Being a physician is like trying to parent two thousand teenagers

I walked down the hospital corridor listlessly. My feet dragged as they fought each attempt to lift off the ground. My body was tired and achy. The phone calls the night before had been relentless. Each stolen moment of sleep was interrupted before a deep, restful state was reached. It was Monday morning.

I sat at the nursing station flipping through charts. A colleague across the table was staring intently at his computer screen. He previously had been a private practitioner like myself, but he shuttered his practice to become a hospitalist. He glanced over at me appraisingly, taking in my disheveled hair and unshaven face.

Hard night?

I nodded in his direction, and looked up from the progress note I was struggling to complete. I wasn’t making much headway.

So why did you leave your practice anyway?

A look of pity came over his face as he stared down at a coffee stain on my wrinkled gray lab coat.

I was tired!

He went on to explain that it was not physical but rather emotional fatigue that spurred his decision. He was tired of fighting with his patients.

***

As I exited the hospital and walked a few hundred feet to my building, I pondered my patient interactions over the the last week.

A healthy thirty five year old woman called my office daily for a benign upper respiratory tract infection. During each conversation she demanded an antibiotic, and each time I explained how it was inappropriate. I cited studies, explained the possible harm to herself as well as society, and gave a number of recommendations for alleviating symptoms. She responded by saying that all her friends doctors gave them antibiotics. Eventually she decided to leave my practice and find care elsewhere.

A hundred year old demented woman was placed in a nursing home after a devastating stroke which left her completely unconscious. Her previous doctor had dutifully ordered a feeding tube and transferred her to the nursing home for further care. Last week her kidneys began to fail, and her son demanded that we initiate hemodialysis. I invited the family to the nursing home and spent an hour discussing futile care and it’s consequences. We talked about how hundred year olds don’t tolerate dialysis well, and that her quality of life was already low. After becoming very emotional, the son stormed out of the room and accused me of trying to kill his mother.

A 60-year old woman with chronic back pain came to my office for a refill of a narcotic prescribed by her orthopaedist. I talked to her about the pain ad nauseum, and described how narcotics are not affective for long term control of musculoskeletal pain. I looked her up on the Illinois prescription monitor, and my eyes popped as I calculated that she received over 250 hydrocodone pills from three different doctors over the last week. When I refused to write another, she stormed out of the office and threatened to call the local medical board.

***

The doctor-patient relationship can be difficult. At it’s best, it is a mutual, symbiotic connection between client and consultant. Sometimes, however, being a physician is like trying to parent two thousand teenagers. Although there is great affection on both sides of the examining table, the perspective is markedly different.

I admit that I can never know exactly what my patients are feeling, I haven’t walked a day in their shoes. On the other hand, I have years of experience treating just the sort of complaints they come to my door seeking help with.

There are days when I fervently wish they would let me use this experience to help them.

And there are days when I wonder if I should have ever decided become a parent in the first place.

Jordan Grumet is an internal medicine physician who blogs at In My Humble Opinion.

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  • http://pulse.yahoo.com/_3CY2U67646G7UIAHBQVTT2UP4Y Kristy S

    Dr. Jordan,

    What an excellent article.  Thank you for the reminder and also thank you for all the hard work you do to try and help your patients.

  • http://www.facebook.com/people/Lezlee-Maupin-White/100000077693322 Lezlee Maupin White

    so true

  • Payne Hertz

    Patients are such losers. Why don’t they stop being afraid, angry and skeptical and just do what I tell them to do? Why are they so obsessed with pain relief? Don’t they realize I’m infallible and always guess right? Don’t they realize I am capable of creating my own reality, like that pain medication doesn’t work for the long term management of pain?

    You’re all heart.

