Wednesday, December 26, 2018

How I Stopped Worrying About Giving Up Chronic Pain

I decided last March to give up chronic pain.  I blogged about it.  I am now down to my last few clinics.  I had continued to agonize about whether I was making the right decision.  Until last Friday’s clinic.
The last pain clinic before Xmas is always interesting.  People bring in baking, candy and occasionally liquor.  (I have for years thought about asking them to donate to charity instead but this of course presupposes they would even give me a gift.). On the other hand it is a littler busy and you end of dealing with a lot of prescription faxing because people need early releases or realize their prescription is going to run out over Xmas.
Three things on an otherwise good day just pissed me off.
  1. One of my patients has been going to the local block shop where she has been getting blocks.  I have no idea what type of blocks or where because they never send me reports.  I may have referred her there, it wouldn’t matter, they hardly ever send me their consults.  Anyway she told me she was getting rhizotomy and she had been told to take 2 weeks off after it.  Then the capper.  She brought her disability form which they had told her to have me fill out.  I was a little shocked and told her I didn’t fill out those forms.  I told her to take them to her family doc, which I am not proud of.  I should have told her to take them back to the block shop. She left disappointed, maybe angry.  Probably the last time I will see her.
  2. Next I get an email from my PCN pain clinic pharmacist. Another patient had a rhizotomy at the same block shop.  This time I had referred her there.  This made her pain worse rather than better.  Funny how nobody doctors or patients considers that that might happen when you apply radio frequency current with a large needle.  Anyway the block shop was refusing to prescribe any analgesics.  After initially refusing myself on the basis of “you break it, you buy it”, I thought better and faxed in a prescription for hydromorphone.  If you think that this is just a problem with one particular block shop; actually this is the best block shop  It is mostly physiatrists, they actually examine patients.  Just about everybody gets a block though.  Did I mention her family doc has taken 14 days off over Xmas with nobody covering her practice?
  3. Later that day a patient I see sporadically came in.  He has a very complex pain and psych history.  So his psychiatrist decides this is a good time to wean him off all but one of meds.  Yes this includes narcotics but also included a lot of psych meds.  Surprise, surprise his pain is worse and I am supposed to sort this out the Friday before Xmas when I’m going to retire in 3 months.  “Did you tell this to your psychiatrist, “ I asked.  Turns out he had seen the psychiatrist 2 days earlier but they had only talked about his mood.  I suggested that he go back to his psychiatrist and ask to go back on his meds.  As if this is going to happen before January.  I have nothing against deprescribing, I think it is good idea sometimes as long as you are prepared to admit when it isn’t working.  I know there are 2 sides to every story and his psychiatrist might have had a very good reason to want to wean him off.  I of course don’t know because he never bothered sending me a copy of his notes.  And he can’t say he didn’t know I was involved in his patient’s care, because I sent him a copy of my last progress note.  I could try to phone him except that in 25 years I have never gotten through on the phone to a psychiatrist nor has one ever returned my calls.  Not to mention it is Friday, Friday before Xmas.

Hey I know that disability forms are a pain to fill out and most of us think if a patient tells his employer he needs time off, they should within reason believe them.  I also know that our colleges and people like David Juurlink have made the prescription of narcotics dirty.  The point is when you accept care of a patient you should take responsibility for their disability forms and for the complications of your treatments.  You should also communicate with your colleagues.

I thought that I was giving up chronic pain because I had lost my compassion.  In fact I now realize that it is the whole medical environment that has finally.  Not administrators, EMRs or lack of resources.  It’s the whole “not my problem “ attitude that has malignantly affected medicine.  Every week some patient tells me about their latest interaction with a physician, it could be their family doc or a specialist, and I think of how ashamed I am to be a physician.  To be fair, there are some doctors who give their chronic pain patients excellent care, with whom it is possible to work with.  The thing is, that these doctors are now so uncommon that they stand out.

