How to talk about pain in the ER, with Dr Jeremy Faust

[00:00:02] Hey everybody, this is Overlooked and I'm Golda Arthur. In December of 2025, I found myself in the emergency room here in New York City. I went there with what I now know to be a thunderclap headache, a painful, blinding headache that came out of nowhere. It terrified me, and I even made an episode about it. By no means was this my first visit to the ER. But as I sat there, waiting to be seen in a bright, crowded, noisy room,

[00:00:32] my coat over my head to try and block out the blinding lights, I had a chance to watch the room. To watch it move, patients in, patients out. Patients slumped over and waiting, residents, nurses, doctors moving all the time, keeping the wheels of the place turning. I watched patients try and communicate, to say what hurts, where it hurts, how much it hurts.

[00:01:00] And I watched the doctors listen and ask questions and listen again. And as I watched this dance of talking and listening, communicating and miscommunicating too, and all of this was taking place against a really stressful background, a modern day emergency room. It really lit up my curiosity about how emergency medicine works. What brings you to the ER is of a completely different nature than going to your family doctor or going to a specialist. That,

[00:01:30] is obvious to say. But how then do you communicate with doctors and nurses in a way that helps you advocate for yourself as a patient better? What do emergency room staff pay close attention to? In this episode, I use that visit as a case study to understand how we as patients can better communicate with our healthcare providers and the other way around.

[00:01:54] So, I talked to an ER doctor. Dr. Jeremy Faust is an emergency physician at the Brigham and Women's Hospital and an assistant professor at Harvard Medical School. I find the pain scale to be almost completely unusable. I think one of the most challenging parts of our job is this idea of what we call pretest probability, meaning who you were before this happened. He's the editor-in-chief of a website called MedPageToday and an award-winning science communicator.

[00:02:23] So, who better to have a conversation with about doctor-patient communication? We have a really candid conversation and get into talking about what most people don't understand about emergency medicine, about pain and the pain scale, and what doctors are looking for when you describe your pain. And after I talked to him, I was able to make sense of what happened with my visit to the ER.

[00:02:47] And in my newsletter this week, I'm pulling together all the lessons I've learned about advocating for yourself in a medical setting and communicating better with your doctors. You can use it as a resource, so check it out in our show notes and subscribe to the newsletter. My conversation with Dr. Jeremy Faust is coming up after this quick break.

[00:03:14] Are you curious about what it's like working in healthcare today? Do you believe in the power of storytelling? I'm Dr. Emily Silverman, the host of The Nocturnist Podcast, where healthcare workers share personal stories of joy, sorrow, and self-discovery. Each episode, whether a compelling performance from one of our live shows, an intimate series of audio diaries from one of our documentaries, or an engaging conversation with guests such as book authors or filmmakers,

[00:03:43] aims to connect, provoke, and inspire. Learn more at thenocturnist.com or subscribe to The Nocturnist wherever you get your podcasts. Jeremy, hi. Welcome to Overlook. Thank you so much for joining me. It's good to see you again. Before we go much further ahead, tell our listeners a little bit about you and what you do. Sure. I'm an emergency physician.

[00:04:08] I finished residency in 2016, so I've been faculty here in Boston since then. I see patients about twice a week, so I'm not full-time clinical. I spend a lot of time in other spaces, research, writing, both for the public and my colleagues. So it gives me a pretty nice balance between actual frontline care and sort of metacognition, thinking the bigger thoughts, and trying to think about issues beyond that, systemic issues. So that's how I spend my time.

[00:04:37] I wanted to call this episode How to Talk So Your Doctor Listens, and that is an intentionally provocative title because I really want to do two things here. I want to recognize that a lot of women feel like doctors don't listen to them, that they are dismissed. But I also want to get inside the mind of a physician, and that to me is like rich and intriguing place to be. So I hope we can do some of that here.

[00:05:04] So this next question is, I think, pointing to the fact that there's a little bit of a gap between what we as patients understand about emergency medicine and about what you on the inside know about how it works. So let's talk about that gap a little bit more. What do you think that the public kind of fundamentally misunderstands about how emergency medicine works? They understand very little of how emergency medicine works.

