[Grace Oz]

Originally Posted by TiredMD

You're right. It's my job.

It's my job because it's my license on the line when I turn "fibromyalgia" into "fibromyalgia with opioid dependence". It's my malpractice insurance when the recovered patient-addicts come looking for a fat settlement for failing to recognize their developing addiction. The DEA (you know, the guys who give me that number that goes on every narc scrip I write) has my phone number in the rolodex, and yes, they come calling.

I won't treat chronic pain. Period. I have that luxury in a surgical field. I will blast them into nirvana with dilaudid for the first 1-2 days postop, but after that, forget it. Sorry you've been taking Morphine drops for 10 years for your back pain. Sorry you normally get Fentanyl lollipops for your chronic headaches. Want to get back to your usual insane narcotic schedule? Then get out of bed, walk, poop, and go home. Worried about withdrawl? Don't be, I'm a doctor, I can see that coming a mile away.

Sorry about your chronic pain. But not my problem.

So no, I won't start handing out narcotics for chronic pain. I don't care about these stupid studies ("risk/benefit" doesn't come from statistical analysis, it comes from assessments by providers of individual patients). I'm not worried about addiction; I'm worried about having these people coming into my clinic every two weeks for "just one more" Percocet scrip. I don't want to deal with it.

Every patient in America who needs regular, unending opiates for whatever pain syndrome they have should be seen by board-certified Pain guys. Every one of them. For the life of me, I will never understand these idiot Primary Care docs handing out Duragesic patches and PO dilaudid.

Thank goodness you're NOT practising in Australia!

[ingelein]

The godlike surgeon has cured you . Now go forth and be painless forevermore.Compassion not taught in med school?



http://www.ama-assn.org/amednews/200...4/prsb0324.htm

Students lose empathy for patients during medical school

Researchers found that female medical students showed more compassion than male students.


It only takes a year to start draining empathy from future physicians, according to a study of medical students in the March issue of Academic Medicine. But empathy is a key quality medical schools should promote, experts said, because it makes for better physicians.


"We know as a medical community that really good communication skills with patients help the patients to comply with the instructions of the physician," said lead study author Bruce W. Newton, PhD. "It puts them more at ease with the physician, a bond of trust is established, and if something unfortunately goes wrong, if you have this bond and communications skills, you are much less likely to be sued."

[TiredMD]

Originally Posted by ingelein

The godlike surgeon has cured you . Now go forth and be painless forevermore.Compassion not taught in med school?

I'm not compassionate because, as an Orthopaedic Surgery resident, I refuse to treat people for chronic pain syndrome?

Yes yes, you're right, I should throw endless narcotics at everyone who asks. This despite the fact that narcotics are notoriously poor at treating chronic pain. And despite the fact that there are fellowship-trained physicians who specialize in this very issue.

If I wanted to pass out pills to every person who told me they needed them, I wouldn't have wasted my time on this medicine stuff. I'd be standing on the corner slinging smack, making a lot more money.

Apparently drug dealers are more "compassionate" than physicians who actually use their training to make informed medical decisions.

[ingelein]

Originally Posted by TiredMD

I'm not compassionate because, as an Orthopaedic Surgery resident, I refuse to treat people for chronic pain syndrome?

Yes yes, you're right, I should throw endless narcotics at everyone who asks. This despite the fact that narcotics are notoriously poor at treating chronic pain. And despite the fact that there are fellowship-trained physicians who specialize in this very issue.

If I wanted to pass out pills to every person who told me they needed them, I wouldn't have wasted my time on this medicine stuff. I'd be standing on the corner slinging smack, making a lot more money.

Apparently drug dealers are more "compassionate" than physicians who actually use their training to make informed medical decisions.

No, you are not compassionate in the way in which you describe those with chronic pain.It is your right not to give opiates.What concerns me is how you speak to them when you tell them this.My concern is based on your statement:

Originally Posted by TiredMD

You're right. It's my job.

It's my job because it's my license on the line when I turn "fibromyalgia" into "fibromyalgia with opioid dependence". It's my malpractice insurance when the recovered patient-addicts come looking for a fat settlement for failing to recognize their developing addiction. The DEA (you know, the guys who give me that number that goes on every narc scrip I write) has my phone number in the rolodex, and yes, they come calling.

I won't treat chronic pain. Period. I have that luxury in a surgical field. I will blast them into nirvana with dilaudid for the first 1-2 days postop, but after that, forget it. Sorry you've been taking Morphine drops for 10 years for your back pain. Sorry you normally get Fentanyl lollipops for your chronic headaches. Want to get back to your usual insane narcotic schedule? Then get out of bed, walk, poop, and go home. Worried about withdrawl? Don't be, I'm a doctor, I can see that coming a mile away.

Sorry about your chronic pain. But not my problem.

So no, I won't start handing out narcotics for chronic pain. I don't care about these stupid studies ("risk/benefit" doesn't come from statistical analysis, it comes from assessments by providers of individual patients). I'm not worried about addiction; I'm worried about having these people coming into my clinic every two weeks for "just one more" Percocet scrip. I don't want to deal with it.

