Haslam D. Should we warn patients about painful procedures? Practitioner 2019 Feb 2019;263(1823):31

Should we warn patients about painful procedures?

22 Feb 2019


Professor Sir David Haslam CBE FRCGP, Chair NICE, Past President BMA, Past President RCGP


Over the past few months I have been experiencing rather more of the NHS than I would have hoped, from the other side of the consulting room. It’s really something of an eye opener when you discover just how unpleasant some procedures can be, or what a course of a particular treatment actually entails.

Having now experienced a depressingly wide selection of medical and surgical procedures, I feel more than a little embarrassed looking back that I didn’t truly appreciate exactly what my own patients were going through.

Now this poses a really tricky problem. If I had known how unpleasant a treatment was, would that have made me more likely to dissuade my patients from giving their consent to having it done – albeit subconsciously or in the way I phrased my discussion?

Indeed, I rather suspect that we all inevitably subconsciously display our personal views when we are trying to help our patients when they are faced with decisions. As an example, just think for a moment about the way you discuss statins with patients. However hard you try to be completely evidence based and neutral in your choice of words, there is a strong likelihood that your phraseology subtly discloses your personal opinion on whatever topic is under discussion. If this is the case, might this actually be doing your patients a disservice, putting them off an unpleasant but important procedure, for instance?

This thought very much came to mind following one particular surgical procedure. After I regained consciousness I begged for analgesics and lots of them.

When the time came for me to be discharged, I recounted to a senior nurse how surprised I was about how painful the procedure had been. She said, ‘Yes, everyone tells us that.’ And I replied, ‘So why didn’t you warn me?’ To which she said: ‘Because you would probably have refused, and it really was essential.’

I know she was right, but I still get the sense that this entire story could be used in an exceptionally challenging examination question on medical ethics. Was the nursing team’s behaviour really justified in pursuit of the overall benefit I gained? Or was this the very opposite of being patient centred? Discuss.

Many decades ago, when I was a still a student, I wrote to a medical journal about this very topic, suggesting that – as part of their training – every medical student should experience a barium enema, so that they knew what it really involved and were better placed to advise patients. I am now very aware that I was a naive hypocrite. Naive because I hadn’t taken on board the potential disadvantages in terms of patients being inadvertently discouraged from undergoing an investigation that might be essential in terms of diagnosis. Hypocritical because to this day I have never myself undergone such a procedure.

But I still remain anxious about the rights and wrongs of not being completely open about what a procedure might really feel like. Social media and other patient generated descriptions may also influence patients. However, one person’s subjective description of an experience may be very different to another’s.

On leaving hospital, I was asked to complete the Friends and Family Test about my experience. Would I recommend it to my friends or family? Now that’s a tricky question. To be honest, I wouldn’t wish that procedure on my worst enemy. But if they needed it, that would be a very different question.