PAIN, PART 2

Facts about narcotics that doctors assume patients know (and therefore don't address):

• Narcotic medications are addictive. Period. Even if you really need them, you can still be addicted. There was a big scandal recently which revealed that some drug companies had mislead doctors and patients about the dangers and addictive qualities of narcotics, so everyone needs to be aware.
• "Narcotics" aren't just illegal drugs like heroin. Narcotics are also those "pain pills" you get as a prescription. Sometimes the doctor asks if you've ever been dependent or addicted to drugs- THESE COUNT, and doctors assume you've never had a problem if you say no.
• TOLERANCE: The more narcotics you take, the more your tolerance builds up. Then when you experience even more pain, you need more medication. It's excruciating to watch people who are dependent on narcotics after surgery or an injury experience excruciating pain that we can't control because your body has such a high tolerance....

PAIN, PART 1

Being in a surgeon's office this week has really made me reflect about the wide variation of pain perception. Clearly, assessing and treating pain presents major quandary for physicians- who is really in pain? Whose pain are we missing? Are we killing people by over-managing pain?

I've heard the surgeon discuss narcotic pain medications multiple times with patients this week, and the bottom line is evident: doctors often do a horrible job of screening for pain (I'll place most of the blame on a lack of tools, because there's no magic lab test or xray) but also explaining the proper use of narcotics and the risks of inappropriate or long-term use.

Narcotics are a big pet peeve of mine (not when used "correctly" of course, but even that's not well-defined). Volumes of books could be written on this subject (and have been) so ill try to be brief (and also divide this up into multiple posts).

This is a bit like discussing politics around election time, so I'll try to be as objective as possible (which is impossible)....

TAKE A HIKE, SAVE YOUR BRAIN

Doing crossword puzzles was my "morning coffee" during college- the absolute only thing that kept my forehead off the desk in 8am classes. I justified it by convincing myself that word puzzles were just as important to keeping my neurons happy and healthy as the chemistry I was unable to concentrate on.

Well, it turns out that might not be true....

UNDEADING

So you're driving down the road, and look ahead to see some idiot slowly crossing the road. My first response has always been utter exasperation and wonder- don't they know they're going to get hit?

This morning when I saw that, I had a revelation: Maybe they just don't care.

I never had this thought before medical school, and it still greatly bothers me when it goes through my head (so don't feel the need to call a shrink on me or anything). But long days, hazing, frequent ridicule and a (relatively) bleak near-future, and suddenly you have the occasional fleeting thought that you might NOT care if a car hits you when you cross the road. I don't think that thought even counts as passive suicidal ideation (again, that might be relative), especially If you're on certain rotations in medical school, like cardiothoracic surgery.

Life can be tough....

GREAT MINDS...without chairs

So, a while back I posted about chair hierarchy in the hospital. Someone else (who clearly has better artistic ability) had the same thought!!!

It's a bird! It's a plane! No...it's the correct diagnosis!

Excerpts taken from Dr. Bernard Lown's The Lost Art of Healing:

"[The physician] urged us, as beginning medical students, never to prescribe for a chief complaint unless we had come to know the patient well and figured out what was truly troubling the person. A physician committed to healing could not and should not focus exclusively on a chief complaint, or even a diseased organ. If one was to help those who were sick, the stressful aspects of life had to be exposed."

"Limiting history-taking to the chief complaint often initiates fruitless pursuit of irrelevant matters that are quite tangential to the main problems."

Unfortunately, this happens every day- time constraints result in doctors focusing on the one chief complaint, and the underlying problem is never addressed. Medications, "bandaids," often cause more harm than good, and these patients end up undergoing a battery of unnecessary treatment and tests.

A solid HPI is essential to establishing a correct diagnosis but is rarely conclusive, and should naturally lead to a detailed social history which provides context for the "chief complaint."  The easiest and fastest way to handle multiple complaints is to send someone to a specialist.  So the depressed patient who comes in for back pain, headaches and low energy gets referred to an orthopedic surgeon, neurologist and endocrinologist (or cardiologist!), when an extra 10 minutes gathering history (recent death of spouse, or lost job) would result in a logical, easily-managed diagnosis.  In fact, the 2 or 3 weeks of trialing an anti-depressant would likely be faster than making an appointment with a specialist, and clearly would be less stressful and much less expensive for the patient.