So I will mostly be spending the rest of my career working almost exclusively with surgeons.  I have written and thought a lot about surgeons, some of it in jest.  Surgeons are economic with the truth, a little arrogant, tardy and make me work when I would rather not.  But...surgeons give a shit about their patients at least for the time under surgery and frequently for a few days before and after their operation.

Wednesday, September 5, 2018

First days of medical school

With getting older comes all sorts of anniversaries.  I started medical school 40 years ago today.

There were the prelims of course, getting the letter of acceptance sometime in June, writing back to accept their offer and I believe there was a deposit cheque involved.  There was also a trip over to Vancouver to pick up the microscope they said we had to buy.  I quit my summer job a week early much to my father's distress; everybody except him thought I needed a little time before starting medical school.

Starting was simpler than for some.  I had been at UBC for 3 years of undergrad already; I only applied to one school and planned to be either starting medical school or finishing off my degree.  I had a room in the student residences.  My friends had got a house off campus; I preferred to have the familiarity of residence and the ability to roll out of bed and walk to my classes instead of dealing with traffic or buses.

My recollection is I went over by bus and ferry on labour day.  At UBC the week after labour day was registration week, a week of drunken debauchery before classes started the following week.  No registration week for the medical school.  Classes started the day after labour day.

So it was on September 5, 1978 that I found myself in a lecture theatre in the Woodward Building sitting in my usual seat at the back, looking around wondering if I knew anybody in my class.  As people filed in, I recognized a few faces from lectures and labs and even somebody I didn't know all that well but had gotten drunk with a couple of times.  I had a negative opinion of what I thought would be my future classmates.  I expected a serious, hard working, cut-throat group of people.  I expected the next 4 years to be a busy, hard and socially very boring time.  (The summer before I started I was introduced to a visiting fiance of a co-worker as a medical student.  "Oh," she said, "I know a few medical students....I don't like any of them."  Great, I thought I've known you for a minute and you've already insulted me.)

Negative thoughts notwithstanding it was an exciting time, the culmination of three years of undergraduate always with a goal of getting into medical school.  We were welcomed by the Dean who informed us that we were the chosen people and welcomed us to the great fraternity of medicine.  We were then registered, and photographed.  I am not sure whether we had further classes that day.  There was a trip to the bookstore to pick up all the texts they said we needed, including the anatomy trilogy written by our Professor of Anaesthesia.  I also bought an ugly short white lab coat.

I went to the Pit (the student bar at UBC) that night and ran into my old friends and got little drunk which meant starting my first anatomy lab the following day with a bit of a hangover, which I would not recommend but I survived the day.

Thursday afternoon was the useless touchy-feely course we took in first year and we were divided into groups of 8.  The 8 of us sat in the room and some older adult asked us to tell the group something about themselves.  It was a round table and the talk started to my right so I got to talk last.  That was not good.  The first 6 had all had incredible lives, attending schools overseas, volunteer work and they all knew exactly what kind of doctor they wanted to be (and that kind of doctor was not an anaesthesiologist or a general practitioner).  Fortunately the person to my left, turned out to be a down to earth person, with an ordinary life, actually from Victoria although from a different high school.  Then I told my boring life story and we went on to something else.

Later that Thursday we had a tour of VGH lead by 4th year medical students who seemed so incredibly cool, followed by a party in the Medical Student Lounge on 10th avenue.  This party was by tradition put on by the second year class who had survived first year.  They were, as I later learned, by UBC standards an intense group.  Talking to them was somewhat anxiety provoking as they told us about the amount of work we could expect to do in first year (which was mostly true) followed by telling us that second year was worse (which it wasn't).  This was very depressing but  we had Friday morning off and the beer was cheap, so I got to have a few and made some friends in my class and I remember in the early morning a bunch of us heading off to Bino's on Broadway for pancakes before somebody drove me back to the campus.  This was to be the first of many drunken parties in medical school. 