[00:05:32] And that's fine because the only way to understand it is to do it, and the only way to do it is to drop what you're doing and do it, and that's impossible. So when you've been doing this for years, you do have insights that people aren't able to otherwise have. You've sort of seen what happens, and you've seen the numbers go through. So I think that people have very different ideas about emergency medicine.

[00:05:55] Some of them are on the extremes, right, that everything is going to be like some crazy case like you saw on television, and that we're saving lives every five seconds. And others are going to be the nature of what we do in terms of diagnostics. So are we able to make certain diagnoses? Are we not able to make certain diagnoses? I think people have a misunderstanding about that. They have a misunderstanding about the time it's going to take.

[00:06:23] They have a misunderstanding about the alternatives. So I actually think that emergency medicine is hard to pin down because every day is different. Therefore, the patient's expectation is never correct because what they thought is true might have been true on a prior experience. It might be true next time. It might not be true today.

[00:06:48] I want to tell you a story, and this really just opened my eyes to this gap and also had me challenge myself, right, about like I always thought of myself as a really great patient. I ask a bunch of questions. I advocate for myself. I listen to the answers. But I found myself in an ER in December when I had a very sudden headache, like a headache I'd never had before.

[00:07:16] It was just short and it was blinding and it was intense. And I was like, right, I'm not messing around. I'm going down to the ER. And when they asked me initially when I went into triage and when they asked me on a scale of 1 to 10, Golda, how bad does it hurt? In my head, I was saying 11, but I heard this word come out of my mouth, 8. And I'm like, what am I doing? What is happening here? And so that leads me to think about the pain scale itself, right?

[00:07:44] I think everybody that I've talked to so far is like, yeah, it's kind of a flawed system, but it's still being used because it's a very quick shorthand for me placing me as a patient on the scale, for a clinician to try and figure out, okay, where is this person? Flawed though it may be. But let me just ask you straight up, what do you think of the pain scale? And I can't think of anything to replace it, much as I don't like it.

[00:08:12] I find the pain scale to be almost completely unusable. Well, I'm serious because I think there's this idea that it's linear, that low pain means good, and a low number is good and a high number is dangerous, and it's just not useful in that way. So is qualitative language better then? There are certain details of your story that matter more than this number. So if you come in saying I've got a 10 out of 10 headache,

[00:08:40] I promise you whether I quote unquote care as an ER doctor, and what I mean by care is not do I care to help you, I care to help everybody. What I mean by that is does that alert me to the need for, say, a CAT scan or an MRI or for some specialist to be called in? The number means nothing in that way. What matters are what we call historical features. So the thing that you told me about your story, which would have gotten my attention,

[00:09:07] was not whether you said an 8 out of 10 or a 9 out of 10 or a 10 out of 10. If you had been my patient, whether you said 8 or 10 would not have impacted the kind of studies or tests that I would do. What would have impacted the kind of study or tests I'd do was something else that you already said, which is that you said you'd never had a headache like this. So much more interesting to me as an emergency doctor trying to identify life-threatening, dangerous pathology is not that you downplayed from 10 out of 10 to 8 out of 10.

[00:09:36] I want to absolve you of your guilt towards yourself and say, don't worry, that didn't matter. Or it shouldn't have mattered. It wouldn't have mattered to me. What would have mattered to me was you said, Jeremy, this was a headache that I've never experienced before. That to me would have been like, oh, it's a new headache. New headache is a different beast entirely than if you said, I have had this headache before. It's been a while. I haven't had this headache in years or months, but I've had this headache before.

[00:10:04] Those two things, that difference, new kind of headache versus not new kind of headache, has extraordinary power in my mind in terms of changing what I'm going to do in a way that the number on a scale of 1 to 10 for your pain simply never will. That's really interesting. And in fact, the nurse practitioner that I talked to when I was there said to me as she

[00:10:31] was discharging me, if this happens again, you come straight back here and you tell the triage nurse, you know, this is a new headache. This is a new thing for me. This is the worst headache I've ever experienced in my life. Use that exact phrase. And I thought, ah, so this is like, she's giving me a phrase. She's giving me a little bit of language and it didn't happen again. And I had follow-ups with a neurologist and I had an MRI and all this other stuff. And I've never had migraines or anything like that.

