Using the concept pain to symbolise an experience makes it possible to tell other things about it. For example, “I feel better now”, “It burns”, “The pain is spreading”, “I need a break”. It also allows a person to tell other people what is happening and to solicit their help in delivering analgesia and care. However, in the swing and play of life, people tend to be careful about who and when they communicate pain (4). The unpredictability of social reactions to pain in others reveals indeterminacy in our concept pain, which is reflected in different uses of “tell”. In pain discourse, “telling” can be used in at least two ways. We can say “Eli can tell that Susan is with pain”, or “He could tell you that Susan is with pain if he wanted to”. Again, these uses are linked to participation in a social milieu where specific rules are learnt for the regulation of concepts. For example, people growing up and living in rural communities in Australia and New Zealand conventionally learn social rules for the use of certain concepts, commonly self-reliance, stoicism, or fatalism (8–11), which make them more accepting of chronic pain, disease, or illness than people in urban environments. These concepts are paired with rules that instruct when it is appropriate to tell others about being with pain. A common rule in rural communities is for adults to tell other adults about personal pain when it interferes with work or important social activities (12). Otherwise, it is appropriate to “carry on” (8). One farmer in New Zealand observed (8, p. 403):

Who in particular is told about pain in rural areas is also guided by rules. In rural and remote Australia, the GP in some communities is from a different culture and speaks English as a second language (13). Rural people tend to distrust “outsiders”, including medical professionals, consulting instead with their own community networks for assistance or advice about pain or illness (14, 15). This practice could mean that rural people prefer concepts to function against a more stable than changing background; therefore, concepts must be more determinate than indeterminate. Such speculation highlights the importance of tight kinship in rural community networks, for correct use of the concept pain involves convergence in judgements about what is significantly the same; thus, it involves understanding the consequences of pain in the rural milieu. Telling another about being with pain involves having some idea what to expect from the other and being able to relate to and understand this person. Thus, together with applying certain rules, “telling” in this setting also involves a sensitivity, or “feel” for human behaviour. This could explain why rural people prefer not to tell “outsiders” about personal pain.

Telling another about being with pain if one wants to can create divergence between patient verbal self-report and non-verbal pain behaviour, which can limit or obstruct the efforts of health professionals to intervene on the patient's behalf, resulting in inadequately managed pain (17). In comparing rural and urban nursing homes, rural nursing home staff, “more so than their urban counterparts, emphasized stoicism as an attitudinal barrier on the part of residents that interfered with pain assessment” (18, p. 745). A foundation of pain discourse is that the person's sincere utterances about his or her own pain are treated as correct. To introduce doubt here (e.g., “stoicism as an attitudinal barrier”) could alter normal discourse; specifically, it could undermine the authority of the subject. In contrast, convergence in pain definitions and judgements can preserve the special role of the person with pain and improve the clinical interaction. In a qualitative ethology study (17), Spiers describes a rule co-created between patients and nurses in urban home-based care, for which “stoicism did not imply enduring excessive pain but…the ability to know where one's pain boundaries lay and to take appropriate measures to keep pain within those boundaries” (17, p. 296). The nurses effectively implemented this shared rule using different communication strategies (17).

From clinical cases like these, Beeckman et al. (18) speculates that rules in the pain setting are a “double-edged sword” as rigidly following pain-related rules despite costs could be a risk factor for worse outcomes, whereas flexibly switching between pain-related rules—e.g., exchanging a rule stipulating pain-related avoidance for one stipulating acceptance of pain—depending on the situation and benefits could help explain “resilient functioning” with chronic pain. According to rural nurses, generational and geographical factors explain stoicism in rural people with chronic pain (19). Residents in rural nursing homes expect to be with pain; according to nurses, “It's how they age here” (19, p. 745). For rural residents with pain, the switch to following a new pain rule would need to contribute to desired consequences (e.g., minimal interruption to work) but perhaps more importantly, the new rule would need to integrate into the fabric of rural life: “…we don't just look for what's gratification for ourselves, we’re looking through for the next generation, wanting to provide” (8, p. 403). As our needs or interests change, or simply as part of life, our concepts can evolve over time. An evolved concept could supply us a new rule guiding the way we behave, which could correspond more or less with existing rules (3). Although our concept pain is flexible on the rules we use, the rules we adopt must be usable.

In experimental studies, rural groups tend to report higher rates and more intense chronic pain than people from urban groups (e.g. 20),. Poorer access to pain treatments for rural compared to urban residents could partly explain differences in pain outcomes (e.g. 21–23),. Another possibility is that urban residents are less attentive to their pain due to the multiple interruptions that can compete for their attention in the city environment (20). By contrast, rural living is described as “peaceful, tranquil, spacious, friendly and caring” (24, p. 211). With fewer external interruptions competing for personal attention in the rural setting, rural residents could have learnt, on average, to be more alert to pain and its qualities than urban residents.

In this article, I have argued for the perspective that pain is not merely a “raw feel” that is privately and unproblematically perceived by human beings; it also has a social role, which is learnt. When a person can correctly signal that she is in the requisite bodily state, then she has a conception of pain. The risk of disagreement in our judgements about others with pain, which rests on our diverse and unpredictable reactions to pain behaviour, should motivate trust-building and shared decision-making in the clinic. I have lent support to these claims in the article through linking the ambiguity of “tell” to rules for the use of concepts, such as stoicism, as applied in rural settings.