Djordjevic Charles, Saab Carl Y
Nursing, Cleveland Clinic Foundation, Cleveland, OH, United States.
Department of Humanities, Lorain County Community College, Lorain, OH, United States.
Front Pain Res (Lausanne). 2024 Oct 3;5:1397645. doi: 10.3389/fpain.2024.1397645. eCollection 2024.
To an individual, pain is unambiguously real. To a caregiver, assessing pain in others is a challenging process shrouded in doubt. To explain this challenge, many assume that pain "belongs" exclusively to the bearer of that experience and accept the dogma that pain is private. However, privacy also entails that it is possible to identify, share, or communicate that experience with others. Obviously, this is not true and the consequences of pain privacy would be devastating for healthcare. Pain is indeed unique and subjective, but not necessarily private. Pain is in fact readily communicable, though perhaps not as effectively and reliably as caregivers would like. On the other hand, healthcare systems mandate objective metrics in pain diagnosis. Smiley face caricatures are a staple of clinical practice and a universal standard for reporting pain levels. These conditions create a double paradox: Assess a private experience that is inaccessible, use numerical scales to measure subjective attributes. Navigating this stressful environment, medical professionals experience intellectual dissonance, patients are frustrated, and value-based care is undermined. Offering a way out, first, we refute the privacy and objectification of pain citing philosophical, behavioral, and neuroscientific arguments. We discuss Wittgensteinian views against privacy, explore the clear evolutionary advantage of communicating pain to others, and identify neural circuits in the mammalian brain that contribute to empathy. Second, we highlight the subjectivity of pain, embracing the complexity and uniqueness of an individual's pain. We also provide compelling evidence for brain mechanisms that actively shape the pain experience according to predictive coding principles. Third, we offer a vision for the development of biomarker technologies that assess pain fairly without engendering bias against the patient's narrative. Our recommendations are based on the overwhelming appreciation that "medicine by emoji" is inadequate for capturing the multidimensional nature of pain. Our view is that the most promising candidates for pain biomarkers consist of self-reports as ground truth by physiological signatures of biological relevance to pain. Integration of subjective and objective multimodal features will be key for the development of comprehensive pain assessment models.
对个体而言，疼痛无疑是真实的。对护理人员来说，评估他人的疼痛是一个充满挑战的过程，充满了不确定性。为了解释这一挑战，许多人认为疼痛“只属于”经历疼痛的人，并接受疼痛是私密的这一教条。然而，私密性也意味着有可能与他人识别、分享或交流这种经历。显然，这并非事实，疼痛私密性的后果对医疗保健来说将是毁灭性的。疼痛确实是独特且主观的，但不一定是私密的。事实上，疼痛很容易传达，尽管可能不像护理人员期望的那样有效和可靠。另一方面，医疗系统要求在疼痛诊断中采用客观指标。笑脸漫画是临床实践的主要内容，也是报告疼痛程度的通用标准。这些情况造成了双重悖论：评估一种无法触及的私密体验，使用数字量表来衡量主观属性。在这种压力环境中，医学专业人员会经历认知失调，患者会感到沮丧，基于价值的护理也会受到损害。首先，我们通过引用哲学、行为学和神经科学的论据，反驳疼痛的私密性和客观化。我们讨论维特根斯坦反对私密性的观点，探讨向他人传达疼痛的明显进化优势，并识别哺乳动物大脑中有助于共情的神经回路。其次，我们强调疼痛的主观性，接受个体疼痛的复杂性和独特性。我们还提供了令人信服的证据，证明大脑机制根据预测编码原则积极塑造疼痛体验。第三，我们提出了生物标志物技术发展的愿景，该技术能够公平地评估疼痛，而不会对患者的叙述产生偏见。我们的建议基于这样一种压倒性的认识，即“用表情符号诊断疾病”不足以捕捉疼痛的多维度性质。我们认为，疼痛生物标志物最有前途的候选者包括作为基本事实的自我报告以及与疼痛具有生物学相关性的生理特征。主观和客观多模态特征的整合将是开发全面疼痛评估模型的关键。
