By Dr Zahin
It’s 4:30pm on a Friday afternoon. You still haven’t finished your notes from clinic, there are scripts waiting to be signed, and you’re hoping to get through it all before handover. But your pager goes off:
“Please review Mrs Smith in bed 16, complaining of 8/10 pain.”
Mrs Smith has been in and out of the hospital for weeks; a complex polytrauma patient with severe left foot pain in the context of newly diagnosed CRPS. She’s known to multiple teams, has a well-documented pain plan from the pain service, and you’ve already reviewed her twice today for pain.
Before you even walk into the room, there’s a familiar thought: What am I actually going to do that hasn’t already been done?
These reviews are incredibly challenging – not because we don’t know the medications, but because we’re often unclear on what success even looks like. We vaguely understand that managing these patients isn’t just about adjusting analgesia. It’s about how we approach the conversation: how we listen, what we validate, and how we set expectations in a situation where there often isn’t a simple fix. So what do you do next?
Step 1. Do not ignore the page and wait for the nurses to page again (hopefully when the cover resident takes over).
It’s tempting to delay this review and hope it gets handed over. Clinical inexperience and workload both push us in that direction. But delaying these reviews rarely helps.
Recently on the paediatrics ward, I started a cover shift to a parent-initiated MET call for pain in a patient on a PCA who had lost IV access. While re-siting the cannula was already the priority for the evening medical team, the parent had no clear sense of when (or if) this might happen and was left watching their child in pain. What should have been a straightforward procedural review quickly escalated into a more complex situation requiring longer discussions, additional documentation, and increased nursing support.
When a patient familiar with chronic pain asks for help, it usually means the current plan isn’t working. Leaving it escalates the situation and signals to the patient that no one is listening.
Step 2. Enter with an open mind.
We are not strangers to cognitive bias in medicine. It is easy to get bogged down by the things we think we know. It is far too easy to rule out important differentials before we have all the clinical evidence and, as uncomfortable as it is to admit, it is easy to dismiss a patient before we have even entered the room. At times, I find it helpful to approach the interaction as a blank slate.
In practice, this can be as simple as letting the patient speak uninterrupted for a couple of minutes. Evidence suggests that up to 78% of patients do not speak for longer than 2 minutes when allowed to speak without interruptions, and often, what they say in this time can reframe the entire objective of the review (Kreijkamp-Kaspers & Glasziou, 2012, pg909).
I’ve found open ended questions can help reset the conversation:
- “What’s different about today?”
- “What were you hoping I could help with?”
Additionally, taking a moment to ask “what if it’s something else?” has changed my management more than once. I once revisited a non-English speaking patient’s abdominal pain, previously attributed to chronic constipation, with a formal interpreter service and uncovered a urinary tract infection on a day she would have otherwise been discharged.
Step 3. Don’t be afraid to treat your patient, and escalate early if you think you can’t.
Severe pain can make history taking and examination tricky. In some situations, it may be more helpful to offer a stat or PRN dose of rapid-onset analgesia before attempting a detailed assessment. This can create enough space for a more meaningful review, rather than trying to assess a patient who is too distressed to engage.
At the same time, consider whether you may be walking into a pain crisis that requires early escalation with an urgent clinical review or MET call. Managing acute pain in patients already on significant multimodal regimens can be daunting, and it’s not something you need to manage alone.
Step 4. Acknowledge, reassure, and validate.
Managing acute on chronic pain challenges our ability to troubleshoot complex clinical dilemmas, which often do not have satisfying solutions. It’s uncomfortable to acknowledge a symptom without being able to offer a quick fix, but this is often a hidden barrier to a meaningful and productive conversation. Simple acknowledgements such as “It sounds like today has been particularly difficult” can go a long way in letting someone know you are seeing them, that you believe them. Validation doesn’t have to mean agreeing with everything said, but rather reassuring a patient that their lived experience is an important part of the equation too.
Step 5. Set expectations!
The best pain reviews I’ve seen have been honest and a bit humble. These conversations can go either way. I’ve seen them escalate into full-blown arguments (and even a code grey once!), and I’ve also seen a single conversation completely change how the rest of the admission goes. A lot of that comes down to expectations.
One thing I’ve taken from discussions with various pain specialists is to avoid overpromising. Most of the time, we’re not going to make someone pain-free, and not all patients know what the end point of inpatient treatment may look like without a transparent discussion. The NICE guidelines for shared decision-making recommend early discussion of the patient’s goals for treatment and clarification of any misconceptions they might hold (NICE, 2021).
Simple things like:
- “We might not be able to get rid of the pain completely, but we’ll try to make it more manageable.”
It also helps to be upfront about the longer-term plan:
- “We can try these medications to settle things over the next few days, but we’ll need to start weaning them before you go home.”
In my experience, having this conversation early saves you or an unsuspecting colleague from having a much harder one later.
Step 6. Come up with a plan, knowing that it may fail.
I find it helpful to frame each management plan as a trial run: all possible options are weighed collaboratively, but only one distinct route is chosen by the end of the review. For example, many patients tend to insist on premature escalation of opioids. While this is not necessarily always appropriate in the first instance, especially for patients being overseen by a pain service, it can be reassuring to let them know that there will be a plan for staged assessment of effect and that medication changes are still on the table for discussion depending on how things progress.
One situation where this negotiation process comes up often is when I’m reviewing patients that have declined simple analgesia, and usually this is followed by a “paracetamol never works for me.” While I’ve come across the odd patient or two who are receptive to explanations around the analgesic ladder and multimodal analgesia, most patients just prefer simplicity. One phrase I tend to reuse often is:
- “Worst case scenario, the paracetamol won’t do anything. Best case, it takes the edge off while we figure out what else we can do, while giving me more information to work with.”
In my experience, setting it up this way makes the next review easier, for both you and the patient. It turns the interaction into a shared process that they understand, rather than a single moment where you’re expected to get everything right.
In summary,
In 2020, the IASP revised their definition of pain as being “an unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage”, taking into account the subjective and personal nature of pain that is influenced by not only biological factors, but also psychosocial factors (IASP, 2020). Patients in pain present in vastly different ways.
The above suggestions won’t suit every patient’s communication style, but it is not possible to communicate without first starting a conversation. And it is not possible to hold a conversation without listening to what the person in front of you needs.
Some days it will feel like your patient hates you and the entire hospital no matter what you try. Many patients will find these discussions frustrating, while some need you to acknowledge that their experience is real and difficult. Some patients like to know about every piece of the puzzle, while others are just waiting for someone who can subtract all the medical jargon from the details that matter. Regardless, all patients deserve to be spoken to in a language they can understand.
References
IASP Announces Revised Definition of Pain – International Association for the Study of Pain. (2020, July 16). International Association for the Study of Pain. Retrieved April 1, 2026, from https://www.iasp-pain.org/publications/iasp-news/iasp-announces-revised-definition-of-pain/
Kreijkamp-Kaspers, S., & Glasziou, P. (2012, November). A is for aphorism. The power of silence. Australian Family Physician, Volume 41(11), 909. https://www.racgp.org.au/afp/2012/november/a-is-for-aphorism
NICE. (2021, June 17). National Institute for Healthcare and Excellence. Shared decision making. https://www.nice.org.uk/guidance/ng197/chapter/Recommendations#putting-shared-decision-making-into-practice
