[2/20/05] Brother Pain

by Dan Schmidt
February 20, 2005

Opening words

It is mere nonsense to put pain among the discoveries of science. Lay down this book and reflect for five minutes on the fact that all the great religions were first preached, and long practiced, in the world without chloroform. -- C.S. Lewis , The Problem of Pain

Autobiography in Five Chapters

-- Nyoshul Khenpo

1) I walk down the street.
There is a deep hole in the sidewalk
I fall in.
I am lost...I am hopeless.
It isn't my fault.
It takes forever to find a way out.

2) I walk down the same street.
There is a deep hole in the sidewalk.
I pretend I don't see it.
I fall in again.
I can't believe I'm in the same place.
But it isn't my fault.
It still takes a long time to get out.

3) I walk down the same street.
There is a deep hole in the sidewalk
I see it is there.
I still fall in . . . it's a habit
My eyes are open
I know where I am
It is my fault.
I get out immediately.

4) I walk down the same street.
There is a deep hole in the sidewalk
I walk around it.

5) I walk down another street.

Sermon

First, I want to acknowledge the generous welcoming nature of this church community. You let me, a parishioner, share this pulpit with your minister, the Rev. John Montagnes and with yourselves. It speaks volumes. I am grateful.

Second, a disclaimer. This is not a sermon with answers. I do not have a miracle cure for pain. We all have suffered pain. Some of us are crippled by it. For some of us it is the hole in the sidewalk we cannot find a way out of. But I want to talk today about some of my reflections, some of what I have learned in my life is a physician, listening to people, listening to myself, and learning from pain. Martha, my wife, has given me some advice. When Martha gives me advice -- I am like Yogi Berra when he comes to a fork in the road -- I take it. She says sometimes my words are too personal, too direct, and people may take offense. So today, as you listen to me, remember the advice from Joan's first sermon of 2005. You remember The Three Things That You Need to Know... well let's just review number two today. "It's not about me" Remember how she had us repeat that so we got more exercise. Let's do that right now: "It's not about me". So when I share this talk with you today, remember, it is not about you. This is my sermon. It's about me.

I am a physician. I've been schooled in the subject of pain. We are taught in the medical tradition to list the patients "Chief Complaint" to distill the patient encounter. We ask the questions, you all know them, how long has it hurt? Where does it hurt? When does it hurt? What makes it better? Does it hurt when I do this? This is our litany of questions. But a maxim of medicine I have only recently learned, not in medical school, is: If you only ask questions, all you will get are answers.

You know how I love to show slides. Today I have a PowerPoint presentation, an improvement on my slides from my last sermon. We will dim the lights. I love a good lecture. Science. First I will show you a nerve cell. Here is an electron micrograph of the receptors of a pain fiber. Nerve cells talk to other nerve cells with chemical transmitters. We can block these receptors. Here you see a diagram of the molecule for morphine. This is a diagram of how it fits into this receptor to block it. We can block the transmission of the signal for pain from one cell to another. Simple really. We have modified this molecule with our wonderful chemical technologies to make very long-acting narcotics. If people have pain for a long time it makes sense to block the signals for a long time, doesn't it? Or at least, that's part of the thinking. There is more to this concept. This is a graph of the number of prescriptions written in the state of Washington for long acting narcotics between the years 1997 to 2002. Please note the fourfold, 400 percent rise. We also have data on the abuse of these narcotics. This is an estimated 200 percent rise in the same time. I also have a graph to show accidental deaths from these prescribed narcotics again, during these five years, and it shows about a 250 percent rise.

By the way, do you know how someone dies from a narcotic overdose? When we block these pain receptors excessively, the body no longer feels the need to breathe. It is an inescapable physiological fact, true on the tissue and cellular level, when the pain message is completely blocked we also block the drive to breathe. One step beyond bliss is the grave.

So I am speaking today because I sense a serious failure. While we physicians are treating more pain more aggressively I believe it is at a great price. Often we are mistaken about what we are treating. We do not always turned toward the pain and listen for more than answers, but for the meaning. I want to take this opportunity to turn toward the sense of failure that I feel. I want to examine this, and to do this, I want to discuss what I consider the meaning of pain. I would like to share with you a children's story. I called this The Parable of the Sandbox.