[00:11:00] But that too was kind of illuminating that, you know, if I said one thing versus another, it would be a slightly different pathway, maybe a slightly faster pathway. Well, I just want to unpack this. This is fascinating. You're right. Absolutely. What you say does matter. It's just that the pain number doesn't matter so much. Now, what's interesting here is that she is essentially giving you sort of a cheat code, right? Like, oh, you better say that it's the worst headache of your life and that's going to

[00:11:29] get you triage faster. Well, if that nurse practitioner was encouraging you to invoke something in order to get seen faster, I would say yes, but only if it's true. Yes. Yeah. Because if it's the worst headache of your life, but it's tied for first with the other times you had it, I'm sorry, you should not be triaged faster. You should be triaged slower. Can I ask you this? Did they do any neuroimaging, a CAT scan or an MRI during the ER visit? They did a CAT scan. Yeah. Yeah.

[00:12:00] And they were like, we don't see any immediate danger. I was like, okay, cool. And then the other thing I learned actually is that as I was, you know, getting ready to be discharged, I, and I look back on this and I think, was that a naive question? I don't know. Anyway, it was like just a very interesting lesson. I turned around and I said, so what, what do I have? Like, what's the name for what I have? She said, we can't tell you that you need to see a neurologist. And I was like, wait, so I don't even have like a little label to stick on.

[00:12:29] Like, why was I in the ER? Like, what is the name of the headache? She's like, no, you got to follow, you got to follow up with a specialist and, and figure that out. Cause that's how that works. And I was like, oh, okay. Okay. Fine. Okay. I'm like, you know, I was not happy. Jeremy, I can't tell you that much, but it was an interesting, it really was an interesting kind of learning experience. There's a lot there. And one of the things that you will hear in situations like the one you just described is

[00:12:58] that I was quote dismissed without a diagnosis. And you asked me, what do people not understand about emergency medicine? And this is a great sort of locus for that, for this part of the conversation. The job of the emergency clinician evaluating a patient with a headache is to do one thing, one thing.

[00:13:25] And that is to distinguish between dangerous headaches today and not. That's it. It is not to diagnose your non-dangerous headache as a tension or a cluster or a migraine with or all these other possible headache conditions that a headache specialist in the outpatient environment might be able to label it with, which by the way, may or may not be useful. It might because it might imply certain treatments would be more successful than others.

[00:13:56] But the job of the ER clinician, the ER doc, is to make sure that your headache is not a ruptured aneurysm, is not a new mass, is not a stroke, is not carbon monoxide poisoning, is not zoster on your skin causing a headache, is not acute angle closure glaucoma, is not encephalopathy from an infection, right? So there's, is not trauma that you forgot about.

[00:14:22] So when you talk about this idea that you were frustrated, that is a great example of the miscommunication or misunderstanding about what emergency rooms and emergency departments are for. Here's what happened as far as I can tell. You went there and you said you had a new headache that was different for you. That is what necessitated the CAT scan, by the way, because everyone who has a new headache or a different headache than they've had in the past probably should have imaging versus someone who says, God, this is terrible when I've had this before.

[00:14:51] It was negative. They did not think you had high risk features that required any further sort of investigation. You probably felt better after medications and fluids, yada, yada, yada. And then they said, and our job now is to refer you to someone who can make the correct diagnosis in this bucket of conditions that we believe is not emergency pathology.

[00:15:15] That frequently can be interpreted as, quote unquote, being dismissed or being told that you have nothing. That is not the correct messaging. That's not the, that's not, that's either the incorrect interpretation by the patient or that's a reflection of suboptimal communication by the clinician or both. But very frequently people want a diagnosis and I am humble enough to know that I am not going

[00:15:42] to be telling you whether it's a cluster of migraine, attention, this or that headache. Like, and if I do, you might actually do something that is very common, which is to immediately embrace this diagnosis that someone gave to you as an immutable part of their identity. Yeah. And I was told that I had, that I have cluster headaches and how dare you tell me I don't and blah, blah, blah. And so if you're going to give someone a diagnosis, you have to remember that it's sort

[00:16:12] of like, they're very sticky and clingy. And I think, you know, some of that comes from the, I was thinking like, why is it sticky? What, why is the diagnosis sticky? Because we as patients are in such a vulnerable spot in that ER. And I'll speak only for myself. I am just like, I gave my whole self to whoever the clinician was. I was like, here I am. I am broken. Please tell me what to do. Right.

