The good pain patient: a critical evaluation of patients' self-presentations in specialist pain clinics

Established research supports collaborative patient-clinician communication as a means of improving pain management and decreasing opioid use by patients with chronic pain. However, much of this scholarship emphasises clinicians' capacities to shape and improve communication; limited research investigates patients' roles in this process. Drawing on 40 ethnographic observations of patient-clinician interactions, clinical spaces and case conferences within one specialist pain clinic in Brisbane, Australia, this paper investigates how and why patients present themselves in particular ways within consultations. Our theoretical lens combines concepts from Goffman on patienthood and stigma with Foucauldian theories of pastoral and disciplinary power. Findings suggest that elements of the clinical environment - namely posters - usher patients towards presenting in what we conceptualise as the 'good pain patient' role. In this role, patients demonstrate that they are moral, responsible, and contributing members of society. Yet, such a role is problematic to opening communication, with the role constraining what is socially acceptable for patients with chronic pain to say, do, or feel. In recognising how clinical contexts facilitate problematic good pain patient presentations, this paper directs attention to the spatial and relational nature of implicit clinical expectations and constrained good pain patient presentations.

Venturing Inside the Body: Transformative Experiences of Pain, Anatomy and Age among Danish Patients Undergoing Awake Arthroscopic Surgery

When patients who undergo awake arthroscopic surgery follow the surgery on a screen, medical image technologies enable a rare look inside one's own body. Based on ethnographic fieldwork at an orthopedic surgery unit in Denmark, we investigate how patients experience their bodies during surgery. Patients see surgery as proof of their pain, experience an anatomical re-categorization, and contemplate the decay of the aging body. We argue that awake arthroscopic surgery constitutes a liminal setting transforming patients' perceptions of their body and their sufferings. Furthermore, we discuss how awake arthroscopic surgery can be understood as a frame for producing new realities. It constitutes a particular way of seeing and understanding that highlights the seductiveness of the visual as an objective carrier of truth and reminds us to remain critical toward the power of certain frames of knowledge production in medical settings.

Pitfalls and Traps in the Surgical Evaluation of Patients with Irritable Bowel Syndrome (IBS)

BACKGROUND

Irritable bowel syndrome (IBS) is a complex disorder involving a variety of severe life-altering symptoms and yet-to-be-discovered biologic mechanisms. Patients with IBS are often referred to gastroenterologists who initiate a work-up to rule several potential confounding disease processes. This work-up often involves a consult with a general and/or vascular surgeon to determine if their IBS-like symptoms have an anatomic or surgical etiology. Potential concurrent problems may include the discovery of points or angulations at which gastrointestinal flow is impaired, median arcuate ligament syndrome/angulation, superior mesenteric syndrome/compression, the incidental finding of intestinal malrotation, and others. Once these diagnoses are entertained and/or documented in a patient's chart, "anchoring" on the diagnosis can lead to the belief that their IBS-like symptoms are due to a well-defined, operatively treatable anatomic condition.

METHODS

In this piece, we will breakdown the potential pitfalls in communicating, advising, and caring for patients with IBS-like symptoms presenting for surgical consultation.

RESULTS

Discussion points are offered with the goal of avoiding unnecessary operations even when faced with compelling anatomic evidence, a highly motivated patient, and a desperate and persuasive family.

CONCLUSION

Patients suffering from IBS presenting for surgical consultation with a defined anastomotic abnormality that may or may not be related to their symptoms represent a major challenge for surgeons. A multidisciplinary team approach can be useful to avoid unindicated surgery in these patients.