pain control

Tuesday, November 18, 2014

Interesting events were happening even before  one NFL game was played this weekend. Team physicians were visited by Drug Enforcement Administration investigators to see what narcotics and other restricted medications might be in their possession as they travelled along with their players to away games. The DEA actions might be part of an investigation triggered by a player class action lawsuit that alleged indiscriminate pain medication distribution by doctors, trainers and coaches, in an attempt to return injured players to the game.

It is not illegal for physicians to prescribe and also dispense narcotic medications, but there are stringent rules, regulations and paperwork that needs to be followed. Most often, physicians prescribe drugs and pharmacists dispense them. There is a check and balance in place to help patients understand dosing, side effects and potential medication interactions. For narcotic prescriptions there are more legal layers in place. A physician not only needs a medical license, but also a DEA certificate (and in some states like Texas, a state controlled substance license). There is a whole other set of regulations in place and documentation required if a doctor decides to dispense narcotic pain pills. This is where NFL team doctors may run afoul of the law. DEA certificates are assigned to a specific location, so a team doctor in Seattle cannot use the same DEA number in Miami. Narcotics for commercial use cannot usually be transported across state lines and there needs to be a medical record that notes the diagnosis and rationale for prescribing pain pills. Then comes the dispensing issue, with documentation matching inventory and prescriptions, and medication lot numbers and expiry dates in case a medication recall should occur.

That physicians sometimes inappropriately prescribed pain pills is not the real story. It all has to do with the expectation of patients and family when it comes to pain control. Perhaps one of the most influential changes in the practice of medicine occurred when pain was promoted as the fifth vital sign. But where blood pressure, pulse, respiration rate and temperature can be objectively measured, pain is very subjective. When zero became no pain and ten, the worst one could imagine, patients were expected to decide their own vital sign and expectations of pain control slowly changed. There are hospital quality indicators that ask nurses to assess pain status, regardless of whether the patient visit is associated with an injury or illness. Patient satisfaction scores often ask the patient to rate how well their pain was managed and this has led to perhaps to a societal expectation of a pain free experience.

The NFL experience proves different. Collisions on the field yield bumps and bruises, broken bones and torn ligaments and yet players want to play as soon as possible. Their coaches and general managers also want them back on the field. Pain medications, whether it is an injection of Toradol (an anti-inflammatory) or a couple of Vicodin pills (hydrocodone-acetaminophen combination) will mask the pain but not necessarily help recover from an injury. Yet playing is important. The average NFL player’s career lasts less than 100 games and there is always another player to take an injured player’s spot on the roster. Playing in pain is expected.

The real world is different. Most pain cannot be completely resolved but can be controlled. Patients should not suffer but the expectation of zero on a pain scale is unrealistic. Patients with new onset abdominal pain or broken bones can have their pain controlled so that they don’t suffer, but pain free may not be possible. Too often it is difficult for the patient, nurse and care provider to understand each other’s perception of pain. While a patient may be suffering significantly and coping by talking on their cell phone, the provider may see that patient chatting away and presume that the pain is not intense. Or vice versa. A patient who is trembling and sweating on the gurney may not see their pain as severe enough to need help.

Unfortunately, there are less than scrupulous physicians and less than scrupulous patients. Some doctors can’t say no to a patient who asks for narcotics and some patients either abuse or divert their narcotic prescription. Aside from DEA regulations, states have set up websites that allow physicians and pharmacists to monitor the number of narcotic prescriptions and the number of pills that have been dispensed to a patient. And for those who decide to divert their narcotics, there is a healthy incentive to sell their medications on the street. Oxycontin (a long acting pain medication) can sell for $1 per milligram. A prescription of 40 mg tablets taken twice a day for a month works out to a street value of about $2,500.

Somewhere between “a little pain never hurt anyone” and “there is no trophy for hurting” lies the reality of medical care. Trying to measure pain is difficult since it is different for every patient. In the NFL, pain is better when the player can return to the game but that level of pain may not be tolerable for a frail patient with cancer or a broken hip. In the end, doctors and patients have to talk to each other, manage expectations and goals. Somehow that does not translate well to a zero to ten pain scale and deciding appropriateness of care based on something that is so subjective seems unfair to both patient and physician.

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what a diploma really means

Monday, November 10, 2014

For football fans of the University of North Carolina, the issue should be about trust, not scapegoating individual players. It should be about perspective, putting academics above athletics. Unfortunately, the UNC story is about scandal and the loss of integrity. Michael McAdoo came to the UNC campus to play football with the promise that he would get a world class education. He had academic aspirations in criminal justice but those in charge of nurturing his football talent placed him in a major that would fit his football practice schedule. Though he was a solid high school student with a 2.9 GPA, he was enrolled in sham courses and others helped write his term papers. He was dismissed from the team fro academic impropriety and presumably scapegoated, because during an 18 year time frame, dozens of other athletes followed the same path to a degree and allowed to succeed on the football field.

Imagine though, if the same game plan was followed by those trusted with our health care. Imagine a university medical school that failed to give adequate training and testing before conferring an MD. Consider the consequences of postgraduate internships and residencies where failure to perform was considered acceptable. Remember that the person who graduates last in their medical school is still called doctor. The public has to have faith that the degree on the wall actually has validity. When the University of North Carolina president signs the diploma in bad faith, it calls into question the good standing of all graduates.

In medicine, there are more than a few checks and balances but also some major loopholes. Training physicians depends on building expertise on the base of a previous level of training. Not all doctors can be brilliant but they certainly must meet a minimum level of competence coming out of medical school. But four years of undergraduate education and four years of med school is only enough to get a newly minted doctor into the postgraduate training of internship and residency. At least three years more are devoted to learning a primary care specialty (family medicine, internal medicine or pediatrics). For other specialties and subspecialties, the training may last up to ten years.

The doctors in charge of the training program have a responsibility to make certain that a certain level of expertise is reached after each year of training. There are national exams to pass, but more importantly, the art of medicine at the bedside needs to be developed like an apprentice. A problem can occur when performance lags. It’s tough to fire a resident or ask them to resign. More frustrating is that after one or two post graduate years of training, that physician may qualify for a medical license, regardless of whether they completed their training. While hanging out an independent shingle in the new corporate world of medical care is difficult, that career path of general practice remains an option.

After a successful residency training, the next step is to enter practice and then take board certification examinations. Pass the exam and you’re a specialist. Fail and you can try, try, try again. Not passing on the first attempt is not uncommon and does not presume incompetence, but failing to finally pass those certification exams may be a red flag.

Once in practice, there are other safeguards to insure good care, especially for those doctors who practice in a hospital. The credentialing committee and medical staff certify the ability of their physicians every two years and review not only their degrees and training, but also any recent complaint and malpractice allegations. This information is not publically available and often state medical examining boards aren’t aware of hospital decisions. Each state has a medical examining board that is charged with making certain that physicians are safe and not a danger to their patients. Unfortunately, the states don’t often talk to each other and suspect physicians can slide for years from one state to another.

The public trust in the medical degree is only as good as each patient-physician interaction. When a physician defrauds Medicare or Medicaid or runs a pill mill to dispense narcotics or performance enhancing drugs, every physician’s reputation suffers. It’s no different than the UNC football players who did it right and graduated without the “help” of others. How much would the football fans be disappointed had Mr. McAdoo shown up on campus at 6 foot tall and weighing 180 pounds, instead of 6’7” and 245? How sad are the UNC fans knowing that the university administrators took advantage of their gridiron heroes and stole their opportunity for an education. And how upset are these same alumni knowing that their diplomas have been devalued?

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