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10 Articles in Volume 6, Issue #3
A Muscular Approach to Headache
Adjuvant Analgesia for Management of Chronic Pain
Breakthrough Pain In Non-Cancer Patients
Case Presentation of Munchausen Syndrome
Electroanalgesic Medical Device
On Knowing
Opioid Malabsorption: Can You Stomach This?
Sedation Safety and Comfort
The American Board of Independent Medical Examiners (ABIME)
The Role of MMPI-2 in Assessment of Chronic Pain

On Knowing

The use of knowledge and intellectual virtues in practical pain management.

The emphasis of this journal is upon those issues that are practical in the effective and sound management of pain. These issues are diverse, and include understanding the mechanisms of pain, their manifestations, and the use of various approaches and paradigms of assessment and treatment. The information provided in this, and recent issues about deterministic testing, and methods of evaluation are critical elements in the armamentarium of the pain practitioner; so too, are strategies and tactics for treating different types of pain.1,2 To be sure, this knowledge is diverse in kind, scope and application. But what makes this information practical? By definition, that which is practical is action manifested by an agent based upon ethical decision.3 Thus, I argue that knowledge must be used in ways that are both technically and ethically sound. Specifically, this essay will address the questions of 1) what are the domains of knowledge of pain and the pain patient; and 2) how the clinician should utilize this multi-dimensional knowledge in applied practice of pain management. In so doing, I propose that how we know about pain and the pain patient is both a foundation and a guide to what we know, and ultimately impels the type, nature and extent of care.

Balancing Value-ladeness

The rapid progress of technology in medicine has afforded enhanced capacity to detect, depict and discriminate various pathologies. Undeniably, the use of such methods as imaging, biochemical tests, and new molecular assays have greatly enhanced the ability to evaluate the objective features of pain. In quantifying particular physiological characteristics, these approaches are used to classify pain as a pathological condition that is generalizable across individual persons and groups, thereby befitting the disease-model.4

Certainly, the focus upon these properties of pain is important, and the efficiency of technological approaches is particularly viable in certain pain conditions that result from identifiable organic insult. But I posit that we must be cautious in the use of such technology and its resultant depictions for several reasons. First, technologic value-ladeness has resulted in a pervasive reductionism reflective of the disease-model throughout the epistemic and evaluative dimensions of medicine.5 Given that an implicit goal of pain medicine is to objectify the subjective, the lure of technology with its ease of application and rapid provision of quantities and images can be exceedingly seductive, appeal to the contemporary epistemological bias, and incur a self-deceptive complacency of clinical rigor.6 Second, pain is not objective, but is by its nature, a subjective state. Thus, the sole reliance upon objective measures fails to provide the completeness of insight necessary to enable apprehension of the subjective realm of pain as illness, and thereby understand its existential impact in a specific patient. Last, pain is not simply a disease, rather it is disorder that is subjectively manifest as phenomenal illness in a person.7 If illness dimensions are left un-heeded and/or un-attended, two possible adverse scenarios could easily occur: 1) that pain is treated using a solely curative approach; or 2) that disease-based markers of pain may not be present. In the first case, the failure of a wholly curative approach could exacerbate symptoms in those patients whose pain progressed to a point that has assumed predominant characteristics of illness. In the second, the absence of detectable measures could suggest that a patient’s pain is ‘not real.’ In both situations, these misperceptions could incur patient and clinician frustration, lead to inappropriate care, and threaten the therapeutic and moral integrity of the patient-clinician relationship.8

By no means do I wish to suggest that the use of technology or objective assessment is without merit. To the contrary, these tools are both practical and important, but cannot represent a unitary approach to diagnosis, discernment, and determining the care of the pain patient. Domains of knowledge that reflect distinct ways of understanding the problem, the patient, and the potential treatment(s) must be stewarded through intellectual virtue(s) to execute the skill and art of medicine. I have argued elsewhere, and re-iterate here, that as a therapeutic and moral agent, the pain practitioner must use these forms of knowledge, in the right ways, at the right times, to guide the technically right and ethically good care of the person in pain.9,10