Clinicians get sucked into the idea that we have to explore every possible cause (again, thanks to lawsuits), but why are we still looking for zebras??  Modern technological advances have unfortunately created a safety net for poor history-taking and physical exams.  Just because we CAN find more zebras doesn't mean we SHOULD!

My advice to a patient (or potential patient), would be to tell your doctor EVERYTHING! (If your doctor won't listen, get a new doctor.)  Many people don't associate their chest pain with their family feud, or their headaches with caffeine withdrawal.  If your doctor doesn't know about your stress or your quitting coffee cold turkey, they might forget or not have time!  While I'm far from condoning "quick" histories, I think patients have to help out and pick up some of the slack, unfortunately.

Patients are their own best advocates, and it's tough to speak up sometimes. Clinicians have to do a better job of making them feel comfortable asking questions or questioning a medication, procedure or even a diagnosis (within reason).

A Wholesome Gallop

While straining to keep an interested look on my face while "listening" to a resident physician go through a consent for a procedure, I noticed that the patient was also not listening. Rather, she kept a suspicious eye on the nurse setting up for an IV, and finally put her hand on the nurse's arm and sassily told her that last time she was in the hospital, no one could get the IV and she was not going to allow someone to stick her five or six times again. Anyway, it really set up for a dismal outcome and it made me realize what an impact a patient can make on his or her own outcome.

As a paramedic I heard that 20 times a day- "I'm a hard stick, don't even try." Honestly, that made me really angry. During some of my "darker" days I took that as a challenge (I had a good track record, pun intended).

Now I realize how that sort of comment can be horrific- if you set the stage for failure, both in your head and the other person's, you'll probably fail. I know most of the "I'm a hard stick" patients are the frequent flyers and the purpose of the statement was anything but the denotation, but nonetheless....

So that was going to be the blog. But later that day in a lecture, a physician mentioned a story along the same lines and it really made an impact.

Long story short, a well-renowned cardiologist was treating a patient with bad heart failure, and made a point to have all the students and residents listen to this man's "wholesome gallop" (a heart sound usually only heard in heart failure).

No one thought this guy would last long, but within a few weeks this guy's heart function was completely back to normal! The cardiologist asked the patient what happened, and the patient told him that he was encouraged when the doctor told him he had a "wholesome gallop," because he reasoned that only a strong heart could still gallop.

The doctor clearly hasn't meant "strong" heart; in fact, he meant the opposite, but the patient's positive interpretation resulted in complete recovery!

According to the physician giving my lecture, the moral is that you should always find the good news. If they have a nonresectable cancer: "Good news! Your cancer doesn't need surgery! We can treat you with chemo and radiation!"

I've always held the opinion that words are a physician's most powerful and influential weapon. Unfortunately, on a daily basis, I hear them misused. To many, a doctor's words are the be-all, end-all, and sometimes assumptions are made on both the doctor's and patient's sides. Seemingly minute details in a conversation can change someone's view or even possibly outcome.

I think the toughest part of learning to be a doctor is how to use your words. The easy way out is to be enigmatic and vague- a commonly used tactic. Many healthcare providers, it seems, are comfortable with medicine but are unsure of how to talk ABOUT medicine with patients (somewhat justifiably so given all the litigious people out there). We need to better teach how to feel comfortable talking to patients by giving the whole picture. We need to tell people what we know, and what we don't know. Sometimes we don't like telling patients when we don't know the answer yet, and they interpret our silence as a deliberate omission (and patients therefore make assumptions about why information was withheld).

Deferring- "why don't we wait until the test results come back to discuss this-" can cause weeks of angst and worry. Granted, there are probably situations where this wouldn't be the best decision, but I think that talking to patients is comforting to them. Being in the dark is a thousand times more frightening than knowing (again, in most cases).

That same cardiologist whose "good news" cured his patient's heart failure wrote an amazing book which I started today: The Lost Art of Healing (Dr. Bernard Lown). A parting thought from Dr. Lown:

"As the patient is empowered, the doctor's curing power is enhanced."

Life of a med student..per parodies of popular music

Some of the best med student videos out there:


The Doctor's Out Tonight (Dynamite remix): ALL-TIME FAVORITE!

I wear a coat (I'm on a boat remix):

Somebody that I used to know remix (2nd half is best; pretty much about first aid)

I'm at a code (another I'm on a boat remix)...still pretty funny: