By: Mary Brennan, RN, MBA, CWON and Diane Krasner, PhD, RN, CWCN, CWS, MAPWCA, FAAN
By Michael Miller DO, FACOS, FAPWCA, WCC
I always wanted to be a doctor. Family and friends cannot remember me identifying myself in adulthood as anything but a medical healer. I am not sure from whence this devotion came. I was not an especially sickly child, nor did I have more than the usual number of medical visits expected from a boy growing up on the East Coast. My family doctor, Marvin Malamut, DO encouraged my dreams but not to the point of obsession. In my medical school interviews, I can report that my answers regarding wanting to be a doctor to help people were genuine.
Unfortunately, the times, they-are-a-changing. Besides needing a law degree, business degree and training in human resources, a new skill is now required in order to survive the burgeoning plethora of mandates and requirements being foisted upon all medical people but more so, docs themselves.
Imagine a young wanna-be doctor having successfully navigated college, MCATs, and countless attribute juxtapositions with other candidates of equal, better or lesser qualities sitting down for his final hurdle: the medical school interview. Instead of questions designed to vet his humanity, common sense or character foibles, they are grilled regarding their ability to act like a human lie detector. Questions like "How do you know you can trust someone?" or "What would you do if a patient lies to you?" or "Could you turn a loved one into the law enforcement authorities?" are fired at them like verbal paintballs. Moreover, if they survive this inquisition successfully, they are proudly told by the medical institution that, at the conclusion of their training, they will be a member of an exclusive club in which they will be respectfully known as a healer, confidant, counselor and snitch.
It seems counterintuitive that while assessment of pain has achieved such stature that it is now considered the fifth vital sign, that treating it places the prescriber squarely in the crosshairs. There are two diametrically opposed positions that physicians take on the issue of narcotic prescribing. Since the war cry was first uttered to make sure patients have quality of life regardless of their ailments, many docs have adhered rigorously to the tenet "Undertreated pain is worse than addiction." Of course, recognizing that unlike the grades on a high school geometry exam, there is no realistic middle ground, the equal but opposite polar answer is "Addiction is worse than undertreated pain." I am confident that on any given day, for any given patient, either of these philosophies would be considered by ethical physicians.
Of course, googling the topic provides more expert opinions and smug self-serving answers than a 15 year old girl's sleepover party.
As will come as no surprise, the immediate bureaucratic answer to perceived bacchanalian pain management is to mandate that docs take on the responsibilities of microscopically vetting each and every patient who has pain. This might involve spending hours trying to make sure that no patients get 1 mg of pain medication more than they need and not one second sooner than allowed. Moreover, that there must be penalties placed on a health care provider when their patient is deemed to be an abuser or when the doctor is determined to have "overprescribed."
The naïve rush to fix this perceived social aberrancy means that there will follow a mandate for draconian rules and protocols such as:
- All patients requiring narcotic pain medications will need to be seen by specially trained Pain Management specialists who will only make recommendations for their pain control but not write the prescriptions themselves.
- All currently licensed physicians will be mandated to take extra training in correct narcotic prescribing with restrictions on their prescriptive authority until they demonstrate competence.
- Patients will need to have their initial pain controlled with non-narcotic analgesia (Advil for a hemicorporectomy?) which after a suitable period (to be determined by those same non-medical authorities) of hellfire agony, will then receive a consultation to the aforementioned Pain Management specialists (who will have no open appointments for 6 months).
The problems with these solutions to this unwinnable scenario are incalculable but the two that most immediately spring to mind are:
A. Will there be enough pain management doctors to see all who need them?
B. Is not treating a patient (or undertreating them) truly in line with our most basic credo of, First Do No Harm? Should this not be changed to,First Do NO Harm* (See State Regulation 65-44-12, paragraph 13, sub paragraph 4B, excluding Sugar coated Enema Nozzles). The ultimate question is...will all these proposed legislative gesticulations really make a difference?
On the current legal front, let there be no question that from each, every and any "authoritative" source you may want to read, to date, interdiction has been essentially an abysmal failure on all fronts. The reasons are simple. You cannot legislate stupidity, avarice or a persons right to try to self-control their own pain.
Perhaps the legal profession needs a dose of their own medicine rather than allow them to perpetrate a "holier than thou" attitude. I propose that when any person with a criminal history who is identified as a chronic offender or who commits yet another crime, that those attorneys who previously represented them be punished for failure to intercede by preventing that person from committing yet another crime.
Recognizing that the search for self-gratification of any type is written in fine print on our genes, we need to consider the stark realities. Patients who decide they have pain will do what they must to alleviate it, be it self-medicating psychological problems with alcohol, stealing pain medications from family and friends or resorting to criminal means to obtain them. Why do we waste so much time, energy and effort in a futile attempt to play guard dog when the results have been less effective than giving Snoop Lion acting lessons?
Let's cut to the chase. The real keys are to eliminate the unrealistic, cost-ineffective, crime promoting activities we not only have in place, but are trying to clad in more iron.
Perhaps simply eliminating narcotic prescribing and moreover, the concept of "Controlled Substances" needs to be considered. Why not simply allow patients to self-determine their own pain medication needs and then resolve them? Health care providers would do what we are trained to do, diagnose and treat those patients who require and want our help. You cannot help a patient who refuses to see you, disagrees with or refuses to accept your diagnoses and then refuses your treatment or elects to provide their own. Pharmacies would simply put narcotics alongside the cold beer. Patients would grab a box of what they need and off they go. No more hold-ups, frightened pharmacists, etc. No one selling narcotics to make money because everyone would have access. Those who need or want pain control can obtain it in atmosphere of realism and self-determination, not some quasi-medical oversight.
It is impossible to legislate stupidity nor should we try. Our country was founded on individual liberties and self-responsibility and yet, there are ongoing mandates for abdication of these same tenets to be replaced by omni-parental guardianship. I did not become a health care provider to spend my time doubting the veracity of my patients, nor weighing their histories against some government mandated truth or consequences scale. Does the Netherlands have a more realistic handle on man's inhumanity to man? Recognizing that people will do things that they find arousing, attractive, satiating and "fun", they have simply chosen to legalize and tax it all. Is this ideal in "pay to play" an irrational approach? I think not when you consider the costs and quixotic success our own system holds so dear despite abject failure. The words to the song they sing from the Man of La Mancha,
To dream... the impossible dream...
To fight... the unbeatable foe...
To right... the unrightable wrong...
To reach... the unreachable star...
only underpin the need for a more realistic approach to what is perceived as a problem. The real concern is that the cure may be far worse than the disease. As for me, I diagnose, then ethically and morally treat my patients pain to the best of my ability. But let me assure you, I do what I do as a proud member of what I feel is the best medical system in the world and have no interest in trading my current degree for what the bureaucracy would have me put on my shingle... MP – Medical Police.
Until we ramble together next time.
About The Author
Michael Miller DO, FACOS, FAPWCA, WCC is the Founder and Medical Director of The Wound Healing Centers of Indiana and IndyLymphedema, as well as a clinical consultant, teacher, inventor, and published author.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.