Friday afternoon the first week was our 3 hour Biochemistry lecture and I was most impressed when Dave, my new dissecting partner loudly announced that the lecture would be continued in the Pit.  It just happened to be the night of the second Ali-Spinks fight which was on the big screen and it was great to see Ali regain his title.  Between that and running into my old friends, I think I closed the Pit down.  Medical school was not looking bad.

First year was heavily weighted on Anatomy with 3 or more dissection labs a week, along with a histology lab and 2 hours lectures 3 days a week.  It became apparent that most of us were in grave danger of failing anatomy if (or even if) we didn't work our buns off.  This was memorization of trivial details on a scale none of us had ever encountered.  It was, I am sure, humbling for all us, accustomed to being at or near the tops of our classes to have to shift into survival mode.  The whole stress of the situation seemed to bring everybody together perhaps in the same way basic training brings together soldiers.  We spent so much time together in those days as we all had same lectures and same labs.  We usually ate lunch and had coffee together, and frequently drank together.  People started inviting the whole class to house parties. 

Our class was the largest ever at UBC with 88 students.  There were supposed to be 100 but they weren't able to expand the anatomy lab to fit that number (which may have been galling to the 12 people who found themselves left on the waiting list the day after Labour Day).  Also a first we had 33 women which was most ever at UBC.

I think back now on how little I knew of what was ahead.  I knew nothing of details like specialization, certification exams or what was involved in being on call.  I had no idea what an anaesthesiologist was.  The only one I was aware of was the morose Australian on MASH, who always seemed to say, "Oim losing 'im Hawkeye".  Looking back it is interesting of how little we were prepared for the world we were going to go into  or that in which we live today.

I believe all but two of our class graduated although it took some more than 4 years.  One poor fellow failed anatomy and the summer supplemental anatomy course and was turfed.  The other developed schizophrenia in second year which was fascinating but depressing to watch.  We all went away to internships, did locums, residencies, settled down in various parts of country, a lot of the class eventually washing up in the lower mainland.  We had a 5th, 10th, 15th, 20th and 25th anniversary.  Only about 40 people attended our 25th anniversary in Vancouver, surprisingly given the number who lived in the area.  Nobody bothered organizing a 30th or 35th (maybe they did but didn't invite me).  Two of my classmates work in my city.  I used to see one, a neurosurgeon, a lot when I worked at the Centre of Excellence.  The other a psychiatrist, I last ran into over 10 years ago.   At least 3 of our class have died including my good friend Dave and also Phil who was in my dissecting group.  (The fourth member of our dissecting group, contacted me a few months ago on LinkedIn and introduced herself as the other surviving member of our group.)

40 years on now, I can just look back to the excitement, the fear and the relief of those first days in medical school.

Sunday, March 25, 2018

Leaving Chronic Pain

Sometime last month was my 25th anniversary of my first pain clinic.  I was at the Centre of Excellence, and the person doing the Pain Clinic went on to better things.  The Professor told me I could do the Pain Clinic until they found somebody smarter than me to do it.  Problem was there was nobody smarter or stupider and 25 years later here I am, although not at the CofE.  I should have had a party, moreover somebody should have thrown one for me.

A couple of weeks ago, I gave notice that in March 2019, I will be giving up most of my chronic pain practice and become a more or less full time anaesthesiologist  again.  Like many decisions there was no “last straw” moment, it was a series of small things.

One reason is that despite everything we complain about, being an anaesthesiologist is a pretty good gig, if only for this reason.  When you see the hospital in your rear view mirror at the end of the day, unless you are on call, you know you are finished.  No phone calls from the ward, patients, pharmacies or other doctors.  If for some reason you want to go on a long vacation, you don’t have to arrange coverage and you know that you won’t spend your first two weeks back, putting out all the fires that started while you were away.

