The one that starts with "D"
I’d first like to clarify that I am not an expert on pain, and my perspective on pain is based on my personal experience in medical school, residency, and my time as a hospitalist. I hope for this to be a space to share thoughts, advice, and encourage discussion for our collective edification.
Throughout medical school, internal medicine residency, and working as a hospitalist at a quaternary care center, I’ve spent hours-days-years learning about and treating complex medical conditions. Despite all the training and experience, I still find that the most difficult condition to treat is pain. Managing pain is an assignment that often leaves both patient and clinician dissatisfied at best, and miserable at worst. For the patient - pain is suffering, many struggle with addiction, and for those with chronic pain also comes stigma, labels like “drug seeking,” and dismissal of complaints. For the clinician – the daunting task of objectively creating a relief strategy for a largely subjective entity, the mental fatigue from receiving frequent or high volume pages, and feeling ill-equipped to effectively target the root cause/multifactorial nature of pain.
What is pain? The pathophysiology and treatment of pain that are taught in medical school nearly always deal with the “physical.” Only rarely do med school curriculums meaningfully try to equip future doctors to navigate the emotional, social, and psychological aspects regarding pain. If the mind perceives pain, whether or not we find a clear source, is it not still pain? Therein lies the difficulty – how do we treat something that we can’t see? The world is advancing in its knowledge of the body-brain connection, and we see more and more how the psychological can mimic/affect the physical, but effective inpatient treatment strategies are still massively lacking.
This is clearly an issue that requires a multimodal approach; behavioral health, addition medicine, and consistent primary care follow up may all play important roles for successful treatment. I greatly appreciate my outpatient colleagues for their contributions in care, and often wonder how we in the inpatient setting can effectively continue the progress, despite the barriers to do so.
It is hard to order a medication (or dosage/frequency) that you do not feel is medically appropriate for a patient. It feels wrong, and in some cases, raises concerns about perpetuating addiction. This is challenged by patients insisting that the regimen is not adequate, and can lead to a very difficult situation that includes self-doubt (which can be good, because we’re not always right!), patient hostility, increased burden on nursing staff (and subsequently and increase in pages from nursing staff), culminating in emotional exhaustion and burnout. It is hard to want to do the right thing while having no objective measure to guide it.
Two, given the multifactorial nature of pain, it can feel like no progress is being made when only the physical aspect of pain is being treated. Unfortunately, the inpatient setting is a difficult place to get the necessary behavioral health and/or addiction medicine therapy, as they often require long term treatment and follow up. Too often, patients are simply flooded with narcotics while no meaningful progress is achieved, and the cycle repeats. At the same time, how does one begin the discussion to initiate long term therapy with a medication like buprenorphine when the patient is demanding IV hydromorphone?
Three, and this may be fueled by overall cynicism regarding the US healthcare system - are hospitals turning a blind eye and allowing overtreatment to occur to avoid drops in patient satisfaction scores, “how well is your pain controlled” polls, and the financial/US World and News ranking implications? Will hospitals shoulder the cost to implement multifaceted strategies starting in the emergency room and including the hospitalist, behavioral health, pain management, and addiction medicine teams to tackle the root causes of frequent readmissions due to pain, and provide meaningful help to our patients?
I don’t have an answer to many of those questions, but I hope we individually and collectively work to improve our understanding/treatment of pain for the sake of our patients and the sake of our healthcare workers.
Thanks for reading,
-A tired hospitalist