Patients Who 'Must Have' Pain Medicine NOW

Michael J. Schiesser, MD


March 25, 2015

In This Article

A Deeper Problem—and a Solution

In this case, it's not that I didn't care about my patient's concerns, nor was it my assumption that my staff didn't have the desire to genuinely support me, but you can probably relate to the whole drama—the disruption, the suspicion, the insufficient information, and the frustration when support staff are not properly oriented to the tasks that can truly support the physician.

It's not unusual to feel annoyed about an interruption relating to a patient problem we believe either shouldn't happen, or we wish weren't happening. Or perhaps we don't even believe the story to be true in the first place. It feels like the patient and everyone around me are conspiring to get me to press the "easy button" (that is, replace the medication).

I find it's not just the people around me who are part of the (imagined) conspiracy. My own emotions start to work on me too. Like, "What kind of mean doctor are you, that you don't care about this patient crisis?" or "This patient is not an abuser" or "Don't you realize your staff are just trying to help? Show your appreciation by stopping what you are doing and giving them a response. Don't lose their trust because you are annoyed."

It took me some time to realize that I wasn't annoyed because I didn't want to help my patients. I also appreciate having staff to help me with my patients. I realized the reason I was annoyed was because there was no structured system in place to organize my staff's work, so that they could actually be helpful.

Improvised Care: The Elephant in the Room

Introducing some sort of guidance or policy for my staff as to when or how to message me in the face of these aberrant behaviors seemed doomed from the start. Every curve ball thrown at our clinic by our patients was a new twist—and nearly every response was ad hoc and improvised. Sometimes I would end up replacing medications; sometimes I would not.

When certain patients reported a compromise to their medication supply, I felt compelled to respond right away with deep concern. Others I perceived as "abusers." This was the category of patients whom I didn't want disrupting my day, or my scheduled appointments. However, there was no way to codify this with support staff, nor would I really want to.

I ultimately determined that one of the biggest issues was the ease of getting my attention, and the lack of actionable information that went along with that. The patient could merely call and leave a message suggesting that there was a circumstance that compromised their medication supply (then "just add drama"). Some minutes later, a communication was given to me, typically minus sufficient information to understand the scope of the circumstance, or to follow through with any diligence.

I realized that some standard questions typically came to mind for me right away, as I tried to better understand what was being requested of me. Without this information, a highly inefficient back-and-forth communication among me, my staff, and the patient might take place. The painful exchange above, vintage 2005, is an example of that.

The solution that emerged from that turned out to be a simple form. Whenever a patient was making an unexpected request to replace medications, I told my staff I didn't want to hear about it until a form was completed in the patient's own handwriting.

Use of the form provided no guarantee that the medication would be replaced. Rather, it simply required the patient give me some basic information that I may need to define action steps; this included the pharmacy where they last filled their prescription, the date, what they are asking me to do about it, and why they think that is reasonable. If it involved someone else taking their medication, I asked them to identify that person, and the form reminded them that transferring possession of a scheduled medication from one person to another for consumption or resale was a violation of federal law.

If they took more medication than authorized, there was a check box for that. There are 16,000 unintended deaths each year from prescription opioid overdose. Not good.

At first, my staff didn't entirely understand, so I would continue to get interrupted with crises. I calmly reminded them about the new form, and that I wasn't going to address requests for controlled medications because they had been lost or stolen unless the patient first filled out the form. I suppose I should have expected it, but as a result of requesting the form, I experienced a precipitous drop in the number of requests to replace medication.

I actually had to change the process quite soon after that, so that staff would document at least something of what the patients said on the phone before they declined to fill out the form. This saved the front desk staff a lot of time, too.


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