I have been pretty good about setting boundaries and have a great colleague who covers me when I am gone.  Patients expectations about availability are less too, I get a lot fewer calls now.  Still I have voicemail and a fax which go to my email which I check even on vacation and the hospital switchboard has my cell number.   I could ignore them because switchboard is supposed to know when I am away and my voicemail greeting usually says I am away and who is covering but I still feel guilty, even when the problem is not one of my creating.  For example I spent a great deal of time on my 60th birthday dealing with a patient who had messed up big time.  I did this after the pharmacist from the PCN pain clinic emailed me to say he needed urgently to speak with me.  Okay why was I checking emails on my birthday?  Because that’s what I do.

I met a pain specialist from another centre about 10 years ago at an anaesthesia meeting.  "I'm thinking of going back into anaesthesia", she said, "I want to retire soon and I can't handle the demands of my patients."  Sounded strange at the time; most people give up anaesthesia and the call involved to do chronic pain, I almost did a few years ago.  This encounter did plant the germ of this idea in my head.

The biggest thing however is that I realized a few months ago that I have lost my compassion.   I no longer have patience for people who won't try do anything to help themselves, I no longer want to hear about problems that I have no way of solving.  90% of my patients are good people who try do everything possible and I have a treatment that might help them or is helping them.  Like most things in life, it is the other 10% that take up most of my time, that leave me feeling drained at the end of the clinic.  I don't want to be seen as blaming patients for their misfortune, its just that quite a bit of the time I have nothing to offer and don't really want to hear about it anymore.  So often I want to say, "YOU have a problem, what are YOU going to do about it?"

Pain medicine and medicine in general have changed over the last 25 years that make it less attractive to practise.  25 years ago most of my patients had a family doctor, moreover they had a family doctor to whom I could make recommendations that they would follow.  Now when I get a referral, I get the sense that the family doctor has washed his hands of this patient.  That is of course if the patient has a family doctor and a significant number don’t.

Paradoxically we have way more physicians doing chronic pain than 25 years ago.  This should make it easy.  It doesn't.  25 years ago, I was almost always the first person to see a patient.  Now quite often they have already seen one or more chronic pain specialist.  Quite often they are still seeing someone else (I saw a patient a few years ago who was seeing 4 other chronic pain doctors; she was quite disappointed when I told her I didn't think there was any point in my following her as well).   This would be nice if I actually had the records from their previous doctor so I could see if I had anything else to offer but that is the exception not the rule.  Moreover some of my colleagues have developed boutique-type silo practices where they offer single modalities, usually interventional treatments.  Quite often the patient is still getting these treatments but the expectation is that I will prescribe medication for them.  Or one of my colleagues has started them on some toxic cocktail of multiple classes of drugs that I am supposed to unravel and continue.   And with all this expertise floating around we should be able to work together in the patients' best interest?  What universe do you live in?

So why don't I, as somebody suggested, just carve off the parts of chronic pain practice I enjoy and forget about the rest?  If only it was so easy to tell in advance who was going to be easy and who wasn't.  And the easy patient of course so easily becomes the hard patient.  I have for the last few years been more selective in screening out referrals and in my new consults so that I am accumulating fewer patients I know I can't help with the resources I have available.  But I have never been comfortable telling a patient that just because I can't do some lucrative procedure doesn't mean I can't try to help you.

It is hard to talk about chronic pain without mentioning the opioid crisis or epidemic whatever you want to call it.  I still prescribe opioids for chronic pain, although not in the industrial doses some of my colleagues prescribe.  So far I have escaped scrutiny from our medical licensing body.  Every quarter I do get a list of patients who are over the recommended dose which I read with some interest.  Talking however to some of colleagues who have undergone scrutiny and have had to pay 10s of thousands of dollars in  "costs" of the investigation or fees to attend remedial courses scares me a little bit.  I am less than 5 years from retirement, slowly building up my nest-egg.  I look at some of my patients and think, "is patient X, the hill I want to die on?"

