around the cervix.

 I encourage you to click on the link below for the full essay.

https://www.nytimes.com/2024/09/12/opinion/painkillers-wont-fix-iuds.html?unlocked_article_code=1.KU4.Texh.3sd1m6m3mzLH&smid=url-share

By the way, I got both my flu and Covid shots today. My tips for making this virtually pain free (for real):

• 600 mg of ibuprofen (3 of the over-the-counter, 200 mg pills), about half an hour before my appt. You could also do 2 extra strength tylenol, which is my plan if my arm hurts or I feel wonky later.

• windmilling my arms for about 15 seconds just before the shot--a weird but helpful suggestion from a slightly crazy but smart clinic nurse

• actually relaxing my arm when the shot was given

• treating myself to a coffee afterwards, because I can.

It's that time of year again. Both shots are what we do now. Don't overthink it.