Patients Who 'Must Have' Pain Medicine NOW

Michael J. Schiesser, MD


March 25, 2015

In This Article

Important Lessons That Changed the Dynamic

Although it makes sense on a superficial level to feel frustration toward patients whom we perceive as "abusers," this was merely a distraction from the fact that I had neglected to create an appropriate communication protocol between me and my staff.

The improvements didn't end there. I eventually automated delivery of the patient agreement through a video orientation, eliminating the all-too-frequent "nobody told me that" or "I just signed it; I didn't realize what it said." Now I work with 60 doctors, and I never need to hear "Dr Smith didn't tell me that," because the expectations and accountability around that are universal and standard throughout the clinic, and I can see the date when the patient watched the video and a scanned copy of their signed agreement. It doesn't prevent the patient behaviors, but it unambiguously defines accountability when problems do arise.

More important, it's obvious that patients with undiagnosed addiction to painkillers who exhibit abuse and misuse behaviors are emotionally challenging for the entire clinic.

What's not obvious is that the lack of organized infrastructure within the clinic was amplifying my frustrations, making my staff appear unsupportive and difficult to replace and contributing to provider burnout. These solutions were within my grasp. It didn't depend on my patients changing their behavior. Rather, it required that I design simple, organized processes within my clinic to better equip my organization for the emerging and complex needs of the patients.

For example, the "lost/stolen" form described above is a means of capturing objective data in the patient's own handwriting that previously would have been relayed via a phone message from reception staff. When the patient checks a box that says, "I took more medication that the physician authorized" (for example), it serves as an unambiguous indicator when considering the question: Does this patient's existing care plan represent an unreasonable risk?

When faced with such data, in this format, clinicians can more easily generate a thoughtful care plan in response to aberrant behavior. This process also helps to make follow-up communications with the patient less awkward, because the patient now fully "owns" the narrative on the paper (and truth or not, it's less likely to spiral into time-consuming modification).

A review process that, for example, involves consulting with a colleague can also be defined as standard when a patient fills out the form. This generates further objectivity, and it can provide a more reasonable basis for what are often emotionally charged interactions.

For example, a very authoritative and professional delivery of an unwelcome message to the patient might be, "I spoke with a colleague (eg, pain specialist, addiction specialist, medical director) about your situation, and we agreed that [new care plan]." A pause in decision-making, or conferring with colleagues, protects the patient from bad outcomes that occur as a result of on-the-fly, ad hoc, or improvised care that otherwise requires more careful consideration.


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