She could have been my charming tiny kindergarten teacher, sitting there nonchalantly in her wheelchair with neatly folded arms in her lap. The delicate, airy cloud of silvery blonde hair on her head resembled Queen Elizabeth’s style. I named her Ms. Elizabeth. A few moments ago, though, she looked like a young child who could not comprehend the meaning of her condition. Whenever she was spoken to, her mind seemed to fixate only on one thing: could her pain management intensity be increased? Due to her chronic pain, Ms. Elizabeth begged for more morphine, more pills and more medication.
As a medical scribe, I was tucked away in the corner of the surgical exam room waiting for the doctor to return and hoping for pleasant news for Ms. Elizabeth. I only worked at the hustle-and-bustle pain management clinic for nine months, but it was long enough for me to appreciate the depth of care that could still be offered to patients.
Encounters ranged from brief 90-seconds meetings to more complicated cases requiring several phone calls and radiographic analysis. New patients undergo a stepwise process of physical, orthopedic, anesthetic and neurosurgical therapy in addition to oral medications as appropriate for their pain. The last and most invasive treatment for pain management, reserved for patients who failed to derive benefit from multiple surgeries, was a surgically implanted intrathecal pump. Designed to deliver injectable opioid medication directly to the spinal cord for treating pain, this procedure was typically irreversible and required medication refills regularly.
It was rare for patients to leave a surgeon’s care at this point in their care, as the surgeon had a unique responsibility to the patients to ensure their pump was well maintained and functioned properly. When Ms. Elizabeth arrived, she already had a pump, and unlike many of the other patients with a pump, she continually stated that her chronic pain was not well managed. Generally, patients without a referral from a physician were not accepted, but an exception was made when an established patient asked for a favor for their good friend, Ms. Elizabeth, who had been struggling to find another physician, to be seen. Gradually, small increases and adjustments were made to her medications and infusion ratios. Around her fourth visit, she was informed that the doctor was not comfortable further increasing the strength of her pump and oral medications for safety reasons. Despite pleas for mercy on her pain, the decision was final: she was fired as a patient, there was nothing more to be offered for her pain, and the process of transferring her care to another physician would begin. She was reduced to tears, and I imagine she felt abandoned. I wonder if she was viewed primarily as a liability, addict or an impossible case.
Later that day, I learned more about Ms. Elizabeth’s former physician from the radio. He was a pain medicine physician who performed numerous intrathecal pain infusion pump surgeries and other procedures for patients when insurance and Medicaid provided high reimbursements. For even mild or moderate pain, this doctor hastily encouraged his patients to undergo the most invasive and expensive treatments. He provided patients with concoctions of multiple high efficacy medications despite the increased risk of mortality and serious adverse effects. An investigation began when one of his disoriented patients caused a fatal highway motor vehicle accident which ultimately led to the anesthesiologist’s imprisonment. An appalling amount of unnecessary harm was inflicted on these patients in the name of monetary gain. This physician’s greed directly resulted in his patients’ opioid-dependence. Ms. Elizabeth, reduced to being in denial about her insatiable morphine addiction and silently crying is a patient I will never forget. I wonder about her outcome and the changes that an addiction rehabilitation program could have made in her life.
I am fascinated by the processes of rehabilitation and addiction. In the history of medicine, addicts were discriminated against for seemingly making poor choices.
Recently, addiction has finally found its place in the medical disease model, now being understood as a stress-induced defect susceptible to genetic vulnerability and acting on reward memory areas of the midbrain and specific areas in the frontal cortex. At this point in my study of medicine, I do not yet understand all of the complexities of pain management using medications or surgical interventions, but I know I cannot place business and profits before patient safety. As medical professionals, we are invited into a unique relationship with patients where the patient exposes their life and body to us. Is it in the patient’s best interest to provide the strongest medication available for their pain?
If we feel we no longer have anything to offer our patients due to time constraints and the fear of losing our medical license, are we making the best decisions? What I have already wholeheartedly committed to my future patients is that I will advocate for and contribute to their welfare, providing to the best of my ability fair and equitable treatment. I challenge myself to always search for creative solutions to solving my patient’s needs, and my ultimate goal is to help patients achieve health, wellness, and a new state of independence from disease.
The author is an anonymous physician assistant student.
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