As I move into my second year of residency, I have acquired a number of patients with chronic pain. This is challenging because of the regular number of prescription refills that then fill my electronic medical record inbasket requesting opiates (narcotics). These are not medicines I have ever started a patient on on a chronic basis, and I hope to avoid doing so. These patients, however, have been on these medicines for years in many cases, and it is left to me to try to help them deal with the impact of chronic pain on their lives, including writing prescriptions for medicines on which their bodies are now dependent to stave off the pain that initially debilitated them in various ways.
In addition to my discomfort with regularly prescribing (sometimes large) quantities of highly legally controlled medicines, this situation has caused me to examine myself as I see my own reactions to these patients. My level of frustration and feeling of helplessness surpass what I would expect from the need for frequent appointments, urine tox screens to ensure there is no other drug (ab)use going on, and simple script signing associated with these patients. I hear the same frustration in other residents as they talk about these patients. I think it comes from a deeper cause.
When interviewing for medical school, most applicants are asked, "Why do you want to be a doctor?" The most common answer is, "To help [hurting] people." I think the key is here. We go into medicine hoping to help, to cure, to be part of healing. Most patients with chronic pain cannot be cured or healed by the reach of medicine. We seek with the pills within our reach to do some small part of helping instead. And even that is complex.
The medicines used for chronic pain run the gamut from medicines used for regular pain (Advil, Tylenol, Aleve) to medicines used for neuropathic pain (gabapentin, pregabalin) to antidepressants to (sometimes) opiates. This reminds me of the complicated nature of chronic pain. It is a case-in-point of the integrated nature of who we are as human beings. Our emotional, mental, and spiritual status deeply impacts our physical well-being and our subjective experience of our physical illnesses.
Pain is hard, too, since it is so subjective; with chronic pain patients, often there's nothing there to point to and say, "This hurts" as one can to a broken bone. Do I believe my patient's report of pain without questioning? Is their early request for a refill evidence of undertreated pain or of possible abuse, taking more of the medicine more frequently than prescribed? There's a lot of judgment involved, and it's hard to judge another's complaint of pain.
I think dealing with chronic pain well requires a re-working of how I think about the role of medicine. It requires seeing a good part of my role as a doctor as that of care rather than cure. It means seeking to remember the patient is a whole person and reminding them of it, that they are more than the pain that can become so all-consuming and -defining. It is encouraging their health in the other ways that affect their experience of physical pain - mental, emotional, relational, spiritual. It requires a steady balance of firmness and boundaries with compassion and connection. It is challenging, and I'm not sure that I have it worked out; sometimes I think I lean too far with one patient towards leniency and too far with the next towards strictness. Trying to achieve some level of evenhanded fairness while still feeling with patients' expressed pain and desire for relief that I can provide, even if it means an addictive, abusable medicine, is hard. I don't want to become jaded or cynical but allowing my patients to manipulate me into giving them what they want if they may be abusing it is not loving to them in the long run, either. It's a hard road to walk, and I'm still figuring it out.
In addition to my discomfort with regularly prescribing (sometimes large) quantities of highly legally controlled medicines, this situation has caused me to examine myself as I see my own reactions to these patients. My level of frustration and feeling of helplessness surpass what I would expect from the need for frequent appointments, urine tox screens to ensure there is no other drug (ab)use going on, and simple script signing associated with these patients. I hear the same frustration in other residents as they talk about these patients. I think it comes from a deeper cause.
When interviewing for medical school, most applicants are asked, "Why do you want to be a doctor?" The most common answer is, "To help [hurting] people." I think the key is here. We go into medicine hoping to help, to cure, to be part of healing. Most patients with chronic pain cannot be cured or healed by the reach of medicine. We seek with the pills within our reach to do some small part of helping instead. And even that is complex.
The medicines used for chronic pain run the gamut from medicines used for regular pain (Advil, Tylenol, Aleve) to medicines used for neuropathic pain (gabapentin, pregabalin) to antidepressants to (sometimes) opiates. This reminds me of the complicated nature of chronic pain. It is a case-in-point of the integrated nature of who we are as human beings. Our emotional, mental, and spiritual status deeply impacts our physical well-being and our subjective experience of our physical illnesses.
Pain is hard, too, since it is so subjective; with chronic pain patients, often there's nothing there to point to and say, "This hurts" as one can to a broken bone. Do I believe my patient's report of pain without questioning? Is their early request for a refill evidence of undertreated pain or of possible abuse, taking more of the medicine more frequently than prescribed? There's a lot of judgment involved, and it's hard to judge another's complaint of pain.
I think dealing with chronic pain well requires a re-working of how I think about the role of medicine. It requires seeing a good part of my role as a doctor as that of care rather than cure. It means seeking to remember the patient is a whole person and reminding them of it, that they are more than the pain that can become so all-consuming and -defining. It is encouraging their health in the other ways that affect their experience of physical pain - mental, emotional, relational, spiritual. It requires a steady balance of firmness and boundaries with compassion and connection. It is challenging, and I'm not sure that I have it worked out; sometimes I think I lean too far with one patient towards leniency and too far with the next towards strictness. Trying to achieve some level of evenhanded fairness while still feeling with patients' expressed pain and desire for relief that I can provide, even if it means an addictive, abusable medicine, is hard. I don't want to become jaded or cynical but allowing my patients to manipulate me into giving them what they want if they may be abusing it is not loving to them in the long run, either. It's a hard road to walk, and I'm still figuring it out.
sounds like a very difficult judgment call to make. :/
ReplyDeleteBekah
I remember still my total shock when my physical therapist told me I was being treated for chronic, not acute, pain. When I understood that this pain was not going to go away, I had to learn to re-think about pain in a different context.
ReplyDeleteI have learned to tread the fine line between ignoring my pain too much and thus ignoring my body or paying too much attention to it. Is the pain today going to keep me from doing what I need to do? Is it manageable?
We should be taught to pay attention to the pain as well...what makes it increase or decrease? What is it telling us? To rest, to stop doing something or eating something? That the weather is changing?
We in the First World are conditioned to believe that somehow life will be pain free. I think often of the sufferings in the Middle Ages or in other countries where very little pain medication is available. But we want relief instantly. Pain is a messenger to us, and sometimes we need to live with it.
One thing that I feared is that if I used too much pain prevention medicine, it would no longer be effective for me. How little can I use for this issue?
Finally, I often remind people that living with chronic pain does take energy, and is exhausting. It takes energy to suppress in a small way some of the calls of the pain. I thank my body for telling me what is going on, and don't see pain as an enemy. So I thank it, tell it that I now have the information, and I would like to be notified if things change. Then I give myself permission to rest, or abstain from doing something, or generally healing my body.