The manifestations of pain

Yuvreet Kaur,1 Leah Steinberg,2 James E Teresi,3,4 Carol J Swallow1,5,6

1Department of Surgery, University of Toronto, Ontario, Canada; 2Temmy Latner Centre for Palliative Care, Mount Sinai Hospital, Sinai Health System, Ontario, Canada; 3Department of Anesthesiology and Pain Medicine, University of Toronto, Ontario, Canada;  4Department of Anesthesia, Mount Sinai Hospital, Ontario, Canada; 5Department of Surgical Oncology, Princess Margaret Cancer Centre, University Health Network and Sinai Health System, Ontario, Canada; 6Division of General Surgery, Mount Sinai Hospital, Ontario, Canada

We first met in the surgical oncology clinic where you were referred for a recent finding of a retroperitoneal sarcoma. Your friend assisted us with translation as you spoke minimal English. You were in debilitating pain from the mass compressing your nerves and constipation from the opioids you were using. You told me you live by yourself, and have no close family members in Canada. We reviewed your investigations, and you were not a surgical candidate for resection of the mass. We admitted you, and I have since seen you every morning for three weeks. Some mornings your pain is manageable, and some mornings you are tearing up from the excruciating pain as you had not been able to sleep all night. We arranged radiation therapy and hoped that would help with the pain. Not once did you express disappointment in your diagnosis, prognosis, or treatment plan. The only thing you complained about during your hospital stay was your pain. Over the three weeks, with assistance from a multidisciplinary team, we tried a myriad of treatments for your pain, with little relief.

We first met on the ward. You had gone through four abdominal surgeries in the past eight months and required multiple hospital admissions. You were now in the hospital for weeks, and your major complaint was debilitating bilateral leg pain that significantly decreased your quality of life. You could not support yourself after some walking. When I tested light touch sensation on your leg with a tissue, you screamed in pain. We ordered multiple tests and investigations, consulted neurology and pain services, and yet we failed at identifying a cause of your pain and managing it. Some days when I saw you, you were up and walking and going to Second Cup and grabbing a coffee. Other days you were lying in bed in excruciating pain and had reduced physical function. We had to eventually tell you that there is nothing more we can do to improve your function. You asked us how you will be able to go back to what your life was eight months ago if you could not even support yourself on your legs for more than a few minutes. We had no answer for you.

When we first met on the ward, you were in bed curled up in a fetal position. You had a flat affect, and expressed the emotional pain you were in. You wanted to leave the hospital to be reunited with your passions- art and photography. You needed a few more days to physically recover. You opened up about your past suicide attempts, and that you would rather be dead than confined to the walls of your hospital room. We reflexively consulted psychiatry. The following week, I noted no changes in your mood or affect. Although I never saw you smile during your stay, I did see the joy in your eyes when your niece brought in your artwork to decorate your hospital room, and when we initiated your discharge planning. I wish we could have done more to address your mood during your hospital stay, and I can only hope that your emotional pain is more at ease at home. I hope we meet again, perhaps at an art exhibition, and I can see you in something other than a blue hospital gown.

I discussed my encounters with Dr. Steinberg and Dr. Teresi, experts in pain management. I learned two key things from them that I hope to take with me as I continue to work in patient care. Firstly, pain is multifactorial, complex, and inevitable. The goal of pain management is not to completely eliminate the pain, but to assist patients return to their baseline level of functioning. Multidisciplinary teams, a deeper understanding of the physical and psychosocial factors leading to the patient’s pain, and personalized management plans for each patient are essential when managing pain. Secondly, it is okay to not be able to fix everything, and it is critical for us to acknowledge those limits. We will see our patients suffer, and one of the most difficult aspects of our work is to sit with them through their pain, rather than walking away from it. This may come in the form of our continued availability and support for the patient, or involving other healthcare professionals when we have reached the limits of what we can do. It is not sufficient to try our best, but a lot more important to not abandon our patients in their suffering.

Dealing with changes to clerkship during a pandemic: perspectives and lessons learned at Dalhousie    

Christopher Gallivan,1 Magnus McLeod1

1Dalhousie University, Nova Scotia, Canada

Across the globe, clerkship directors and other educators had to deal with the unprecedented chaos caused by the COVID19 pandemic leading to the cessation, modification, and then resumption of clerkship.  This posed a challenge for educators – and students. There had to be a balance between maintaining a safe learning environment for students and ensuring that students had adequate clinical learning experiences but still allowing students to complete their clerkship year in a way that does not completely disrupt the learning of the following cohorts’ clerkship year.  We would like to share some perspectives and lessons learned from the point of view of the internal medicine clerkship program at Dalhousie University.

