I recently had a conversation with a new patient who was referred for surgery.
As it happens, she discussed me with people she knew before her appointment. I like patients to look me up, talk to friends, find out who I am, and come with an expectation of what they will get in my clinic. We had a normal new patient visit, and per my typical workflow, I explained the agenda: a full medical history, a discussion of the evolution of her problem, the impact on her life, a physical exam, a discussion of her options for management, and scheduling of surgery.
This often takes a full hour, and sometimes patients forget the questions that are most important to them, the things that don’t always come out in a medical history, so I leave time before we start to allow patients to tell me what is most important to them. After setting the agenda, I asked her to tell me the things she wants to get out of this visit, any fears she has, and to alert me to anything in her life that may affect her care. This is where the conversation with this particular patient got interesting.
She told me something that I have heard before, and I think it reflects a misunderstanding about my practice. It is an unfortunate side effect of standard medical practice and our culture of medicine. She told me that she was unsure she would choose to be my patient because a coworker had warned her that I do not prescribe pain medications.
This made me giggle — out loud giggle. I understood where this was coming from. She asked me to explain. Otherwise, she is not interested in my care, no matter my reputation. Here is what I told her.
Her coworker is both wrong, and at the same time right … it depends on what she means. I have quit prescribing routine narcotics. For this, she is right.
Due to misunderstanding about how pain is best managed, as well as the culture of narcotics in the U.S., some patients seek care elsewhere. This is a shame. What is not true is that I withhold pain medications or that I do not address pain. We then spent a good deal of time discussing how I address pain.
The big difference between how I manage pain and how it is managed with standard medical care is that I reject the idea of pain as the fifth vital sign, I reject numeric pain scales, and I reject the idea that excellent care requires that pain becomes the central aspect of care, or that care should be completely pain free.
I treat pain. I do it very well. I do it by addressing the causes of pain, not by focusing on pain. Pain is not a disease. Pain is a symptom of disease. Nothing more. Treat the disease, and the pain ceases. Those who expect immediate cessation of pain without treating the underlying cause will create other problems, other diseases. Pain is not objective, and pain cannot reasonably be reduced to a number. When you do, you lose the reality of the pain, and the pain number takes over, with narcotics becoming the dial that you turn up and up and up, until patients report lower numbers. This is the root of our current opioid crisis in America.
So, I do things differently. Not only do I not participate in a toxic opioid-centered medical culture, but I also address pain more effectively.
Patients who have been operated on by me can tell you the results. Those who embrace my method have remarkable recoveries, with little pain and very few side effects. Those who do not treat their pain how I ask, who do it their own way, they hurt. They resent that I do not give opioids as a standard practice. If they do things the way I ask them to, they have significantly less pain, without the need for excessive opioids.
I am very aggressive about pain. I have to be, to provide better than current medical culture does. It works. It is proven, not just by me, but by many disciplines. I am not alone, even if my way is uncommon. I use what is termed multimodal pain control — multiple modes or methods to address pain, not just a bunch of Percocets. Pain is a cascade of events, beginning as insult or tissue damage, through local and systemic stress hormones and inflammatory markers, with nerve conduction and synapses, ending in the brain with the experience of pain.
When you recognize the cascade nature of pain, using multiple agents makes sense. Each mode of treating pain addresses a different cascade step, providing better pain control than using a single agent would. I start with pre-medication of patients with three non-narcotic pain medications prior to surgery. This is followed by a tailored and fine-tuned anesthesia, limiting both stresses and intraoperative narcotics. I then place three different nerve blocks for pain, each lasting for multiple days after surgery. Then we continue the non-narcotic pain medications post-operatively.
I counsel patients on strategies for limiting pain and discomfort after surgery. I advise that surgery is not completely pain-free, our goal is pain tolerable, and I need them to be active after surgery. This all helps them to put their body back to normal in the fastest way possible, thus limiting the duration of any pain. Finally, I invite all patients to call my office day or night after surgery if the pain is more than expected. Most of these calls result in a discussion of their pain, and we can usually treat the source of their pain, again limiting pain.
Some patients have very limited pain tolerance, and all the things we do still leaves them with intolerable pain. For those patients, I cautiously prescribe narcotics, but only after we have assessed that all the non-narcotic strategies have failed and there are no correctable causes for pain. With this strategy, almost none of my patients need the narcotic. This doesn’t presume that narcotics are evil or inherently bad. They are just typically unnecessary and will often come with side effects that actually slow down the recovery.
This process has taken years of trial, error, significant study and research, as well as cross-discipline training to learn and get right. My mentors are not all gynecologists. Some are anesthesiologists, some are from other surgical disciplines, like orthopedics, urology, and colorectal surgery. I have learned a lot from stepping outside of the knowledge base of gynecology. My patients have reaped the benefit of this continual improvement. They report truly remarkable recoveries. Surgery is not the same as it once was.
After discussing all of this with my skeptical patient, I asked if this was a satisfactory answer to her fear of pain after surgery. I said that I do not need to be every patient’s doctor, and I am confident in what I do for my patients. I even refer patients to other surgeons if any patient does not want my care. My goal is for them to get the best care possible. I believe my way is the best I can provide, but I do not need them to have their care from me. There will be other referrals.
Her response was reasonable. She told me she had suspected that her coworker was wrong about something. Otherwise, she would not have come to her appointment. She liked what she heard and wanted to continue with the medical assessment. She scheduled surgery at the end of the visit.
Lee Hammons is a gynecologic surgeon.
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