Persistance is the key here because the severity and intractibility of the pain are the clues that the Patient has a pain problem that is not being addressed.
Some Dr's tend to focus on the source
of the pain. Other Dr's (string 'em up!) focus on the rationality
of the pain--that is, they judge whether the patient's condition is a likely pain source and Rx accordingly.
Both are wrong. They do not address the problem because they are not seeing the pain as the problem.
Emphasize to Dr. that regardless of the source of the pain, and regardless of whether he believes her, the patient has certainly got a lot of pain that her usual med is not covering and that she needs something more until the source of the pain is dx'd, if nothing else because the staff can't handle her ADL's without causing her to go through the roof. Let him know that it is (sigh) your job to phone him or on-call whenever Pt. c/o "severe, intractable pain" or exhibits s/s of "severe intractable pain" such as "grimacing, immobility, irritability, refusal of care, crying, depression" and that according to the nurse's notes, this patient's pain began X days ago, and can't we get her something on a prn basis?
Read to him from the nurse's notes. Make sure he knows there are a lot of nurse's notes on this problem and his previous responses have been documented.
If he refuses increase or change in meds, ask why not. Chart the conversation and "no new orders" and why. Confirm with him, "OK so I will just document for the 4th time this week, no new orders, because I do have to document on this, as you know."
Continue to chart patient pain, responses to passive pain control teaching, and MD response qs or prn.
Keep calling doc with the same litany. REMAIN CALM AT ALL TIMES. This will give him the impression that you don't care if you have to call him 30 times a day, you will. Direct any behaviors that interfere with getting the pt. her pain meds (cursing, name-calling) back to the original problem. (After you get the Rx, have a chat about that, but not before. )
But the main prob here is to persist on behalf of the patient. This isn't a popularity contest, this is patient advocacy.
(I've done this happen so often in LTC, it makes me wish for a book called "CYA Clinical Procedures Made Easy" because the family/patient could sue the NH and win if her pain issue is not adequately addressed.)
Good luck, and let us know what happens, please?