I often see a neighbor of mine who is an older man chopping wood, carrying sizeable boulders, taking care of his large yard (his lawn looks velvety, exactly like the green you would see at a golf club) and clearing his snow. He does use lots of yard equipment (his “toys” as he calls them), but working on his property day in day out, in summer and winter, seems to be what he does best. One Sunday morning while chatting on the front lawn, I couldn’t resist asking him how old he was. “I’m a young 76”, he answered with a gracious smile.

In my part of the woods (a rural area at least an hour outisde Toronto where I commute daily) properties are large, typically 5 acres or more. I persevered: I see you working hard to maintain this very large property. Don’t you need any help? My friend, he smiled, I need 3 men half my age to do what I do. With young people today’s work ethic, I am better on my own. Besides, the land keeps me active and healthy.

Some weeks after this conversation, the neighbor’s wife knocked at my door. I need your help, she said. My husband seems to have had lot of pain in his back for some months now. He never had never previously had this pain and it bothers him mostly at night. He does not say much but I know he is in pain because he tosses and turns in bed, often moans and rubs his back while walking stiffly. But when I ask him, he always plays his pain down. The worse thing is that he refuses to see his doctor. He hardly ever goes for a check up and he almost never complains of anything.

The story is that of my neighbor but it also describe partially my father in law, a francophone of similar age, who is tough as nails and has never heard of retirement. Like my neighbour, he is also constantly exerting himself and taking on huge amounts of physical work. The difference between the two is that my father in law actually listens to his wife and obliges by visiting his doctor when unusual symptoms appear. This led to the early discovery of his prostate cancer for which he is currently being treated. By being stubborn, my neighbour may be placing his life at risk: this type of nightly back pain can sometimes be a sign that cancer has metastasized in the spine.

What drives a man like my neighbor to avoid seeking medical care? How common is this attitude in older individuals? As a matter of fact, it is very common. A recent careful review (Gibson and Helme, Clinical Geriatric Medicine, 2001), showed that older individuals report lower levels of pain, less mood problems and less indication that pains interferes with their quality of life and day to day activities. This was exactly what I saw in my own research with my team. Patients older than 65 years of age indeed presented with lower pain ratings and consume a lot less medications despite more serious conditions than individuals much younger than 65 have. We think many factors play a role: a) Older individuals have a much more stoic attitude than younger ones (that means they display courage and do not complain much); b) They may be more accepting of pain as part of the process of aging; and c) With aging the nervous system may become less sensitive to pain. Additionally, we found that in older people law suits and disputes with workers’ compensation are much less common than in younger people, so external factors that may increase the way people experience or vocalize are not there.

Obviously excessive complaining (particularly when the underlying medical conditions are not serious) and running to the doctors all the time, benefit neither the patient, the doctor or the taxpayer paying the healthcare bill. But what about the “tough” ones who never complain and never go to the doctor? What good does that do?

Again our answers come from research. In one study, stoic men were delayed in obtaining diagnosis for prostate cancer. In another one, stoic attitudes coupled with denial (refusal to accept the truth) delayed admission of patients with cancer to a specific facility. In a third study, stoic caregivers looking after Alzheimer’s patients had more depression than other caregivers who were able to talk and seek help.

On the other hand, stoicism can sometimes have its benefits. In a particular study in patients with muscular dystrophy (a debilitating disease of the muscles that leads gradually to serious disability and weakness), stoic patients were able to enjoy life better and had a greater quality of life. So, being stoic in some situations can occasionally enhance quality of life while in others it may be barring the way and preventing the patient from accessing care they really need. The latter is specifically true in pain management, where being too stoic becomes an obstacle to obtaining appropriate and timely care.

I took it upon myself to visit my tough neighbor and spend some time with him. I was able to extract some complaints from him because my approach was subtle (“by the way I saw you bent over last time; are you alright?). Finally, he hesitantly discussed his back pain with me. After that I used my knowledge of research statistics to scare him stiff. It worked because two days later he visited his doctor, accompanied by his wife. Thank God, investigations showed some significant arthritis in his back but no trace of cancer. A course of physiotherapy and a number of appropriate medications for inflammation and muscle spasm helped a lot. I see him now back in his yard and I notice that when he bends, he does so from the knees (proper lifting technique) and carries smaller rocks and tree stubs than he previously did!

Angela Mailis Gagnon, MD, MSc, FRCPC(PhysMed)
Director, Comprehensive Pain Program,
Senior Investigator, Krembil Neuroscience Centre
Toronto Western Hospital,
Chair ACTION Ontario http:// www.drangelamailis.com

Keywords: doctors, pain