Since 9/11, the improvements in managing acute and chronic pain on the battlefield and at home have been a remarkable achievement of federal medicine. Until recently, pain has always been thought of as a symptom of some other disease process or trauma. Providers believed that, if they took care of the physical problem, the pain would take care of itself. Like most things in medicine, it just is not that simple.

Pain, like the other “signature” disease processes of post-traumatic stress injury (PTSI) or traumatic brain injury (TBI), if not appropriately managed, can develop into a chronic, lifelong, debilitating disease. Perhaps most tragic in the management of the polytrauma triad of PTSI, TBI and pain is the stigma that often accompanies these injuries, particularly in a military culture that prides itself on unusually high levels of physical and mental performance under high stress.

Frank Ochberg, in the Time magazine article, “Honor, Stigma … and PTSD” (May 24, 2012), comments on the recent request of former Vice-Chief of Staff of the Army, Gen. Peter Chiarelli (ret.) to change the PTSD (“D” for disorder) to PTSI (“I” for injury) as a needed step to de-stigmatize this condition within our culture. Because the injuries of PTSI, TBI and pain are usually not clearly visible, they lack the “Red Badge of Courage” honor that more clearly visible wounds afford the wounded veteran. This is a serious cultural error, because the wounds inflicted on the warrior from PTSI, TBI and pain are no less devastating or life-changing than any other injury sustained in defense of this country.

To paraphrase Ecclesiastes 3, there is a time and place for everything. The Pentagon T-shirt has its desired effect in creating a culture that hardens the body and mind for the important work of defending this country. That motivational spirit must be coupled with cultural maturity to recognize that the wounds of war are not always visible, represent no less of a sacrifice from the warrior and deserve no fewer honors. From a perspective that I understand and applaud, the Pentagon T-shirt has a place as a motivational tool in our military culture in building resilience in young men and women as they prepare for war. I just hope we remember, when the fighting has stopped and the warrior has returned, T-shirts with the slogan, “Weakness is leaving a body in pain,” are no less appropriate.

U.S. Medicine issues last month and next month (October) will focus on the disease process of pain and its impact on our military. I, for one, am extremely pleased that federal medicine is having this important conversation, for it has been the defining discussion of my federal medicine career.

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