    • http://twitter.com/jordangrumet jordan grumet

      Payne…when my patients aren’t doing well I also get “afraid”, “angry” and “skeptical”.
      As for “guessing” the scientific data is pretty clear on antibiotics and respiratory infections.  And it is well known that 100 year olds do poorly on dialysis.  Especially when they are unconsciouss.  No one would argue this.
      When it comes to treatment of chronic musculoskeletal pain, there is very little data showing opiate medications are helpful (not talking about cancer or acute musculoskeletal pain).  Experientally speaking, often these patients pain increases over time with narcotic treatment. I have seen many palliative care specialists refuse to titrate up or even scale down the opiates on these patients.  I expect this trend will increase over time 

      • Payne Hertz

        Well, it’s all about you. You tell a story of a family in severe pain and distress coping with the most difficult decision they may ever have to make in their lives, and we are supposed to sympathize with you, and not them, as you denounce them as well as all your patients and their families as “teenagers.” I see nothing but contempt in this article for your patients and not an iota of sympathy or understanding for what they are going through and how it effects their judgment.

        “When it comes to treatment of chronic musculoskeletal pain, there is very little data showing opiate medications are helpful”

        There have been numerous studies showing the effectiveness of opiates in treating pain. If you mean long term use as you stated in the article, then yes there is a lack of high-quality studies showing the long term efficacy of opiates, but that’s true of most of the drugs your prescribe. There have been a large number of studies of what happens to patients when you fail to treat their pain, including increased risk of suicide, disability, and all the assorted lifestyle diseases associated with deconditioning and chronic stress. Not to mention the obvious but always overlooked fact that being in constant pain is torture in the here and now.

        http://www.practicalpainmanagement.com/pain/other/co-morbidities/complications-uncontrolled-persistent-pain

        What studies have been done show long term benefits with no risk of hyperalgesia. We also have the benefit of decades of experience with methadone maintenance patients, where we have a worldwide data set spanning decades of millions of the most at-risk patients there are, many of whom have chronic pain. If there was any evidence opiates cause pain or make it worse, it would have surfaced by now.

        http://updates.pain-topics.org/2010/02/followup-safety-of-long-term-opioid.html

        In either case that doesn’t justify jumping to the conclusion that opiates don’t work long-term, particularly given that there are millions of pain patients worldwide who have been on opiates for decades and no evidence that opiates have stopped working for them. Even if it were true that opiates lose their effectiveness over time, it doesn’t justify denying them over the short term.

      • Mary Okeefe

        I like what you have to say. It doesn’t appear condescending or unfeeling to me. I have worked in Pharmacy for several years and have seen the downward spiral and degradation of health brought on by long-term narcotic use. I blame the doctors more than the patients. I am well  seasoned to the arguments and demands of patients wanting early refills, new fills of narcotics from different doctors for varying strengths of the same medication, and the rage when we refuse or contact a physician to let them know about the possible overdosing that can occur. I see more and more elderly people becoming addicted. It is not judgemental to hope to find safer,and ultimately better ways to manage pain – or at least avoid an unnecessary death. Keep up the good work.   

  • http://makethislookawesome.blogspot.com/ PamC

    I may have a solution for you. 
    Bring them over to your side. You know your right. And they will come to understand you’re right too, if you can give them a clear picture of what’s going on in your head. 

    I believe your issue is not your patients but the communication you have between your patients. Right now, I see both sides fighting to get their point of view heard. With the exception of the drug seeker (good catch, by the way!! It’s great that Illinois has a registry like that), what I see is that your patients don’t feel in control. You are trying to explain to them why you’re right and they’re wrong. But no one likes a lecture. They may be acting like teenagers because they’re responding to you *treating* them like teenagers. What I hear you saying is, “No… you can’t have this and here’s why.” Instead, why not try inviting them along your journey of decision making?

    When patients come to you, they’re in distress and they’re scared. Of course they don’t know as much as you. So you’re going to have to help them, and be very gentle and patient with them. You have the education, but they’re the ones who ultimately have to pay the price. They’re depending on you to show them the correct course of action. If they feel that your goals and their goals are different, you’re going to have conflict. My suggestion is slow your conversations down—this is an emotional minefield, laden with hidden traps. It may feel like you have to simplify your conversations and say some things that seem obvious. But nothing is obvious when people are upset and in need. 