One thing that certainly took us by surprise was the speed at which things changed during the first wave of the COVID 19 pandemic.  At Dalhousie, for example, we went from a Monday morning introduction for students starting their third of four clerkship blocks with some passing discussion about the evolving pandemic to a Friday briefing that same week that clerkships were suspended indefinitely across Canada.  It was obviously an incredibly stressful time for students; made worse by the fact that for most of their questions (such as how long they will be off, how this will affect their graduation date, how this will affect residency matching), we simply did not have any answers.  During this time, we felt it important to make sure students were receiving clear and accurate messages and not getting different information from different sources. To do this, I found myself communicating much more with my fellow clerkship directors as well as our undergraduate medical education department.  This also led to, what was for me, both a humbling and frustrating experience of having to tell students with legitimate questions or concerns that we did not have answers.  This involved fighting the natural tendency as an educator to answer questions and provide reassurance. Still, in the long run, it was certainly my experience that telling students to wait for more information caused fewer problems than students getting conflicting information from multiple sources.     

As the year progressed it became clear that the turmoil of stopping clerkship would pale in comparison to the challenges of restarting it.  At Dalhousie, after much discussion, it was decided that the final two clerkship blocks of the current class cohort as well as the first block of the following year’s cohort (that which started in the fall of 2020) would all need to be shortened with each department deciding how to give students adequate training in less time.  I came to the profound but obvious realization that it would be impossible to deliver all the content we do in normal year.  I found myself essentially applying “triage” thinking to the curriculum and focusing on the things that were vital or ‘life saving.’ We ended up deciding to keep the full length of what we felt were our core internal medicine rotations of the MTU (Medical Teaching Unit) and our geriatrics rotations while shortening the time for selectives in outpatient and subspecialty medicine.  Although this certainly altered the experience of clerks, I felt we were able to provide students with the necessary learning in core internal medicine patients and illnesses.

Although there were many challenges to this year, it was also an opportunity for educators to improve and innovate.  We were pleased to see how many of our clinical preceptors and other educators were willing to step up and help find creative solutions to keep students engaged.  For example, many of or preceptors involved students in virtual care and remote or phone consults even though these were new for students and preceptors alike.  This allowed students to be part of the learning and innovation process as they worked with their preceptor to navigate the new clinical environment.  Some preceptors also found ways to involve students in patient care using new techniques, such as taking a table into a patient room and showing the physical exam and history without bringing in their whole team of learners.  The ability of our educators to be open and creative undoubtedly helped our students to get back into the clinical environment and resume learning.       

As we look ahead to the ongoing challenges, we can use some of the lessons we learned during the pandemic to prepare for the future.  By focusing on clear and open communication (even if this means telling students we do not have the answers), realizing that education will be different and that we may need to triage to protect the most important parts of our curricula, and being creative and open to new methods of teaching, we can hopefully make 2021 a smoother year.


Are we undervaluing the teaching of empathy to pre-clerkship students: another side-effect of the COVID-19 pandemic?

Shaishav Datta,1 Wafa Khoja,2 Meera Dalal-Burns 3

1Temerty Faculty of Medicine, University of Toronto, Ontario, Canada; 2School of Medicine, Queen’s University, Ontario, Canada; 3St. Michael’s Hospital, Ontario, Canada.

Compassion and empathy are integral qualities in a good physician. Empathy is a multidimensional construct conveyed through verbal and non-verbal expressions, such as sustained eye contact, careful listening, embodied experience, and tactile contact.1 Both the quality of clinical communication with patients and patient wellbeing are improved when patients interact with physicians whom they perceive as empathetic.1,2 Thus, a physician’s ability to build a strong, therapeutic relationship is grounded in their repertoire of non-verbal skills. But how are these skills taught? While the vast majority of our medical curriculum is knowledge-based, clinical conversation skills are developed through practice and experience during clinical skills teaching sessions. Among other challenges raised by the COVID-19 pandemic, pre-clerkship medical students lacked some of their only opportunities to learn the critical nuances of the art of effective communication with patients during the 2020-2021 academic year. While we have established creative ways to take most of our learning online, pre-clerkship medical students may be missing crucial experiences to develop skills at the very core of what makes a good physician.

Now third-year students across the country experienced an abrupt end to in-person clinical skills sessions beginning in March 2020, while many now second-year students had their very first patient interactions over video-conferencing platforms. As we learned the skills of expressing appropriate empathy, it has been difficult in many ways to display these multidimensional emotions through a two-dimensional screen. Even for those of us who have had experience with patient interactions in the past, we have noticed a stark increase in awkwardness in learners as well as Standardized Patients (SPs). Non-verbal actions that display empathy, such as touch, were no longer possible and left many of us unable and untrained on how to express empathy. It was challenging to read the intricacies of body language and create a welcoming and comfortable environment online, particularly when technological difficulties occur.

Below we provide some of our experiences as first- and second-year medical students in Ontario during the 2020-2021 academic year.

During one of our few in-person clinical skills teaching sessions, I recall instinctively placing my hand on the shoulder of the SP while adjusting my stethoscope to listen for the mitral valve. After the examination finished, the SP remarked: “Of all the things you did during this session, I really appreciate you placing your hand on my shoulder during the physical exam. It made me feel comfortable and showed that you care about me.” This taught me a valuable lesson about the importance of touch in providing empathetic care. While it seemed so natural in person, this is a difficult skill to learn or practice over virtual sessions. – Wafa Khoja

I recall a virtual session on ‘How to break bad news’ with an SP. Throughout our heartfelt conversation in which I told them about their terminal illness, I kept thinking to myself how I wished I could have held their hand or passed them a tissue box. Even though this was a simulated experience, I walked away shocked at the restraints that virtual platforms placed on my ability to deliver empathetic care. I especially found it difficult to gauge the patient’s emotions and read their body language through the screen, and as a result it became very hard to connect on a deeper, more humanistic level. – Shaishav Datta

Over time, as virtual care becomes the norm and we focus more on verbal communication, will we lose our ability to communicate non-verbally? Even now, as my classmates assess their SPs virtually, our communication styles are notably different from our senior colleagues. How will the under practiced skills of eye contact, body language, and reassuring gestures affect current pre-clerkship students in our upcoming training; clerkship and onwards?

Unfortunately, this concern regarding virtual clinical skills training is widespread. A December 2020 survey of second-year medical students at the University of Toronto showed that more than 50% of students did not feel that they had the necessary clinical skills needed to start clerkship.3 This feeling of unpreparedness was directly attributed to the virtual clinical skills curriculum due to COVID-19.3 Many expressed concerns regarding the skills they lacked relating to clinical encounters with patients, including expressions of empathy and compassion.

What is in store for this COVID-19 generation of physicians and how does it affect the profession as a whole? Non-verbal skills are mastered through practice and as an ensemble, comprise the underpinnings of a competent physician in the 21st century. They are qualities actively sought out by admissions committees that are now being omitted from teaching curricula because of the limitations of virtual medicine. During the COVID-19 pandemic, pre-clerkship students have been wholly excluded from in-person clinical settings for public-health reasons. Our lack of experience with expression of these emotions and the current way in which we are learning to communicate effectively through virtual means is likely to make the transition to clerkship difficult and uncomfortable for us and the patients we encounter. While we will hopefully recover and build these skills over the course of our training, it is prudent to consider the extent to which these forms of communication are being undervalued in virtual teaching.

We are grateful that medical school faculties have tried to provide pre-clerkship students with the best possible teaching and skills while adhering to public-health guidelines during the pandemic. Some schools adopted creative and expedited methods to deliver clinical skills training to students. For example, the University of Toronto offered an expedited preparation for clerkship “bootcamp” for current second-year students during the summer of 2021. Alternatively, Queen’s University created a system to permit limited in-person clinical skills sessions within small groups. Schools in other provinces across the country also developed strategies that are in compliance with the COVID-19 guidelines in their respective locations. Despite this, we ask you to consider: Is this enough? Will vastly online clinical skills training affect the ability of current pre-clerkship students to competently maneuver clerkship, residency, and future career? These are important questions that we as a medical community must consider to be potential side effects of the COVID-19 pandemic and must answer to prepare for future pandemics.


  1. Kelly M, Svrcek C, King N, Scherpbier A, Dornan T. Embodying empathy: a phenomenological study of physician touch. Med Educ. 2020;52(5):400-407.
  2. Cocksedge S, George B, Renwick S, Chew-Graham CA. Touch in primary care consultations: qualitative investigation of doctors’ and patients’ perceptions. Br J Gen Pract. 2013;63(609):e283-e290.
  3. Kao J, Chan T. COVID FAQ Survey: A Review of Student Responses [unpublished data]. Toronto (ON): University of Toronto; 2020.