Learning to Prescribe Kindness

“You’re different than you used to be.” The comment came at the end of the visit with a patient I have known for over 20 years. “I’m not sure how to describe it, but you are different.”

“I’m nicer,” was my reply.

“That’s it! You are nicer.” It was as if she was afraid to say it for fear of insulting me. She didn't need to apologize. She wasn't the first person to notice. What she did not know was how the change occurred. I shared with her that one day over 15 years ago that I had stopped to perform a self-assessment, asking myself what people would likely say about me if I were to die. As I listed my dominant personality traits- passion, integrity, honesty, commitment to doing the right thing, I realized that there was something missing. I doubted that anyone would say I was kind. It was a sobering realization.

I told her that became my prayer, that God would make me kind. It proved to be a costly prayer, as within a few years a virus attacked my spine, bringing severe and debilitating pain. The pain faded, but the weakness and numbness never left. A few years later came panic attacks and anxiety disorder. These conditions brought me to my knees and opened my eyes to the struggles of others. They softened me and made me kinder.

She shared with me that she knew that I was someone keen on becoming a better person. She told me she was an avid reader of this blog (Hello Ms. D!) and that she had concluded that I was someone who was working on myself, someone who was trying to improve. I thought this was an incredible compliment, for to me, this should be one of the defining characteristics of a Christian.

We are all sinners, we are all broken and selfish. One of my greatest areas of brokenness over the years has been the tendency to use being “right” as a justification for not being kind or compassionate. God has been working on this part of my life for years now. I still have a long way to go, but if I am becoming a kinder person, if I can be described as someone who is less broken and less selfish with each passing day, then I am comforted knowing that God is doing his work in me. Which is... nice!

-          Bart

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The Doctor at Your Fingertips

The future has arrived. This week we did over 10 visits electronically, visits that would require an office visit in almost any other office.

We had several patients with high blood pressure send us electronic messages with their home blood pressure readings. Most were normal and we refilled their medications for 6 months. One, who is newly diagnosed, needed an increase in his dose. None required a visit.

One patient had a bald patch on his scalp. We made the diagnosis of alopecia immediately upon receiving the photo he sent to our office iphone. The treatment will require a visit, but the diagnosis didn’t.

Another patient send in a photo of a new mole, which looks like a benign seborrheic keratosis. While you probably have no idea what that is, it is nothing to worry about and a visit was avoided.

This morning a patient called me with an asthma exacerbation. As she has had the condition for years she was able to describe her symptoms accurately. Instead of sending her to urgent care I was able to treat her over the phone, saving her time and money.

Two other patients who were seen in the office scheduled their next visits via Facetime, grateful that they would not have to take time off of work to follow up on their conditions.

The overlooked benefit of all of these visits is that they took much less time than an office visit would have. The result was more room in the schedule for those who did need to come in and more time when they did.

It’s a whole new world!

-          Bart

Adding My Name to a List of Uncaring Doctors

She has been in constant severe pain for over 15 years. The pain in her upper back defied explanation, identification or treatment. It continued its relentless course undeterred by needles, pills, scalpels and physical therapy. Family physicians, internists, orthopedic surgeons and pain specialists all failed in their attempts to provide relief or answers. The universal response was an increase in pain medications, with the end result being a daily dose of morphine 5 times the recommended limit yet no discernible change in her pain.

She came to me hoping against hope for an answer. At a previous visit I had promised to set aside time to review whatever records she could provide. She scheduled a lengthy visit and came with a CD of her medical records. I opened the electronic copy of her chart and reviewed with her the 240 pages of data it contained. It contained volumes of data but no answers. All of her tests, MRIs, blood tests and CT scans, were normal. Like so many chronic pain patients multiple explanations had been eliminated but no cause had been found.

The only treatment not yet tried was a frightening one. Research has shown that there are many patients whose pain is actually worsened by high doses of pain medication. “Opioid induced hyperalgesia” is the big-worded label for the condition, a fancy way of saying that not only has the patient become tolerant to pain medications, the pain medications have actually caused the pain to increase. The only treatment is to stop the medication, all of it. For the immediate term, pain is certain to increase. What isn’t certain is that the pain will be better in the long term. As bleak as this choice is it was her only hope.

My heart broke for her as I entered into the computer a referral to the addiction specialist who could guide her though her detoxification. Her tears and fears were overwhelming. The recommendation was so easy for me to make yet the road would be so difficult. I felt a sense of sadness and anger at the failure of the medical profession to help her and my inability to provide her with an answer. Her unhappiness and disappointment were palpable.

A few days later I received a sad and angry email message. In great detail she shared her feeling that I had failed her, that my name was being added to the list of doctors who had dismissed her concerns and failed to listen. She had hoped for more tests, more specialists, more… something. My inadequate reply was that I did not see any other options and my opinion was that stopping the pain medications was the best option.

I have thought about her ever since. I have reviewed her chart over and over again in my mind, wondering if there was any diagnosis that I might have missed. Sadly, the location and nature of her pain had been thoroughly and extensively investigated. There is nothing more that I can do. Her hope in me was misplaced.

My name has been added to her list of uncaring doctors. Her name has been added to my list of patients to pray for. 

- Bart

Thanks for reading and sharing, and for praying for this patient. 

Helpless as a Patient Passes

I felt helpless, because I was. I sat at the bedside of a woman I had known for 20 years and watched her die. It was surreal, as she had seemed indestructible. She was the rock of her extended family, a supportive wife, mother and grandmother. She was a tough and strong woman, qualities I had seen her display through many physical difficulties. I had seen her sick but I had never seen her weak until the cancer came.

The cancer came fast and hard. The diagnosis had come just 2 months earlier, bringing with it severe, unrelenting pain and stealing her appetite. Just before Christmas came a severe infection that sapped her already limited strength and trapped her in her bed most of the time. She went home on hospice Christmas Eve, determined to be with her family. Remarkably she was able to sit up for a few hours and hug her grandchildren as they thanked her for their gifts, as if she was determined to not let the cancer take away Christmas.

Even though I knew she was dying I was not emotionally prepared for the moment when it came. I should have been, as I had visited her at home the day before and observed the decline. It was clear the end was approaching fast. My medical mind knew it was only a matter of days. My heart wanted to believe otherwise. When her husband called the next evening to tell me she was having trouble breathing I didn’t want to go, didn’t want to accept that she was actually going.

When I arrived a few minutes later my fears were confirmed. She was breathing as those who are about to die breathe. I struggled to stay in “doctor mode”, tamping down my emotions so I could be a source of strength for the family. I made sure she was not suffering and made sure the family knew it. It was all I had left to give. When the moment finally came my heart broke as grief flooded the room. I felt helpless again, not knowing what to say. She was loved so much and had so much love left to give.

Afterwards I felt awkward as family members hugged me and thanked me for being there. How could I not be? I had known her for over 20 years. It was the least I could do.

This weekend the family is gathering to say good-bye and to celebrate her life. I am planning on being there, to love, pray, celebrate and mourn with them, as their doctor and as a friend. She deserves it.

Bart

As you read this, please say a prayer for the family. 

Dying in Pain

The overuse of narcotic medications has become a national problem. Current estimates are that over 2 million Americans either abuse or are dependent on prescription opiates. Recent data reveals that15,000 Americans die as a result of an overdose or narcotic pain medications every year. More Americans die from prescription narcotic overdose each year than die from being shot. It is a national crisis.

In response to the crisis the Center for Disease Control (CDC) has issued new guidelines to aid physicians in the appropriate use of narcotic medications in the treatment of chronic pain. The guidelines are desperately needed, as chronic pain is incredibly common. 43% of American adults have been diagnosed with a chronic musculoskeletal condition and over 11% of American adults have pain every single day of their lives. In this context it is not surprising that in 2012 physicians wrote over 259 million prescriptions for pain medications.

The CDC guidelines set definitive limits on acceptable daily doses of these drugs. The limits were set based on evidence that higher doses dramatically increase the risk of overdose without evidence of significant improvement in pain or function. The maximum recommended total daily doses are the equivalent of 50 mg of morphine in most circumstances (which is approximately10 Vicodin pills, or 5 Norco), and 90 mg of daily morphine for the rare case when higher doses are indicated. The consensus is that the higher doses should typically be prescribed by pain management specialists.

Based on these guidelines I was understandably concerned by a patient I saw a few months ago in the office. His daily pain regimen included the maximum dose of an addictive muscle relaxant along with regular doses of oxycodone and methadone. After reviewing narcotic conversion charts I calculated his daily narcotic dose to be the equivalent of over 500 mg of morphine a day, 10 times the recommended daily dose. Remarkably, he was alert and seemingly unimpaired. Sadly, he was also still in severe pain.

I knew from personal research and discussions with pain specialists that he was likely suffering from “opioid induced hyperalgesia” a condition in which high doses of pain medications actually increase the patient’s pain. He needed to get off of the narcotics. While this conclusion was easily reached it was not easily implemented. He had a complex medical history and he needed an expert to aid in the weaning process.

I called several physicians on his behalf, including three different pain doctors and a specialist in addiction. All of them agreed that he needed to go through detoxification but none of them were interested in supervising the process. Even the weaning doses were higher than they felt comfortable prescribing. It took dozens of phone calls and hours of work before I was able to arrange a hospital admission to begin the detoxification process.

This patient reminded me of how and why patients become dependent on pain medications. His pain began with a neck injury and neck surgery that failed to relive his pain. While comprehensive pain programs that include physical therapy, cognitive behavioral therapy (a type of counseling), behavioral modification and now-narcotic medications have been proven to be most effective in managing pain, such programs are expensive, labor intensive and not widely available. His previous doctor did what most doctors do. He prescribed pain medications. When his pain persisted, out of compassion, poor judgment or both the doctor increased the dose again and again.

The patient illustrates the challenges faced in dealing with narcotic addiction. Our current health system and payment models make it easy to do the wrong thing and difficult to give patients the help they need. We desperately need to decrease our reliance on narcotics, but if we do not also work to provide better comprehensive pain care we will be abandoning millions to a life of suffering.

Bart

Update- The patient's wife informed me that he had successfully weaned off of narcotics. Amazingly, his pain levels had not increased. Sadly, they had not improved either. He has a long way to go.

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