And of course with increased scrutiny from the licensing body, a significant number of referrals I get are dumps of patients who have gotten onto these industrial doses not to mention a number that are doing well on a reasonable dose and the expectation is that I will take them over in my solo part-time practice.  Which of course I do because I am an old school doctor, who doesn't want to see patients go through narcotic withdrawal.

Narcotics still confuse me and I have no idea what the right answer is.  I have mentioned above, that I have reluctantly acquired a number of patients on whopping doses of opioids.  Most of these people seem to look okay.  Their function like most chronic pain patients is not the best although I periodically find somebody who is actually working.  Most of them are quite happy on the massive doses they are taking; they don't want to see a psychologist or attend a rehab program and they definitely don't want to come off their meds.

On the other hand I read a lot in the medical literature and on Twitter (where I get most of my medical info now) about all the bad effects of narcotics, and there is no doubt that there is some truth in all of this.  The question is where is the balance because as somebody who follows a lot of patients on narcotics, clearly some of them benefit greatly from them with little or no adverse effects.  Further I have seen a number of ugly cases of forced weans that ended up in my clinic.  Our Workers Compensation board has recently become evangelical about weaning off opioids, at least once a month I have to spend 20 or minutes consoling a distraught patient who has been told they have to go to a clinic in a city 3 hours away to be weaned off their meds.  They all think I have some magic clout with WCB.

Just something I don't want to be bothered with anymore.

In fact these patients are the most difficult for me to abandon.  I hope to transfer those with understanding GPs back to their GP.  Some of the complicated ones I am referring to some of my colleagues and my colleague who is taking over my clinic time will take over some.  Our licensing body told me that as long as I gave them 3 months notice, I had no obligation at all to arrange follow up.

Chronic pain still confuses me.  I still don't know what causes back pain or neck pain.  I could be one of those people who says, "yes it's definitely your facet joints and every three months I will inject steroids into those joints or maybe just burn the nerves"  but I know its not that simple.  So I end up offering what I think might work, usually in my case trigger point injections and an antidepressant but feel like an idiot for doing so.  I should be telling them to exercise and lose weight, like that will ever happen.

Patients often ask me about some bizarre symptom they are having.  "Is this normal?"  they say.  "No", I reply, "it is not normal but it is not unusual."   I have learned that patients have these symptoms, they are real; if they're making it up, that too is pathology worthy of treatment; and that in most cases I can only guess at the psycho-physiological mechanism behind it.

The lack of  supportive infrastructure is another factor.  I usually go to a pain meeting once a year where I hear presentations from psychologists and physical therapists and I come home excited and ready to help my  patients.  That is until I try to refer and find that my patients can't afford any of this and the very few practitioners in the public field have exclusion criteria that effectively excludes all my patients.  Long ago at the CofE one of my colleagues came back from his Pain Fellowship (at Boston College, not Harvard as he now tells everybody) to join me in practice.  "Where," he asked me, "do I refer somebody for inpatient rehabilitation?"  I was polite and supportive.  I didn't roll on the floor laughing.  I told him that no such program inpatient or outpatient existed and that he better learn to live with that.

Periodically we get to meet with our regional admin.  They usually tell us how much they support what we are doing and then we don't meet again.  A couple of years ago when I last got invited, I was a little punchy.  "Are you going to be giving us more resources, " I asked, "because if you aren't I really have no interest in attending any more meetings".  And I didn't.  It is not just not having new resources, it is not being able to access existing resources that bugs me.  And it just galls me to see all the new programs that have sprung up for chronic diseases while we have been told there is no more money for chronic pain.

Things are a little better now, we do have self management programs and also some exercise programs.  Thing is, these are all by self-referral and the likelihood of the passive fix-me-now pain clinic patient phoning the number and driving across the city (because they are never central) to attend one of these programs is close to zero.

Anyway, while I sometimes lie awake at night wondering if I am doing the right thing, blowing up 25 years of practice, I told somebody I was retiring (from chronic pain) and it felt pretty good.  Maybe somebody will throw a party for me.