[earle58]

i understand what tiredmd is saying.
he deals with acute pain.
as a surgeon or surg resident, why should he have to address his pt's chronic pain?

and, i agree about having a pain specialist deal w/those in cp.
there's just too much danged liability, actually, no matter what direction you take.
if you (over)prescribe, you can be hung.
yet if you don't, you're vulnerable to undertreating.

tiredmd, i'm too lazy to reread your post...
but did you say that narcotics don't work w/cp?

leslie

[earle58]

Originally Posted by TiredMD

This despite the fact that narcotics are notoriously poor at treating chronic pain.

ok, this is the statement i was referring to...
do you have any literature/links supporting this?
it would be a fascinating read, for sure.

leslie

[TiredMD]

Originally Posted by earle58

tiredmd, i'm too lazy to reread your post...
but did you say that narcotics don't work w/cp?

You're right to call me out for that; my statement was incomplete and misleading.

To be more specific: opioids are not useful and not indicated for fibromyalgia, are of questionable value in RSD/CPRS, seem to have some role in neuropathic pain (though other drugs seem more efficacious), are poorly studied in chronic back pain, and may actually worsen people with certain chronic headaches. References available on request.

[CaseManager1947]

Sir ( in response to Tired MD). I thank God I don't have to deal with your callous and uncaring attitude; one more of them I'll scratch off my list. IF you haven't lived with pain 24/7 for the past 8 years as I have, please don't tell me what you won't do. Heck I know the Feds are breathing down everybody's neck... we had a homegrown pill master right here in the Medwest.... did I go to him.. no. Can I get a referral to one of the board certified "Pain Guys" which you seem to have in such high regard. NO! Heck, I have had to fight to get a flippin MRI, just to find out what I already suspected 3 level disc bulging with nerve involvement...I wake up in the middle of the night, oh heck, nothing relieves this - even with 1200mg day of neurontin I still feel it. Short of a bullet and 6 feet of earth , I figure i'm still gonna suffer. So go ahead, practice your safe, bitter surgical medicine. And no, I don't get fentanyl suckers, one Lortab 5 at hs, and I am a non-functional (due to my pain) nurse I might add. Oh this is turning into a rant. I'll quit.

[ksilty]

Case Manager 1947
I think we need to play Devil's Advocate here. I can understand where Tired MD is coming from, although his communication skills are less than compassionate. As a Case Manager (as am I), I am certain that you have dealt with hundreds of opiod abusers. I find them to be my most challenging patients. THey function like Zombies because they have prescriptions from several sources, fail to address the serious issues of their healthcare like Diabetes, Asthma or CHF, refuse to follow-up with diagnosis and treatment of the issues that are causing their pain, etc. As a case manager, I encourage their providers to refer them to Pain Management and then stick to that provider's contract with the patient. My biggest problem is the ER in our local hospital. They can't say no. We have finally worked out an agreement that they will only write 48hrs worth of pain meds, and if the patient presents too often, they will be referred back to their PCP or Pain Manager. I do not lack compassion, I consider myself an advocate for people who find themselves addicted because no one sought to control the amount of medication they were being given. When I was a Practice Administrator, one of my docs was known in the community as one who never said "no" to pain meds, and they had quite a following. These patients were disruptive to our practice and a challenge to the entire staff. Unfortunatly, one of them was found dead beside an empty vodka bottle and an empty vial of Percocet that had been filled the day before. No one believed it was intentional suidide, he was simply functioning at his normal level of substance abuse. This opened my eyes to the widespread problem of provider-sanctioned abuse. Our doc was disciplined by the Organization for doing what had become standard practice. It changed our protocol in that anyone on monthly scripts for pain meds had to be referred to Pain Management, and prescriptions were closely monitored.
I have many true (diagnosed and failed treatment) Chronic Pain patients. I am compassionate to their needs and I advocate just as strongly that they receive their medication. But I do not support pain med maintenance for a patient that became addicted years ago while being treated for a workplace injury that has resolved. These folks are not criminals because of their addiction, but they do deserve help in kicking it. I have several success stories in my case load who have thanked me for pushing them to get off percocet, so I know it can be done.....

[CaseManager1947]

Again... no one seems to really understand how truly crippling chronic pain can be... tomorrow I go get my THIRD set of shots into my back. I might add I am actually welcoming these, though the pain relief they provide is short lived. I have sent for my intermittent FMLA paperwork to save my job. Having looked at my own films, I don't see how I keep working. Now, I use a mobility scooter to get around the huge hospital in which I work. But, I still have to sit to chart, and that is becoming too much. I have gotten my Neurontin dose up to 2400mg, and I still have mild (what I call mild) pain. I went to a movie (the first time I have been to any kind of activity in 8 weeks) this weekend. I expect it has a lot to do with perspective... my perspective as to what a pain level of 10 on a daily basis is like as opposed to yours.