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.