A child is playing in the sandbox. He cuts his finger. Ouch! He keeps on playing. He sees the blood. Ahhh! He runs to his mother. She bands down and hugs him. "Oh, did you hurt your finger? Let me help you." She washes the finger. She puts on a Band-Aid. She kisses him. And he goes back out to play. What just happened? What was he feeling when he ran to his mother? Pain, or fear? She asked him if it hurt. She named this feeling. And how did she treat his "Chief Complaint"? I would argue -- with love. So does he now understand fear and pain go together? I believe that the two, fear and pain are intimate. Most of us cannot easily tell the difference. I learned this when I was delivering babies. If women are able to deal with the fear of labor, the fear of childbirth, effectively through training,support and yes even love, their pain (which is real) is much more manageable.

Don't confuse my words. I'm not condemning the use of drugs to treat pain. But I am here to speak about the value of pain, the worth of pain, the meaning of pain. We live in a society that values and appreciates the technology, the wonderful creations of a rational science. And it is wonderful to be able to take away the horrible agony of injury. But sometimes, maybe most times there is a lesson, a meaning to the pain that should not be covered over. It should not be denied. We sometimes help our patients not see the deep hole in the sidewalk. And is this really the help they need? No, this is a difficult and I believe spiritual decision. It is one that I often feel horribly inadequate to make.

My observation is that we don't listen well to the patient. Often also, the patient doesn't listen well to themselves. But that part isn't about me. I'm talking today about me. So I will admit to not always listening well to the patient. The meaning of the pain and the fear associated with it are often more powerful than the actual sensation. I have come to realize the sensation of pain often means a huge sense of loss for the sufferer. A loss. It maybe the loss of function. The painful back may mean that the man who has always been strong must now see himself as weak. It maybe the loss of beauty. The headache may mean the woman does not now see herself as attractive to her spouse as she hoped to be. And the painful joints may mean the loss of activity that brought pleasure and joy. Pain can be the body's reminder of our mortality, a harbinger of the death we all wish to deny. The greatest loss we cannot come to peace with. For these pains, while a pill may block the nerve that transmits the unwanted, abhorrent message, the drug does not change the fear we have for the meaning the message carries. And though the message may be gone, the meaning stays. Like a track in the sand on a lovely beach after the Walker has left, we see and know of his presence. We know we are not alone. We know that something, our mortality, awaits us. How to deal with loss? There is really only one way. You all know it. I had to learn it as I had to accept my inability to relieve my patients suffering. Yes, Accept. Acceptance. Remember, Denial, Anger, Bargaining, Depression, Acceptance. All normal, all stages, all part of the great wheel of life. I have to accept my patients pain. I am continually tempted to fix, offer a pill, a therapy, a surgery, alternatives. And while all of these may have some value, and I do not want to minimize their worth or their meaning, I have come to realize that true healing comes from the peace of acceptance. And my acceptance of their pain is almost as important as theirs.

So when I find pain on the road of life, my own or my patients, for all doctors have a sign on their door "Suffering Cured Here" I have learned to pause and reflect. You all know what to do if you meet the Buddha on the road of life. Yes, the Buddha and his teachings tell us, if you meet the Buddha on the road of life you are to kill him. We are meant to seek in this life. If you think you have found the Buddha and you are going to stop seeking, it would be best to destroy this illusion. But that is a different sermon. If I were to meet Pain on the road of life how should I greet this traveler? I should greet him like a brother. You know, like a brother. Like my little brother who is very annoying. Pain can be annoying. Or like my older brother who is remote or even frightening. We might even be tempted to pretend we don't recognize our brother. Honestly, we may fight. Brothers do. And, I see people fight with their pain all the time. But I believe, if I greet my brother honestly, if I turn toward my pain, I may someday, as hard as it may seem, come to accept my Brother Pain. And who knows, my brother may lead me down a different street.

Closing Words

I would rather leave you in pain then give you an answer that deprives you of seeking.

-- J. Montagnes