Domains of Knowledge and Intellectual Virtues

There is equivocal discussion of whether or not medicine is purely applied science.11 On one hand, there can be no doubt that the growth in scientifically-derived epistemic capitol continues to influence medicine as a culture, and has inextricably woven scientific reasoning into its inherent intellectual fabric.12,13 However, while this may be more or less the case for certain medical disciplines, I concur with Davis, Feinstein, Wieland and others who hold that it is not universal.14-16 Specifically, I believe that the decisional processes in certain medical practices must be more broadly construed to reflect and deal with the particularities of the maladies upon which they focus. I argue that this is the case for pain medicine, as pain is subjective, not wholly objectifiable, evokes unique, experiential manifestations in each patient, and is not a static process with a determinate pathologic course. Thus, while scientific knowledge is important to the establishment of a diagnosis, such knowledge must be incorporated into a more expansive base to allow ongoing assessment and direct appropriate care.

Theoretical knowledge. Still, I maintain that theoretical knowledge needs to be the foundation upon which other forms of knowledge and understanding can be built. Such theoretical knowledge must concede that the conceptual “truths” of science represent a progressive, cumulative understanding that must be ‘framed’ within the intellectual climate of society and culture.17 Medicine exists within particular paradigms that acquiesce to, and hence exemplify the intellectual and social worldview of the time.18, 19 For example, the current paradigm is one that conceptualizes pain within a complexity-based system. This model is important to understand and utilize both because of its resonant value to practitioners and patients, and its contribution to evolving theoretical insight (i.e., about the mechanisms of pain, their effects upon the function of the nervous system as part of a body-brain-mind-environment interaction, etc.). But this theoretical knowledge changes, and therefore the clinician must insure that this knowledge base is maintained and current.20

From this technical knowledge arises a conceptual wisdom that bespeaks an understanding of the technical rectitude of various interventions that access the multiple substrates of pain as symptom and disease. In other words, this type of knowledge gives rise to an operational understanding of the systems and models of pain, and informs what can be done and what is the (theoretically and/or technically) right approach to treat a particular pathology. But this does not account for the entirety of the person in whom a pathology occurs, per se. In the clinical situation, this may provide the grounds for establishing the various options that could be provided for care, without necessarily being specific to the unique circumstances of a particular patient. This type of knowledge is the province of the intellectual virtue of science (episteme) which enables intelligent, deductive analysis based upon an understanding of relevant facts and causal relationships.21

“But pain medicine is not just the application of technology and science, it is an inter-personal relationship between the person in pain and the clinician who professes to be able to diagnose, treat and heal. These are both intellectual and moral endeavors.”

Experiential knowledge. I have argued that pain medicine is not just applied science, and it is obvious that its practice involves far more than a conceptual knowledge of neural systems and their activities. Pain occurs as a unique personal experience and is expressed with considerable variation. Solely technical knowledge cannot afford the breadth necessary to apprehend such diversity. Clearly then, this requires understanding based upon experience (empeira) in both differing situations and across time.22,23 Experiential knowledge is best acquired by direct activity, but can be facilitated through apprenticed learning under the tutelage of those who can provide guidance and relate their wealth of erudition. While it is a conceptual ideal that the pain practitioner should be workingly familiar with the vast diversity of pain disorders, in the reality of pain practice, it is common that some pain disorders are seen more frequently than others, and some may not be encountered at all. Currency in theoretical knowledge (i.e., knowing “what to look for”) and engaging in ongoing educational exchange (e.g., addressing novel disorders, challenging cases, new developments in therapeutics, etc.) can compensate, at least in part, for this disparity in concept and reality, and help to maintain practical, experiential acumen. Ultimately, experiential knowledge can impart a heightened sense of observation and correlation when relating current cases to paradigmatic examples from ones’ prior experience or tutelage (i.e., a casuistic approach). For it is at this point that theory and experience are forged in the need to understand and treat a particular patient.

