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.

1 comment:

Nikhil Autar said...

Hey man. I've read your blogs for a while now. One thing I notice as a theme is one of depression. Of feeling overwhelmed, as if you aren't really accomplishing much from all of this. The great lie that is medicine I guess is that we will proceeed, in our lifetimes, to save hundreds of suffering people.
First off, I wanna tell you something I tell all doctors in your position.
That no matter what, you can, and ALWAYS will be able to make a huge difference to peoples' lives, no matter how insignificant this thing can make you feel.
Pain and suffering, and indeed, death, you can't alleviate all the time. But the way in which you influence someone's life in their most vulnerable, painful, hopeless moments, makes a HUGE difference to patients' lives. I know from personal experience (I'm a 2 time BMT recipient to treat my AML and suffer severe chronic GVHD because of it now). At the beginning of my journey, when I was first diagnosed, it was my doctor's words that got me to feel that I had some control in all of this. It was his actions, and the way that he practiced that inspired me even further to get into medicine. It was a letter from him to the medical board that allowed for that dream to actually happen.
But even now, with this incurable, long lasting, life threatening disease that is graft versus host, even after I developed this thought process that helped me get through the hardest parts of treatment, I find my doctor's words and interactions influence me greatly.
My care changed hands recently, as my old doctor had retired. My new ones left me disingenuous about my own health. They talked down to me, they refuted everything I said, it was almost as if they wanted to prove me wrong all the time (despite the fact that the publications on medications I'd looked up for a more recent disease I'm dealing with, bronchiolitis obliterans, they hadn't even read papers on... since then, I've been put on the medication...), and left me feeling anxious about my health, for the first time in years. The attitude I'd developed to deal with all those kind of feelings dropped away with that, perhaps because it exacerbated my depression.
Then I saw a doctor, as a second opinion, from another hospital. We talked about my health. The back and forth was glorious. Finally! Someone who was well read in his field actually explaining things to me! Finally, someone who actually cared about my sleep, stress and quality of life. Someone who treated even the little things, like my feet which were aching, rather than dismissing them in favour of "the bigger problems". That one consultation changed my outlook on everything immensely. I still know I may well die to this disease. That it could happen in years too. But I no longer worry so much, I feel better cared for, and that's spilled over to my life in general.

You can do that every single day as a doctor. It won't mitigate the long hours, the fact that many patients won't be helped, or listen to your advice, nor will it eradicate this system, that, in your country in particular, often dooms the poor to poor outcomes. But it will change at least 2 lives.
The first of that patient.
The second, your own.

Because if YOU can go into work, everyday, telling yourself that you're going to be that doctor that eases the pain, suffering and misery of others, you'll not just renew your faith in your ability to cause change, but perhaps even enjoy it again.
I hope this gets to you. And I hope this helps you out.

This was a video I did on that matter... check it out.