    First, let them know that your goal is to see them—your patient—happy and healthy. Next, let them know that you understand the decision is up to them. You’re going to provide information, and then they get to make the choice (even if the choice is to go to a different doctor because you won’t prescribe). Let them know that you understand what they want: “I hear that you want me to prescribe these antibiotics. But first, can I let you in on my train of thought?” Then explain how you see the situation, what the options are, and what you see as potential problems. You can say things like, “I would *like* to give you this, but here’s what I’m worried about.” Lay out the consequences. Let them know why you’re so worried about doing what they’re asking. When they have all the evidence, they’ll be able to make a good decision.

    When it comes to end-of-life decisions, you have to know that people are going to become unreasonable. This is End of Life…. the stuff Elisabeth Kübler-Ross won 19 honorary degrees about. There is one simple question I would pose to that man: “How would you like your grandmother’s final days to be? Do you want her hooked up to machines, being disturbed at all hours of the night for this and that… Or would you like her to be able to rest and have peaceful days surrounded by her loving family? Do you want her to have to fight a battle every day until her last?” Let him understand what he’s asking for. He has no way of knowing how difficult it is. You said as much yourself. Explain what the consequences are *beyond* extending life. 

    You know these people would make the right decision if they knew what you knew. What you’ve forgotten is how long it took you to learn those things. Your patients only have these few moments in your presence to learn what you know. You had years of hard work. It’s not reasonable to expect them to understand like you do. And you can’t blame them for being skeptical of your answers—our culture is one of “buyer beware.” Different doctors do different things—if one doctor did it this way and you won’t, you’re going to have to expect to defend your decision. That’s the way it works in any industry. 

    If you don’t want 2000 teenagers, try to stop treating me like a kid ;)

    • NewMexicoRam

      I don’t see where you came up with the idea that this doctor WASN’T doing everything you just said.

      Aren’t you taking the very attitude that you are complaining about?

      • http://makethislookawesome.blogspot.com/ PamC

        He couldn’t have been doing what I suggested if he walked away from the situation thinking his patients are teenagers. The two aren’t compatible. 

        What attitude do you think I’m complaining about?  

  • sFord48

    I generally find primary care a waste of time.  Perhaps it’s just the condescending attitude that is apparent above that I don’t like.

    • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

      Funny until the last sentence I didnt see much condescending in the article. It sounded like a caring clinician sharing his concerns and frustrations about trying to do the best for his patients without doing any harm. He is using this forum to express his frustration and fatigue at trying to help those he took an oath to help only to have them make choices not in their best interests.
      The truth is the good doctor is correct on the antibiotic issue, he is correct on the dialysis issue and he is distraught over the narcotics issue. Physicians with long term patient relationships do become protective and  parental toward their patients like a shepherd toward a flock. That doesn’t mean he doesnt allow them to participate in the decision making process on a shared basis. That doesnt mean he hasn’t outlined the pros and cons and risks and benefits of each situation. That doesnt mean that he will not honor their choices. That doesnt mean he doesnt allow them equal say in the discussion of the problem and reasoning behind his suggestions. It just means that there is a sense of frustration and pain at seeing the choices made be poor ones based on the existing scientific evidence and both his and others experience caring for these particular problems. I expect  Dr Grumet does address his patients and their families as adults with shared decision making options. Its when he sees poor choices made and repetitive questions asked about questions answered about minor illnesses several times already in a caring a professional presentation of the facts that he gets worn down

      • sFord48

        Well, he discussed three patients then characterized 2000 patients as teenagers.

        I understand the difference between a viral infection and a bacterial infection.  I even understand that antibiotics aren’t necessarily needed for a bacterial infection.  The guidelines have changed over the years…I can understand the confusion.  I don’t usually see a doctor when I have a upper respiratory infection, unless it’s clearly bacterial and my asthma is worsening.  At that point, I call my asthma specialist because my PCP will only just site the guideline to me.  I don’t really like taking antibiotics and try to avoid them.

        I have chronic pain issues and chose not to take pain medication.  I want to feel like myself and narcotics makes me feel loopy.  I am not a drug seeker but at times have been treated as one.

        I have already decided to commit suicide with a diagnosis of any type of dementia.  My family understands this.  My medical power of attorney won’t be advocating for unnecessary treatments. 

        I often find my doctors think I am something I am not, and as a result, I get lousy care.