Contextual knowledge. The circumstances and plight of each pain patient must be accorded when attempting to determine how their needs can be best served in the clinical encounter. In this situation, abstract knowledge of facts and causes relate to the predicament of a real patient, at a specific time, with a specific malady of pain. This is the domain of contextual knowledge (peira), which allows the clinician to 1) utilize technical and experiential knowledge to apprehend the plight of a particular patient, 2) apply theory and experience to gain understanding of what is mechanistically wrong, 3) utilize theoretical and experiential understanding to determine the possible etiologies and pathologic processes, and 4) take the additional, necessary step of recognizing that the expression of pain may involve complex factors that render it unique to each patient, creating a specific, individual contextuality.24 This allows the clinician to avoid an inexact approach to assessment and care, and enables inter-subjective appreciation of the phenomenon of pain in a specific patient, objective understanding of the possible substrates of that pain, and analysis of what is wrong, and what options are available to provide relief.25

Surely, experiential and contextual knowledge require and imbue skill, but these elements also contribute a more abstract dimension to the practice of medicine. This is subsumed within the intellectual virtue of art (tekne) that empowers medicine as a craft that brings the realities of the clinical encounter into being through actions.26 Given the subjective nature of pain, and the multitude of pain syndromes and expression, I posit that tekne is a particularly important foundation of pain medicine, for it is this subtlety that establishes the distinction between simply applied science, and the finesse that empowers pain medicine’s hermeneutic character.27

Practical wisdom: Phronesis. The acts of medical agency involve specificity of determining ‘what is wrong’ with a particular patient, whether treatment is possible, and what treatment should be rendered from the range of technically correct, viable options. Frequently, this is the point at which individual and clinical equipoise are reconciled and resolved on grounds that provide the best choice(s) for good patient care. Such care is not just biomedically good (i.e., technically or theoretically right), it must also be good for a specific patient at this time, in this situation, with this disorder (and manifest illness), and thus afford ethically sound provision of knowledge and intervention.28,29 This process of using theoretical, experiential and contextual knowledge to generate an evidence-based approach that recognizes discrete and interacting domains of understanding is essential to clinical decision-making. I have argued that this process is not, and cannot be purely scientific, as it must also consider the personal context(s) of the patient as person.30,31 Thus, it assumes humanitarian dimensions, and concretizes the clinical encounter as an act of moral agency. I maintain that phronesis, the intellectual virtue of practical wisdom, is imperative as it informs and empowers action(s). Phronesis involves forms of knowledge (e.g., theory, experience, context) and moral virtue(s) to discriminate universals and guide particular actions.32 In this way, phronesis is concerned not just with knowing the right things, but in using that knowledge in the right ways to achieve the good(s) inherent to the practice.33,34 Although strictly defined by Aristotle as an intellectual virtue, I humbly offer the view that phronesis assumes significant moral importance in that it serves as a fulcrum that both dictates the good employ of knowledge and other intellectual virtues, and involves moral virtue(s) in the deliberation and implementation of actions.36 To quote Aristotle: “Phronesis is practical”;37 and thus I argue its explicit role in pain medicine.38

Conclusion

In the act of profession, the pain practitioner declares stewardship of knowledge that supports the fiduciary nature of the clinical encounter. The pace of contemporary research is rapidly expanding our understanding of pain. Developments in technology are providing new and novel techniques of assessment and intervention. But pain medicine is not just the application of technology and science, it is an inter-personal relationship between the person in pain and the clinician who professes to be able to diagnose, treat and heal. These are both intellectual and moral endeavors. The task at hand is to utilize technology with ethical probity: to incorporate the theoretical and experiential to assess and treat persons in pain in ways which reflect moral integrity and deliberation. By my definition, that is practical pain management. n

Last updated on: December 20, 2011
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