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.