The Pain We Don’t Trust

“She’s back again,” someone whispered. The voice was casual, but the words stuck, heavy with implication.

Crystal was 28 and had sickle cell anemia. I had just started my night shift as a second-year internal medicine resident when I saw Crystal’s name in the admission list allotted to my team. This wasn’t her first visit, or her fifth, or even her fifteenth. By the time I met her, she had become one of those patients, the ones whose names, unfairly, come with a sigh. But that night, she came in looking different: thin, stiff, curled inward with a face flushed, breaths shallow, and fingers stiff and dusky. She complained of severe bone pain and right-sided chest pain, barely able to speak through the waves of discomfort.

“I tried the oxycodone at home,” she said, breathless. “Didn’t touch it. I need something stronger.”

I reviewed her chart. Each note carried the residue of prior visits: “Vaso-occlusive crisis,” “Dilaudid 1 mg IV q3h PRN,” “Frequent flyer.” Somewhere along the way, her pain had stopped being acute and had become a pattern. The triage note was clinical, but between the lines, the subtext was familiar:

“Patient requesting opioids.”

She was in crisis, and yet the room hummed with skepticism.

When I examined her, I noticed the stubs of her fingers, gangrenous remnants from prior Vaso-occlusive episodes that had auto-amputated. A chilling reminder of the relentless destruction this disease could bring. She didn’t mention them. She didn’t need to. Her body told the story.

She had no fever. Her blood pressure was stable. Chest X-ray was unremarkable. Her hemoglobin was low, but there was no acute drop. There was no clear evidence of acute chest syndrome and no physical exam findings to objectively explain the intensity of her distress.

I presented her case to the night attending.

He listened carefully but then said: “Be cautious. She’s been here a lot lately. Could be drug-seeking. Let’s not escalate opioids too quickly.”

It was not a cruel judgment. It was, in his mind, a clinical calculation. A reflection of the caution we have been taught in the era of the opioid epidemic. But his words left a bitter aftertaste. “Could be drug-seeking”. It wasn’t just a medical concern; it was a presumption and a reflection of something darker that floats beneath so many of these encounters.

Crystal was a young African American woman in pain. And that simple fact, pain, without a scan or lab to validate it, was enough to provoke skepticism.

Pain is not always quantified. This is particularly true in sickle cell anemia. For decades, these patients have suffered not only the brutal, unpredictable pain of Vaso-occlusive crises but also the stigma that shadows it. Studies show that Black patients are systematically undertreated for pain. Their reports of discomfort are taken less seriously. They are more likely to be labeled drug-seeking and clinicians, even unconsciously, project bias onto their suffering.

Crystal told me she had stopped going to the ED in the past because it hurt more to be judged than to be in pain.

“You get tired of convincing people you’re not lying,” she said. “Even when you can barely breathe.”

There is a thin, blurry line between compassion and suspicion in modern medicine, especially when opioids are involved. We want to believe our patients. But we also don’t want to be fooled. And in that defensive posture, we begin to look at some patients not as people in pain but as puzzles or worse, threats.

That night, I felt the weight of all that. I started her on IV fluids and ordered a modest dose of hydromorphone, enough to begin pain control but still within the bounds of safe caution. I checked back on her an hour later. She looked slightly better but not well. Her shoulders remained tense, and she barely moved. I returned to her bedside several times. She didn’t ask for more. She just thanked me.

The next morning, the attending changed. Our attending for the day was someone I admired; thoughtful, unhurried, deeply human. She read through Crystal’s chart and asked me to present the case.

As I summarized the events of the night, I admitted my hesitation.

“She asked for Dilaudid,” I said. “But the night attending was worried about opioid misuse.”

My attending paused. “And what do you think?” she asked.

I looked down for a moment. “I think she’s in pain,” I said. “But I don’t know how to be sure.”

She nodded. “Then you listen without judgment. Patients with sickle cell disease don’t just live with pain. They live with the burden of proving it to us, they come in hurting, and we meet them with suspicion. That’s not medicine. That’s fear disguised as caution.”

That morning, we visited Crystal together. She sat beside Crystal, asking her how this crisis felt different. She asked what had helped in the past and what hadn’t. She didn’t question the legitimacy of her pain. She accepted it. She trusted it.

Afterward, she said to me; don’t ignore your training, just be mindful that not everything worth believing can be measured. Sometimes trust is the treatment. Judgment is a reflex we mistake for discernment, especially when it’s wrapped in data, risk calculators, and clinical guidelines. But underneath it, our biases, racial, socioeconomic, and cultural, slip in unnoticed. And our patients feel it. The tone. The raised eyebrow. The reluctance to believe.

Crystal was discharged a few days later, pain controlled, her dignity intact. Before she left, she said softly. “This was different. I didn’t have to fight this time. I didn’t have to prove anything.”

That was the lesson.

We as trainees are taught to assess pain, titrate morphine, and screen for addiction. But we are not always taught how to listen without suspicion. How to recognize bias in the room. How to treat the suffering in front of us instead of the warning in the chart.

Yes, opioid misuse is real. Addiction is devastating. But the pendulum has swung so hard toward fear that we have stopped seeing the human cost of our hesitance. In trying not to harm, we sometimes inflict another kind.

As I look back on that night, I don’t remember Crystal’s lab values or pain score. I remember how she looked when she realized we believed her. And I remember how it felt to learn that sometimes, the most powerful medicine we can offer is not to be judgmental.

So, to every medical student, intern, and fellow: when you meet a patient like Crystal, pause. Examine your instinct. Ask yourself not just what you are treating, but who you are treating, and whether your doubt is truly evidence-based because medicine is not just about knowing, but also about choosing to trust, especially when the world teaches us not to.