Pain of life

I've generally tried to avoid getting into trouble with opioid medications, but in primary care, it's difficult to avoid. There are a lot of people on pain meds. And there's a lot of chronic pain out there. And all the talk these days about inappropriate pain medications, I feel it's disingenuous.

When I was in medical school, it was hammered bluntly into our heads that pain is an important sign, so important that it should be considered the fifth vital sign. We need to treat pain, and we should be ashamed if we lacked the compassion to address pain. We were told that the likelihood of developing abuse was so paltry that it wasn't worth discussion. We were indoctrinated into a culture of pain control that was whimsical and optimistic and did not take any measure of reality. 

Now, we are told that patient satisfaction is critical to excellent care and best practices. If you know an inpatient doctor who has never heard of HCAHPS, then that's one blissfully ignorant dude. And HCAHPS even has several questions that directly deal with pain. As if patient satisfaction has ever correlated with good medical care. It's a hospital, not the Ritz-Carlton. 

But I think that we have a really poor understanding of pain. From both sides of the fence, people do not appreciate that pain is not simple. Pain is tremendously complicated and the factors that govern it are not easily appreciated. I pulled my back in the gym and actually passed out from the pain. I couldn't walk for two days. I didn't take anything because I knew that eventually, the pain would go away. But for my 50 year old patient who was abused as a child and raped as a teen, abused by her ex-husband and abandoned by her daughter, she has no such confidence that her back pain is going to get better, and guess what — it doesn't. And so pain meds make life just a tiny bit more bearable. Is that the appropriate goal of therapy? Is it okay that the pain meds are only there to make the day go by faster? I don't know what the right answer is.


The digital age

A while back, our EMR system went down. It happens to everyone eventually. Servers have downtime, and sooner or later, you have an outage. Sometimes it's brief, sometimes it's long, but without fail, when it occurs, the frustration is instantaneous and furious. And the old guard bemoans how terrible EMR's are, and how they cripple our ability to care. And that is ludicrous. So let's take a step back and remember the days of paper. I remember them well. There are a few wonderful events that everyone who remembers paper charts should recall, and then find themselves resigned to saying that electronic records really are better.

Handwriting is far and away the most obvious issue with paper charts. When I was in residency, there was a cardiologist with such bad handwriting that anyone who could read his handwriting was often called to interpret, whether or not they were on that patient's case or even whether or not they were in the hospital. I have uttered the words, "That loop looks like a H, so I think we should start heparin." I spent a measurable part of my day as a resident simply deciphering the terrible handwriting of other care providers.

Much more troublesome than handwriting was late charting where people would carry around their notes and then insert them into the chart later in the day, or even days later. I got into an argument with a patient before because he was convinced he saw the neurologist, but there was no note from him. Two days later, a chart note mysteriously appeared. Or nurses would chart an entire shift of vitals at the end of their shift. It was so much trouble fighting for the chart that it was just easier to chart your information some other time, and so it was often impossible to get up to date information. And that's not even accounting for paper reports, like labs or x-rays. It wasn't even worth referring to the chart for those. You'd go to the lab database or the radiology database, or if you were supremely unlucky, some poor loser sacrificed his morning by getting curbside reads on all the chest x-rays from the radiologist.

On the devious side, people would sometimes misrepresent their charting by where and how they did their notes. Some people would slip their note in several days beforehand, or date/time their notes to misrepresent when the work was done. I've seen things charted in different sections so that it would likely be ignored by medical/legal but would be safe for billing.

And then there's the missing pages that would inevitably occur, much more terrible in the outpatient setting where you might lose a note from 7 years ago that suddenly you need. However, I remember losing preliminary cardiac cath results so that we had to go down to transcription and put a rush on the dictation, since the cardiologist went home and we couldn't reach him, and needed the report to determine if we could discharge the patient.

But nothing was worse than the missing chart. I have had a student walk off with the chart to the study lounge for 2 hours and we were in full fledged hysterics. I had an intern take the chart to dictate a transfer note and the patient coded, and we had no idea what was going on or anything about the patient. I had outpatient encounters where another clinic was sitting on the chart (another doc hadn't done notes for weeks), and we sent people over to that clinic to get into a chart fight.

Sure I get frustrated with EMR systems that I've worked with. They all have their drawbacks. But thank God we don't use paper charts anymore. What absolute hell.

Authentic

How long does it take to know someone? How long does it take to be more than 'a doctor' and become 'my doctor'? I have a patient who I've seen for the past 7 years who tries his best to never see me. I have a patient who saw me one time 3 years ago, and he thinks the world of me.

I don't know what it is that I am doing. I don't actually know the recipe for good rapport. Is it listening? Is it patience? Is it time? Is it empathy? I do what I think is right, and is that it?

I know another doctor in town. She is a piece of shit. I have nothing but contempt for her. She is not incompetent. She is not fraudulent. She is lazy. She doesn't follow up on tests in a timely fashion. She doesn't educate her patients. She doesn't start meds when it's appropriate. She is careless and reckless because she cannot be bothered to do her job.

Being an internist requires a certain level of anal retentive behavior. It requires diligence and conscientiousness. It requires that you are, at least some sense, authentic. And maybe that's what people want from their doctor. That at the end of the day, they know that I gave a damn.