[00:16:38] And so I think that's just like such a position of trust that is very different from going to your GP, from going to an OBGYN, right? There's like a longer chance to build a relationship there. There's, you know, it's a different context. The stakes feel somewhat lower. I'm sure somebody will disagree with what I just said there. But I do think that things are heightened in an ER for a patient. And therefore, the trust is also kind of, you know, deeper and more intense, maybe.

[00:17:08] So you're really just kind of leaning hard on whoever takes you on there in the ER. But that was really, that was super insightful. Well, I think that what you're saying warrants a little bit of expansion here, which is that all these things that we're talking about, the pain scale or descriptions of what your

[00:17:29] symptoms are or were, they are all really frequently the patient looking to us as clinicians and, as you said, asking for help. And in some situations, especially based on like race, gender, ethnicity, it could be asking to be believed and, or asking to be taken seriously.

[00:17:54] So it's really, it really falls to us as clinicians to make sure that the patients do feel validated in having come in. And so if someone comes in with chest pain and I, I work them up and I discharge them with the diagnosis of chest pain, which very frequently happens, they're like, what is that? That's not a diagnosis. That's the symptom I came in. And I'm like, that's what you have. But the point is, I need them.

[00:18:22] I want them to understand that I did hear them, that I took their complaint seriously and that I, my whole job is to sort out which chest pains are meaningful in an emergency setting and which ones are less meaningful. And what I didn't love about what that nurse practitioner told you was that she was sort of, like you said, giving her like, giving you like a cheat code or some way to like skip the line or like to get our attention.

[00:18:52] And I find that because we're, we're so busy and we see so many patients and we just met you, it could be, it could be the agenda that you might have is let me say the thing that will get their attention. And even if that's not true. And what that could do is I could end up, like you said, like you could skip the line, which is maybe fine for you, but not good for the system, but it could also lead to an escalation of testing that could harm you. So I'll give you an example. If you really want to be seen quickly, and I don't recommend people do this, you should

[00:19:21] go to the ER and say, I've got sudden chest pain that came out of nowhere that's radiating to the back of my body and it feels like someone's ripping me apart. The word radiation to the back and a tearing sensation immediately tells us to me, worried about a condition of the large blood vessel in the body, the aorta tearing apart, having a dissection, an aneurysm, which is a kind of outpouching or a growth. It's like the walls are ripping.

[00:19:49] This is a life-threatening condition where, where minutes and hours matter. And so if you tell me I've got chest pain, ripping sensation, radiating to the back, I guarantee you'll be seen very soon. You will also receive a CAT scan angiogram that has contrast dye in it, that has radiation. You will, maybe that scan will maybe pick up some benign conditions that look like disease that therefore get pursued and you'll get sort of medicalized. So you can be seen immediately if you say a few code words.

[00:20:19] You don't want to do that. You want to tell the truth. Right. And so what I always, but on the other hand, we are, as clinicians, are so obsessed with finding these kinds of patients that we ask leading questions that you interpret as patients in this particular way. And the headache is a great one. You say, Dr. Jeremy, I've got a headache. And I'm like, okay. I could say, tell me about it. Open-ended question. And you could tell me things.

[00:20:46] And then you could tell me a bunch of details that I don't care about because you can't read my mind. And you're telling me like where it is and the kind of a throb. And I promise you these things will not modify my probabilities for whether it's important or not. I'm actually looking for certain things. And one of them is how fast did this headache come on? Did it come out of nowhere or not? And so I might say, hey, Cole, was this headache sudden in its onset? And you will say almost always, yes.

[00:21:17] Why? Because it's a leading question. All right. And also, of course, it was sudden. Every headache was sudden. You actually didn't have it. And then you noticed it. It's binary. Every headache is sudden. And so patients will say like, yes. And you're like, ooh, sudden onset headache. That's bad. Oh, so interesting. The textbook tells me sudden onset headaches are bad. But so what I will do, and I've written about this, is I'll try to make it so the patient cannot read into my question, not to fool them, but to elicit the truth.