      • Payne Hertz

         There is a difference between being “parental” or caring towards your patients and publicly stigmatizing them as teenagers because they exercised their right to make their own decisions, even if those decisions are wrong.  Where patients have doubts or concerns, it is appropriate and wise for them to seek multiple opinions and change doctors if necessary.

        Apocryphal “drug-seeker” story to the contrary, he is dead wrong about narcotics, and needs to become better informed as
        I would expect any caring physician to do, and not just cherry-pick the
        beliefs based on no evidence that support his obvious reluctance to prescribe opiates. That story would have had the same conclusion even if the woman in question hadn’t doctor-shopped.

        • NewMexicoRam

          Give me a break.
          She was caught red-handed.
          Sounds like you need to spend some time at your local medical school and learn real world medicine.

          • Payne Hertz

            Where I can get 4 hours training in pain management, and 5 years training in misanthropy? No thanks.

            The drug seeker story is dubious because of the way the numbers are presented: “I calculated that she received over 250 hydrocodone pills from three different doctors.” If there were just 3 scripts, and he “calculated” the result, he would have known the exact number of pills. The fact that he gave a rough estimate suggests exaggeration if not outright fabrication. Also, doctors usually give large scripts like that in numbers divisible by 30. So you might get 20, 60, 120 or a max of 180 hydrocodone  pills from a doctor or group of doctors assuming you are drug seeking, but rarely an off number like 250.

            Even if we accept that the person obtained scripts from multiple doctors, she may not be a drug seeker but simply someone who doesn’t understand that this is often illegal. She may be a person in severe pain driven to desperate measures by the lack of willingness of doctors to prescribe an adequate dose of pain medicine (other than exceeding the maximum daily dose of acetaminophen, 250 hydrocodones a  month is a paltry dose for many people with severe pain).

            The willingness of doctors to jump to a particular conclusion and not consider alternative explanations even when a patient’s health and life are on the line is a perfect example of why we shouldn’t allow doctors to play detective, judge, jury, court stenographer and executioner when it comes to resolving the issue of drug-seeking.

            No civilized judicial system would ever hand down a non-judicial sentence of torture so frivolously, but doctors are allowed to.

            If your profession had any ethics at all, it would long ago have eschewed and refused to play the role of drug cop and judge, citing the obvious moral conflict between having to relieve suffering and be called upon to inflict it  through arbitrary denial of treatment.

          • NewMexicoRam

            You are basing your case on calculation of numbers?  The numbers either show overdosing, or diversion activity, and I’ll side with the 2nd one.  If she was innocently taking more than she should have, my experience is that the patient apologizes, not gets angry and walks out.

            Sorry, pal, but your logic doesn’t add up for me.

          • Payne Hertz

            The questionable numbers make the story seem like a fake thrown in to justify the doctor’s philosophy of not wanting to prescribe pain meds. If one aspect of the story doesn’t “add up” it calls the whole story into question.

          • Terry M

            You seem to genuinely care about the topic of pain management, but your vitriol does nothing to help your argument.

            Whether you admit it or not, drug seeking behavior does exist.  Obtaining over 250 hydrocodone-containing pills from three different providers (and the author being potentially the fourth different provider) over a one-week period is absolutely drug-seeking behavior.  If the patient legitimately is suffering from pain which is not adequately controlled by the medications being used, the solution is not to seek out an entirely new physician unfamiliar with the situation and demanding more of the same medication.  Working with your physician who is familiar with you and your condition, potentially considering alternative therapy, is the better course of action.

          • Payne Hertz

             I don’t deny that drug-seeking exists, just that doctors are prone to falsely accusing pain patients of being addicts or slandering them in other ways, as this article and its responses clearly demonstrates. The hatred and animus towards patients in general and pain patients in particular is plain to see reading medical blogs and in this thread. Yet you act as if it’s invisible and there is a rational basis for all this calumny and hate. There isn’t.

            Continuing to work with a physician who refuses to treat your pain makes no sense, particularly if he is hostile or dubious as to your claims of being in pain or has a misanthropic personality. If you have a medication that works at all trying to get more of that medication makes perfect sense. This woman shouldn’t have been on hydrocone/apap in the first place, but a long acting-med and then the dose should have been properly titrated to effect.