The Lord taketh away

Finding cancer is the worst. It never goes well. I remember one week in the hospital, I admitted 4 patients with new cancer diagnoses. There was the 80 year old with metastatic colon cancer with bowel obstruction. There was the family man with multiple myeloma. There was the young father with AIDS associated lymphoma. There was the college coed with AML. Everyone had a tragic story. Everyone had a bad hand to play.  

Last month, I found four cancers. Three of my patients thanked me, and I can't figure out why. Why are you thanking me? You have terminal pancreatic cancer. Why are you appreciative of my effort? You have metastatic breast cancer. This is not the time to thank me. This is not the time to be grateful. You should blame me. Why didn't I see this coming? Why didn't I stop this from happening? Don't thank me. Don't. You have every right to be wallow in self-pity. You have earned the right to be furious. Don't be grateful.

I realized that I really have no understanding of what it means to have cancer. I cannot understand why people are thanking me, as if there is anything to be thankful for. I am Job's messenger crying out 'All that you have and all that you love is lost, and I alone have escaped to tell you!'

And I watch as my patients rend their garments and worship, 'Naked I came from my mother's womb, and naked shall I return. The Lord giveth and the Lord taketh away. Blessed be the name of the Lord.' And much as I imagine Job's servant, I am dumbfounded.

Don't become a doctor #19 - biased

I have many gay patients. One travels over an hour to see me because he says I'm the only doctor who treats him like a person. One sees me because he has a crush on me. In real life, I've had gay men hit on me, so I have some basis for comparison. I don't do anything specifically to draw in gay patients. They just find their way to my practice.

In my heart, I have a lot of sympathy for my gay patients. It's a tough world out there, and being gay doesn't make it any easier, and especially now that there are so many doctors who let their faith and beliefs dictate the care they will provide. One of my gay patients told me how his previous doctor told him that he deserved to have HIV because of his sinful lifestyle. Wow. Yikes.

It's not my job to preach. It's not my call to say who is damned and who is saved. I don't get to look at a person and decide he is guilty or innocent. My job is to deliver medical care. And sometimes that means giving women birth control. And sometimes that means teaching a teenager about condoms. And sometimes that means talking to my pregnant patient about abortion. And sometimes that means that I see people who do things or believe things that I don't like. And that doesn't even cover gays. I like gay people. I can't believe we have devoted so much time and energy to trying to deny rights and freedoms to people who love each other.

I have a patient, he is a convicted rapist. He served his time, and now works a part time job and is 'retired'. He has several chronic medical conditions. His past doesn't mean that his diabetes doesn't need to be treated. He is still human, and still deserves to be treated like one.

If you cannot put your biases aside, and treat all people as deserving of medical care, and care for them without judgment, then you're probably best off staying away from medicine. You are not a priest. You job is to provide medical care appropriate to the patient, not your biases.

Indignation

There are some days where you discover what kind of doctor you are, and then some days where you discover what kind of person you are. I saw someone else's patient in the clinic for a sick visit, and her chart was a mess. Her medications were jumbled and erratic. Her diagnosis list was cluttered and with multiple duplicates. She had labs and diagnostic tests that were not reviewed. I managed to get a few things straightened out, her chronic medications sorted, and hopefully, she will do fine, but it's hard not to feel a little indignant.

In reality, what does indignation get you? Nothing. That smug feeling of self-satisfaction and superiority, it is comforting in the moment, but it does not give the patient a better outcome. It doesn't lower A1c. There is pride in your work, and it's good to have a sense of ownership and pride in what you do, but indignation? It is worth the paper it's written on.

There is always someone who will do a better job, and someone who will do worse. That never changes. Wanting to do better is great, but being better because you've pushed everyone else down doesn't actually improve anything.

Playing under protest

There's a term in baseball called playing under protest. What happens is that a rule is incorrectly applied and the manager of a baseball team protests. If the officials do not side with him, then the team formally protests, but the game continues. They are playing under protest. And the League office will review the game afterwards, and provide an ultimate judgment.

My life has been one long game under protest. When I was younger, I had planned to kill myself. That was the plan. But instead, I was called, By God Himself. Most people wait lifetimes for such a calling. However, I was disappointed. I did not want to live any longer. I didn't want to continue on the path that I was going. Instead, I would push forward, sent on a mission that I didn't ask for.

If I had to play, then I would be a doctor. I was asked to care for the people of this world, and I would do that through medical science. That was my calling. I worked hard for it. I got my MD. And I am still playing this game of life, achieving all kinds of notable things, doing all kinds of good works. I have provided lifesaving care to the sick, I have held the hands of the dying, comforted those in sorrow, and fought against injustice and inequity in the medical system. I have used my office to care for these corporeal vessels, gifts to us from God, and I have done so without judgment, indignation, or evangelization. I have done good things for this world in my life.

But I didn't want to live, and so far, I have yet to find a reason to continue living. Oh, I'm not depressed, and I'm not going to kill myself now. But I find no value, meaning, or satisfaction in my life itself. I love my work. My work is valuable and meaningful, and I am exceptionally good at it, but it is the task that was demanded of me. So, I continue under protest, hoping that at the end of this, I might get an apology or at least an acknowledgment that my protest had merit.