As physicians we are often asked to treat pain in patients with no physiological explanation for pain or a pain syndrome that is not treated as a standard of care with opiates. Internist Dr Centor recently discussed this with his rant on our opiate culture and the tyranny of pain with regards to a NYT article about the no-win situation ER physicians often find themselves in. One of my favorites quotes
The most bothersome aspect of this story involves the "patient satisfaction" component. How do we balance between patient expectations (for pain meds, or CT scans or referral to subspecialists) against the high value cost conscious care that we aspire to give. If I appropriately refuse to order a CT scan, and the patient relates that he/she is not satisfied with my doctoring, have I done a good thing or a bad thing. If I suspect a drug abuse problem, should I worry about patient satisfaction or being a good steward of my responsibility to prescribe opiates appropriately?
I agree and have written extensively about this problem in the recent past. No where in the Constitution does it say we have a right to be pain free. Being free of pain is no more a right than is being free of debt. Some lawmaker somewhere probably had a bad experience with untreated pain in their end-of -life full code great grandmother and decided to make it their mission to make pain free hospital existence a right for all Americans.
Unmanaged expectations lead to irrational patient demands. The customer is always right sacrifices our personal dignity for money. I cringe at patient requests that interrupt nursing and physician work flow in other more critical patient needs because of the perceived right to all comfort all the time. For example, I was once interrupted dead in my work up tracks to address the pain of a canker sore. A canker sore. A canker sore.
I just can't wrap my mind around this incredible pendulum swing towards a patient's right to demand comfort and satisfaction at all times. Where does this expectation come from? Why do patients have a right to pain free existence? At what point does satisfaction end and just putting up with the daily annoyances of life begin? So what if it's 3 am and you have heart burn or constipation. Why must you force your nurse to make your minor annoyances of life turn into a trail of intensive documentation.
We know higher patient satisfaction scores are associated with higher patient mortality. I have my own thoughts on how to improve patient satisfaction scores and they have nothing to do with providing health care, opiates or unnecessary CT scans. It's all about FREE=MORE. At the extreme interpretation of patient satisfaction goals, some institutions might even mandate the AIDET method in circumstances where a little spine and backbone from health care providers is instead the right medical therapy for the patient.
We have to accept that what patients want in the name of patient satisfaction is often not what the need. Higher quality care does not equal happy patients anymore than low quality care equals dissatisfied patients. I have seen lots of highly satisfied patients who have received sub optimal treatment and I have seen lots of upset patients who had everything done perfectly by the book. I have not experienced an obvious correlation between satisfaction and quality. Nor do I believe this correlation exists.
When patients ask for opiates by name we can either give it to them in the name of patient satisfaction or we can tell them no and deal with the consequences. Me? I prefer to deal with these situations on a patient by patient basis and I have found, through a decade of experience, that not all drug addicts are the same but most carry a lot of mental baggage that complicates their insight into their addiction as well as their willingness to seek treatment.
In patients whom I have strong evidence of opiate seeking behavior or have lots of red flags to drug seeking behavior, I will nicely explain to the patient "I am not your drug dealer" and if they are angry I won't provide them with a fix, I calmly explain to them that assaulting a physician is a felony. It turns out not all druggies carry a calm collected demeanor to them, like the guy who told me he used to beat up people like me in high school. Alternatively, I have found a little honest empathy can go either way in these situations, as this someecard helps explain:How do you handle situations involving suspected drug seeking patients without compelling medical indication for opiates?