            “Discussing alternatives” would be fine if any of those alternatives were safe or effective, which for the majority of people in pain, they are not.

          • Terry M

             I’m sorry, but I’m just seeing a whole lot of generalizing on your part (“If your profession had any ethics at all”).

            Do some physicians deal with pain management in the manner you describe?  Sure.  Do all of them?  No.  It’s really the same argument when you consider that not all pain patients exhibit drug-seeking behavior or are drug-seekers (I would posit that the vast majority are not).  Like many things in life though, it’s the squeaky wheel that gets the grease and creates perception.

            Regarding “alternatives,” there are indeed many with varying levels of safety and effectiveness, but in the end much of this needs to be considered on an individual basis.

            You can take my points how you will, but this comes from a chronic pain patient who became a physician.

          • Jake

            The most astute comment in this entire comment section was made by Terry. “The solution is not to seek out an entirely new physician unfamiliar with the situation and demanding more of the same medication.”

            The patient’s initial complaint of pain was obviously acknowledged by at LEAST the first opiate prescriber, otherwise the physician never would have handed her a prescription in the first place. Thus, a logical patient would continue her relationship with that same physician if things either worsened or did not improve at all. Either she’d return to the clinic or at least call the office, where she’d talk to the nursing staff about how the initial treatment plan wasn’t working. 

            Meanwhile, the last thing a non-drug seeking patient would do is bounce to 2 other providers in that same week asking for the same treatment if the initial treatment was less than helpful. However, as Terry mentions, that behavior pattern is exactly how a pill-seeking patient would meander the system.

            So yes, Payne, “if you have a medication that works at all, trying to get more of that medication makes perfect sense.” It does make sense, but in the author’s example, the chronology doesn’t add up. Since you have qualms with the author’s mental “calculation” of the prescribed quantity, well exclude that variable from discussion. 

            Just think for a moment… even if she was prescribed a week’s worth of hydrocodone, her calendar of events doesn’t make sense. Unlike oral surgery patients that might get a mild opiate for a couple days, chronic pain patients receive prescriptions that cover them for much longer than a few days, and certainly long enough that she wouldn’t need to see 2 other physicians in the same week. You said it best yourself in another comment, “If one aspect of the story doesn’t “add up” it calls the whole story into question.”

          • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

            ” If your profession had any ethics at all, it would long ago have eschewed and refused to play the role of drug cop and judge. “””  Really????  One of the tenets of medicine is first do no harm.  We all want to help others and relieve pain and suffering. There is however a crisis in prescription drug deaths and overdoses in our country. You need to establish the most efficacious way to relieve discomfort and pain but not at the expense of contributing further to the problem of prescription drugs for sale or use on the streets. The patient in this example should have been given an opportunity to explain what happened to the numerous other narcotic pills she recently obtained. Most of my colleagues would err on the side of relieving suffering and take a risk on an individuals story. In this case the author used the instate resource , a data base, to identify a potential problem. He acted ethically and appropriately. We may not agree with his position on pain relief and opiates but that is a separate issue.

      • karen3

        As a professional who had many a client make decisions I thought wholly foolish, the mantra is, its their life, they live with the consequences. As long as it isn’t illegal or unethical, I don’t.  As long as they are informed and competent, my job is to try to make it work out the best I can, they way they chose. Patients aren’t owed ‘equal say’ they are owed first, middle and last say.  It’s not the doctor’s decision, “shared” or otherwise, unless he or she wants to undertake all of the costs, personal and financial, of the choice.  Patients are not dumb sheep in need of a shepherd. They are not entities deserving of judgment if the “right” answer is not chosen.  They are full grown, fully competent adults who have the right to live life as they choose. Period. If you don’t like answering the same questions over and over as a professional, then go into research, where the questions are new.  If you are a practitioner, it means that you will practice, and if you have a specialty, you will have the same questions repeated time and again. The challenge is the people, not the technicals. For the people asking, the question is new each and every time. If you want to cede the asking, leave doctor google up in your reception room.  People learn real quick when you are annoyed with questions and will ask elsewhere and leave you alone.  And then you get to be like the guy above who is having to button hole his colleagues for referrals. 

