The Painful Treatment of Pain

I've been following recent discussions in the general press about the treatment of pain. The withdrawal of Vioxx has focused public attention on the FDA and on the subject of pain. Most people are well acquainted with acute pain but fewer suffer with chronic pain and thus the uninitiated often cannot comprehend why anyone would risk significant illness to gain pain relief. Even many physicians question the need for the use of narcotics in the treatment of chronic pain. I read one article where a physician said that the use of Vioxx might be warranted after the patient had 3 or more weeks of severe pain but the med should only be used until the patient had some relief and then it should be discontinued- spoken like a person who has no idea what it's like to have 3 weeks of severe pain! Perhaps the severely dehydrated patient can have water but once he makes urine again he should be cut off from the liquid that restored him. This type of thinking is not logical.
Chronic pain is a significant medical problem that invades and erodes all aspects of a person's life. It makes sleep difficult, diminishes enjoyment of food and company, intrudes on mental activities, stresses the body. Before I started Neurotin I tried to used meditation or mental activity to keep my pain in check. At times I would consider whether chopping off a foot or hand would lessen my pain by 25% or if the remaining 3 body parts would just hurt that much more. When my pain got to a 5 or 6 I would get into a very hot tub and stay there until I risked drowning. My pain would clear using this method but probably at the expense of brain cells that were injured by vasodilitation induced hypotension. When I started having pain at an 8 level I caved in and asked for a prescription for Tylenol #3. At first I was very cautious about its use but now I'm more liberal. If I have breakthrough pain that doesn't respond to heat, massage or rest then I'll take a Tylenol #3 rather than suffer needlessly.
The operative word being needlessly. Sometimes we need to put up with suffering to reach a greater goal- vaccines are a good example of that principle. But many times people are asked to suffer for no apparent reason other than that the person (or people) doing the asking is not willing to help eliminate the cause of the pain or effectively treat it. One of the tasks physicians are charged with is the relief of suffering yet many docs have been frightened away from the use of prescription pain meds by medical boards more interested in preventing narcotic abuse than lessening pain in the ill and injured. Physicians need to practice reasonable care in writing for any pain medication but should not let fear become part of the equation when treating pain. When that happens we all suffer.

Setting the Record Straight

No one enjoys being corrected and physicians are no different. When I speak to community groups about the patient's role in the medical visit I encourage them to get a copy of the physician note from any significant visit they might have. One example of such a visit would be a consultation with a specialist. The rational for this advice is obtaining the note allows the patient a chance to verify that the facts presented in the history are correct. Oral communication is especially prone to errors- nervous patients may mis-speak or be misunderstood. Tired or distracted physicians might miss unique details of the complaint or prioritize the symptoms differently from the patient. The assessment and plan that the patient "hears" might not be what the physician thought they said. Reviewing the note allows the patient to clear up misunderstandings, if they exist. This needs to be done in a timely fashion because what's recorded in the record seems to become "gospel" and could interfere with future evaluations if the facts are wrong.
Patients often find that receiving copies of visit notes can be difficult. I'm not sure why this should be the case as the record belongs to them. But the truly tricky part in this process for patients is getting the record amended/changed if it's incorrect. Calling the physician to inform them of discrepancies may be the easiest route but it doesn't guarantee that the record will be amended. Patients can write a letter which includes the changes they want to make to the history but that can get buried in the correspondence section of the chart, doing little to reflect the true history as documented in the physician's notes. I think the best approach is to schedule a follow up visit to review the history and have the corrected version entered in the note from that visit. On the physician side of things, we need to be open to the idea that we may make mistakes in recording the history. We need to understand that patients who request such changes are not threatening us but simply trying to fulfill their role in the relationship. An honest exchange such as this will strengthen the trust between the patient and physician and will lead to better care. Mistakes in history gathering/recording happen. They should not be compounded by an unwillingness to acknowledge and correct them.

"Who loves ya"

As I consider ending my practice of primary care medicine I am struck by the pain I feel leaving my patients. I have known many of these people for over 15 years. I've delivered their babies, casted their fractures, medicated their illnesses, held their hands. They are part of my life and I will miss them. Most will find a new patient-doc relationship that fits their needs and they'll do well. But there are a few that I worry will become lost. They have quirks or problems that make caring for them difficult. Who will love these patients and see the person and not the problems?
Every doc has patients like this and most of us learn to value them even though they drive us nuts at times. I started the day with a patient that I had not seen for years but I remembered her as scattered and needy. Today was no different but as her story unfolded I saw a strong woman who was holding things together for her children under very trying circumstances. Yet, despite her significant issues, she took the time to buy me a Valentine cookie. What a thoughtful,caring soul. A young woman came in with her child for the 3 year old's exam. All was well but it seemed like she needed reassurance about her child. She, too, brought a Valentine treat for me and her older child had written a message for me on the package. More kindness offered to me even though I'm supposed to be the care giver in these relationships.
As medical care becomes more specialized and disease specific I worry that there will be less room for compassion for the patient as a whole. The therapeutic relationship is a two-way street which I so clearly experienced today. "Who loves ya?" has many different answers attached to many different people.

"Brace yourself"

As I wait for the final results from my muscle biopsy I've decided to move forward in terms of improving my overall function. At work I shortened my day to 4 hours of patient contact 3 days a week. This will likely be 4.5-5 hours in reality but even that schedule will help me conserve energy and avoid muscle fatigue which can be so painful. I'll still do nursing home rounds and weekend call.
I also chose to be fitted for dynamic AFOs (lower leg braces) to improve my gait. These were recommended by a knowledgeable PT but I secretly hoped that the orthotist she referred me to would tell me assistive devices were unnecessary, he didn't. He pointed out the deficits the AFOs could correct and assured me they would not be noticeable under pants. I already wear a clavicular splint when I'm working so I hate to distract patients from their issues by having another visible support device for them to ask about. The patient-physician relationship involves a delicate balance of shared information. It's appropriate for patients to see their doc as a person but not to the point where it interferes with caring for the patient.
Last week I asked a partner who does sports medicine to look at my shoulders because they are causing more pain. He pointed out that most of my rotator cuff muscles are weak and atrophic. So are the lower traps, lats and left pec. I can't stabilize my scapulas so arm use away from my body is inefficient. I discovered that when Ralph made a full pot of coffee and I was unable to lift it out of the coffee maker. I've been trying to increase shoulder strength for the last 9 months so I see this as more evidence that my condition is progressing. I hope to be salvageable when I'm finally diagnosed.
Many patients fear that they won't be "fixable" if a problem is detected and that fear keeps them from seeking medical care in the first place. Most find that their fears are unfounded but for others this is not the case. While we continue to stress the benefits of preventive medicine, expand our diagnostic skills and explore new treatments, physicians also need to develop better methods for extending hope to those we can not fix. It is human nature to not want to face our areas of weakness but we cannot let that keep us from comforting patients in need. Rather than ignoring their phone calls or pushing them off on another doc we need to validate their concerns and offer reassurance that they will not be medically abandoned. Relief of pain, help in maintaining independence and setting realistic treatment goals are physician tasks that need to be done gracefully. Here the "art of medicine" is truly apparent. Medical school training and most residencies fail to teach this but physicians can't hide behind this excuse; they need to find ways to cultivate these skills through workshops or readings or via mentoring with a caregiver who does this well. It can be uncomfortable for docs to function in this role but once a physician gains skill in this area it's importance to the patient's quality of life becomes obvious. As a profession we need to brace ourselves and tackle this area of health care when the need arises.