For better or worse, people are more than just complicated machines. As I’ve written about earlier, medicine can sometimes be a complicated sales job, a teaching job, a parenting job…you name it, it’s part of medicine…
One of my residents came to me recently. He had a patient on the phone who “lost” his Vicodin prescription, and wanted a new one called in. When the resident declined to do this, the patient asked to speak to a “real” doctor.
Vicodin is a problem. It’s a terrific medicine–really. It helps ease severe pain. Unfortunately, like all opiates, it can be addicting, and therefore has a “street value” (about 5-10 dollars a pill, depending on whom you ask). Because of this, large clinics where patients feel they may have a bit of anonymity attract a number of folks who want vicodin for something other than pain.
Most people with chronic pain are quite legitimately miserable–uncomfortable, depressed. And many people with chronic pain may benefit from opiate therapy. We usually know who those folks are. We also know who the less-than-legit people are. They come in too frequently, or not frequently enough, are abusive when they don’t get their way, go from doctor to doctor–they sap the strength out of health care professionals and ignite the inner fires of cynicism. I love them.
OK, maybe that’s putting it too strongly, but they really give me a chance to teach my students and residents some valuable lessons. Most doctors give people the benefit of the doubt. After all, we’re in the business of making people feel better. I usually let my residents try dealing with opiate users on their own before I intervene. “She is in a lot of pain, it’s quite legitimate.” “I don’t think he is using more than she should; he’s very nice.” Ah, the innocence of inexperience. In my state we have tracking system the lets me see every opiate prescription filled by a patient under any of the identities I know about. When I show a young doctor the list of all the different doctors the patient as been getting drugs from, and show them an actual pill count, the warm light of cynicism begins to glow in their hearts.
I got on the phone with the patient my resident was having trouble with. I don’t have any particular accent (other than Midwestern with perhaps some northeastern undertones). My resident has a very slight foreign accent. Doctors with accents, even when completely understandable, are often treated dismissively by patients who want something they can’t have. Not having an accent takes away the first illegitimate complaint–”I didn’t understand the doctor.”
So communication being established, we moved onto the excuse phase. He lost it, never had a problem before, has been on it for years, etc. I explained that once I hand him the prescription, he is responsible for it. Having been on it so long, he knows how valuable that little piece of paper is. What if I had handed him one hundred dollar bill? Would I give him another if he lost it? And what if someone finds it and fills it? I could lose my license!
I offered him a chance to come in and be reevaluated, with no promise of a prescription. I also asked him if he had followed up with the pain specialist we had recommended (I love computerized records). That was when he hung up, making my point for me.
It’s a tough job, balancing cynicism and compassion, but it is as much a part of medicine as selling someone on the idea of a colonoscopy. Hopefully, we get it right most of the time.