    • NewMexicoRam

      Congratulations!  You are teenager # 2001.

      • Payne Hertz

         That would place him 2000th in line behind you.

        • NewMexicoRam

          Ohh, nice one.

          Listen, my point is he didn’t even respond to the post.  Condescending attitude?  Right.

          If all Americans were required to receive the care I saw given to patients in Haiti when I was there, then I think there would be no complaints anymore with American healthcare.

          As it is, the spoiled brats wail on.

          • Payne Hertz

             In my version of Hell, you would be a chronic pain patient dealing with the American medical system. Once you see what it’s like to be stigmatized as a drug-seeker, whimp and “spoiled brat” by doctors of your ilk and unjustly and frivolously denied access to pain relief for decades you might realize just how privileged and comfortable life is on the other side of the prescription pad and stop your incessant moaning.

      • sFord48

        I didn’t really expect middle school behavior…do I get to generalize to all doctors?

        • NewMexicoRam

          Sometimes when you fling it, you find it returns intact.

  • Terry M

    Excellent article, Dr. Grumet.  It’s easy to become jaded when you have to deal with situations like what you’ve described, but you seem to be keeping level-headed.  Keep up the great work.

  • Andrew Schneider

    Payne, you’re acting like a teenager…and a fool.

    • Payne Hertz

      I’m not a teenager, but I am a fool for trying to use reason, logic and science to try and educate convinced bigots.

  • davemills555

    The only thing missing here is background music of the world’s saddest song, played by the world’s smallest violin!

  • karen3

    Have you ever been a “complex” patient trying to balance the egos of a bunch of docs. I wish they were teenagers.  Three year olds??? An insult to children everywhere.  And trust me, plenty of your patients are rolling their eyes behind your back about some lunacy of yours.  I manage to be civil to docs who have no clue about pharmacological pathways, the standards of care, reference ranges for tests, etc.  Bring up some “internet article” to see if it jogs some memory or recognition. I order my own tests with self pay labs so I know what’s really going on.  I manage to pretend that they have “figured things out” when I have given them a line of bread crumbs to figure it out. Sometimes they do, sometimes they don’t. If its a serious mistake, I move on, find a new doc, and start the bread crumbs.  We patients all pretend that you know what you’re doing so as to make sure you get your ego boost, which is the real point of medicine, after all, right?   The reason for medicine is to make sure you feel big and patients feel small.

    Or might you consider that it doesn’t help to foster a “bash the patient”  atmosphere in medicine.

    • davemills555

      Thanks karen3. Well said! I could not have expressed it better myself in so few words. They have absolutely no solutions and they’ve run out of excuses why our health care system is so inefficient and dysfunctional so they’ve stooped to bashing the patient. 

    • davemills555

      Well said!

  • http://twitter.com/gcgeraci Gaspere (Gus) Geraci

    I was fascinated by the comments, and ran across an article that said perfectly what I could not find the words for. Dumpling soup: http://www.medscape.com/viewarticle/761197 Communication is the issue, and the traps we fall into in the attempts to communicate our own views/beliefs. Fall too far either way and the soup/communication isn’t right. To the author and the commenters, please read…

  • http://profile.yahoo.com/WX6RAEC6MP3S42HKFVPCFOURC4 Mark

    Jordan… some of the internet commenters take the teenager comment out of context and ignore the whole of what you try to say.

    (“doctor-patient relationship can be difficult”, “mutual, symbiotic connection”, “like trying to parent two thousand teenagers”, “great affection on both sides”, “perspective is markedly different”,
    “I can never know exactly what my patients are feeling”, “I haven’t walked a day in their shoes”, “I have years of experience”)

    The perspective is that both sides need to drop the arrogance, paternalism, egotism and constant need to control anything/everything in the inherently unpredictable and complex field of medicine. You are basically offering to work out a compromise and get beat over the head by people who want to push a personal agenda (eg, narcotic abuse) or the need to feel superior (I know the pharmacodymanic pathway and you don’t, but in my infinite wisdom I will coach you into doing exactly as I say).

    Keep trying (and deflect the unsatisfied manipulators) and many patients will still benefit from your approach.

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