Narrative Pain and Suffering--Progress in Pain Research and Management.
This excellent text edited by Daniel B Carr, John D. Loeser and David Morris maintains the high standard of the series Progress in Pain Research and Management, published by IASP Press.
Each of the editors, all recognised internationally for leadership in pain medicine, contributes to a volume which reflects the topics discussed at a multidisciplinary international symposium held over three days in October 2003 at Bellargio Study Centre, Northern Italy.
The term 'narrative medicine' dates from Rita Charon's paper in Annals of Internal Medicine in January 2001 where she defined narrative as "medicine practised to recognise, absorb, interpret and be moved by the stories of illness"--that is, patients experience and report pain and others interpret and respond to the information provided. Of particular interest was her change in the format for taking a pain history. Furthermore, at the end of the consultation she gives the patient a copy of this narrative with a request that he or she add any comments so they can be discussed at the next consultation.
Appropriately the responsibility for accurate diagnosis and effective treatment for biological illness is emphasised. In parallel, the importance of the advances in brain imaging (particularly functional magnetic resonance imaging and positron emission tomography) for diagnosis, treatment and research is presented clearly and concisely by Irene Tracey. Her balanced contribution, "Taking the Narrative out of Pain: Objectifying Pain Through Brain Imaging" reflects what she described as her optimistic approach to the increasing relevance of using brain imaging as an objective correlate of the subjective experience of pain.
John Loeser expands on the four components necessary and sufficient to describe the phenomenon of pain--nociception, pain suffering, pain behaviour and the well-known onion skin pattern. He confirms that all except pain behaviour are personal, private and internal and cannot be measured by an observer. He adds that only pain behaviours can be measured because they are truly objective, but they do not quantify events within the patient.
It was rewarding to see that the Loeser "onion skin" has been adapted by Harald Gundel and Thomas Tolle in their chapter on "Evidence Base for a Mutual Neurological Basis of Emotions and Pain", with two "onion skins", one of which shows five different levels of emotional awareness and the corresponding levels of emotional processing in the brain.
For those who have grappled with efforts to develop outcome measures for the different treatment modalities for patients with persistent pain, Dan Carr's masterful concluding chapter "Memoir of a Meta-Analysis" emphasises the dilemma faced by pain medicine clinicians in obtaining the objective data required by the advocates of evidence based-medicine.
Together with asthma and diabetes, persistent pain completes the triad of the most costly components of heath care. It encompasses all branches of clinical practice so an understanding of pain and suffering achieves great importance.
Rightly, the importance of education of all health professionals and students in narrative medicine is recognised.
This book is highly recommended not only for the staff of multidisciplinary pain clinics but for all medical school and hospital libraries.