By Dr. Bradley Carpentier
April 11, 2016
Pain is something every physician is familiar with. It comes in many varieties. There is the pain of late night calls, the pain of angry patients, the pain of poor outcomes and the pain of dealing with billing and reimbursement for your hard work. It is normal to be pain adverse, as most of us are. Who hasn’t found themselves wanting to sneak out the back door while staff is left to deal with a difficult patient at the reception desk? Who hasn’t dreaded that 3:00 a.m. call from the ER or a ward nurse trying to address a problem? If you ask physicians what drives them to leave the practice of medicine in general, or at least wish to change their practice circumstances dramatically, more often than not it comes down to a matter of pain and relief. Pain always has a cost whether it is measured in monetary, lifestyle or satisfaction terms.
Pain is the primary driver that leads patients to seek us out. In most specialties there is a pain component to everything we do. If we dismiss it, we do so at great peril.
Consider pain from the patient’s perspective. When someone is suffering from pain, it comes at great cost: financially; physically; emotionally; and spiritually. There are the direct costs that come from missed days of work, or from complete disability. Even at minimum wage, that can add up to tens of thousands of dollars per year. There is the cost of comfort. The money spent on medications, therapy, surgeries and devices in an effort to gain relief. I have seen patients who spend thousands of dollars of their own money procuring elixirs, braces, machines, alternative care and spiritual healers in a continuous search for relief from pain.
Our obligation to patients is to make a correct diagnosis and render the best therapy our science and experience have to offer. Failure to do this will absolutely result in pain for us. Repeated failure will catch up with us. I have known surgeons who left town because the medical community and patient population lost faith in their ability to adequately address patients’ problems. This could be from lack of technical proficiency, poor patient selection, bad luck, or a host of other reasons. The Internet brings with it powerful tools for punishment such as Yelp or Angie’s List where patients are free to rate their care. These tools are only growing more powerful.
Society also has a great and growing stake in our work and the quality of our results. The pressure to do good, or at least do no harm, grows every day. Along with the expansion of government subsidized insurance comes more onerous policy. Because the government is the payer, it has direct incentive to encourage improved outcomes, or at least to limit costs. Take for example policy surrounding the prescribing of opiates and the advertised opiate epidemic that our country now faces. I spend a good deal of time working with government agencies as an expert as they work to enforce current policy. I see physicians and midlevel practitioners lose their licenses every month for what the government considers poorly managing patient pain.
Now more than ever, we need to render the best care possible and avoid merely trying to mask pain in the long term with powerful opiate drugs. We are all being watched and you can be sure that if your results drop below what is considered acceptable, there will be consequences. Just as transplant services and infertility clinics depend on outcomes to remain in business, so too will all of us in the near future. The option of putting the patient on pain medications and referring them back to the primary care physician or to a pain clinic is quickly being eliminated. It won’t be enough to merely do the work as advertised. One will need to get the promoted result as well. I can imagine no greater pain in medicine than being told I can no longer do that for which I trained for the first 30 years of my life.
The obvious response to all this dire warning is to think, “Good riddance. I can quit and go do something more to my liking.” I’ve tried that. It’s fun for a while, but eventually I missed the intellectual stimulation. I found my professional friends begin to drift away as we had less and less in common. Even attending medical society meetings became painful. I found that as other attendees realized I was not in active practice, and therefore not a potential source of referrals, they moved on to talk to someone else. Even my 7 year old daughter questioned the notion that I was a doctor when she observed that real doctors have patients to see and I did not. As frequently painful being a physician is, not being a physician was worse for me.
Throughout all of this, I have not mentioned the financial costs of unrelieved pain in this country. In 2012, The Journal of Pain estimated that the cost of chronic pain is as high as $635 billion a year. More than the yearly cost of cancer, heart disease and diabetes. These were felt to be conservative estimates. More people seek care for arthritis pain and back pain than for any other cause in this country. Worldwide, pain is estimated to affect 37% of the population. It is impossible to ignore these numbers. If you aren’t in the business of relieving your patient’s pain, you probably won’t be in business for long.
Dr. Bradley Carpentier is a board certified anesthesiologist and pain physician in central Texas. He is the author of Unraveling the Mystery of Chronic Pain: What You Need to Know to Get Relief. He completed his training at Stanford University Medical Center and The University of Texas Southwestern Medical Center at Dallas.