[00:21:46] So I'll say, okay, go with that. Did your headache happen and it reached its maximum intensity within a few minutes? Or did it begin and at first it was kind of mild and then it kind of increased and then it kept increasing and it got to such a point where you felt that you had to be seen in the ER? I've done my best in those two alternatives to make them sort of both sound like they could be bad. Right. And so that way you'll tell me which one it is.

[00:22:14] So I've had patients where I was like, hey, did it come on like really quickly or did it take 30 minutes before it really got to the point where you had to come in or an hour or two? And the patient's like, no, doc, I told you. Like one minute I was walking down the aisle at the pharmacy and the next minute I literally thought someone had hit me in the back of the head with a baseball bat and I turned around and nobody was there. So I felt like I had trauma, but it was actually not. It was internal. And I was like, uh-huh. Let me show you to where our cat scanner is. It's over here. You know?

[00:22:44] So the point is we ask these leading questions because we're searching for these pathologies, but we also need to do it in a way that doesn't lead you to say yes to everything. Right, right. So I think you have done the thing I wanted to do, which is like allow me to get into the mind of a clinician here and like explore the way you guys hear us, I think, as patients. So this has been really fascinating.

[00:23:11] Let me see if I can draw us to a close, Jeremy, and ask you for a story. You know, this is a show where the stories illuminate the way. Do you want to take a minute and tell me your story? Yeah, I have a lot of good stories, as all ER doctors do. And I think that for one thing, the one thing I just want to really impress upon your listeners is that we are rushed. We are moving as quickly as we can. But when I come to a patient, I do try to make it very clear that I'm there for them right there

[00:23:40] and that I'm really trying to help them and that I will invoke as much of a personal connection as I possibly can because we don't have a lot of time. But I think one of the most challenging parts of our job is this idea of what we call pretest probability, meaning who you were before this happened is so important.

[00:24:05] So, for example, if you have a headache that's new and you have a history of breast cancer, I'm really worried about metastatic spread to the brain and you're going to need a CAT scan. Even if that breast cancer was 10 years ago, it could be recurrence. So, this is who you were before. But the other thing that matters so much is this momentum of diagnostic certainty.

[00:24:30] And I'm remembering that I had a case, there's a case where a guy came in and they told me that he has these little space out events where he has these transient ischemic attacks where he kind of loses focus and that's kind of like a mini stroke or like a, or even they call them like stroke warnings, like a pre-stroke. And he carried this diagnosis with him forever and ever.

[00:24:58] And something about it didn't make sense and I started to ask more questions about it. And I realized that actually he was having mini seizures. They weren't strokes. And I referred him to a neurologist. They got him on a medication and it went away. The reason I tell this story is that this guy thought he had the answers. He thought he was having transient ischemic attacks and that he just needed to like take

[00:25:24] aspirin and a statin to try to reduce the likelihood of a real big stroke. And that was the only thing he could really do. Turned out, actually, no. What he thought he knew was wrong. And so, I think a lot of times, especially today's internet age and large language models, people come in and they think they've got the answers and they think that's going to help them and they're advocating for themselves. And whether the answers came from a doctor or from ChatGPT, I think that one of the hardest

[00:25:54] things for all of us to do as patients or as clinicians is to keep an open mind. Because what we think we know might not be so. I think a really important part of what I do is to try to connect with the patient and let them know that I'm taking them seriously. I think that is actually more important than anything. Yeah, I couldn't agree more. Jeremy, this was great. Thank you so much for your insight. And I think I've learned a ton just from this short time talking to you.

[00:26:23] So thanks for joining me on Overlooked. My pleasure. Thanks. Overlooked is written and produced by me, Golda Arthur. Jessica Martinez-Eos is our producer. We're building a community around women's health so that no one is overlooked. If you'd like to be part of it, sign up for the newsletter at overlookedpod.com. And you can get in touch with us by emailing hello at overlookedpod.com.

[00:26:48] What you hear and read on Overlooked is for general information purposes only and represents the opinions of the host and the guests. The content on the podcast and website should not be taken as medical advice. Every person's body is unique. So please consult your healthcare professional for any medical questions that may arise. Thanks for listening.