The Ether Way

Pain: The Sixth Vital Sign?

1996 – Physicians in the US treat pain conservatively.  Their practice pattern is shaped by many forces, including concerns about patient safety, chemical dependence, and diversion of prescribed opiates.  Pain in many patients is undertreated.

1999 – The Veteran’s Health Administration announces an initiative that characterizes pain as the 5th vital sign.  Highly touted, it accomplishes nothing, at least not in the first 5 years (1).

2000-2001 – The JCAHO, perhaps following the VA’s lead, announces its own initiative, also endorsing pain as the 5th vital sign.  Pain is subsequently conquered, victory is declared, and everyone lives happily ever after.  Okay, maybe not. 

    As you might expect, progress was far easier to advocate than effect.  Once again, to practitioners, the supporting documentation reads more like a poorly written horror novel than useful guidance (2)

(Click on Image to Enlarge) This is a graphic from an educational tool (2)…. I have so many problems with it that I don’t know where to begin.
    1. Everyone was taught about pain and how to manage it as a student and resident.  Everyone.  Some learned more than others, but the importance of managing pain was recognized well before the JCAHO and VA discovered it.
    2. CME for pain was proportional to how much you encountered: surgeons and oncologists talked a lot more about it than dermatologists and radiologists.
    3. Dependence, respiratory depression, and side effects are all real concerns…as is concern about regulatory scrutiny.
    4. I will admit to limited availability of role models and access to pain docs in some settings.  Both were legit then, and are now.
    5. Patients are indeed the experts about their pain.  But patients are humans, and that spans the spectrum of personalities and psychiatric disease.  Crazy people get sick and have pain too. Managing pain in patients with psychiatric disease requires a deep understanding, that is to say understanding that is more than one powerpoint slide deep.  If you understand the prevalence of psychiatric disease, and its higher prevalence among the chronically ill, you understand that this is not a minor consideration (but does manage to show up no where on their map of the world).  There are other problems with this whole self-reporting thing, as we will explore briefly below.

There has been little effort to measure the success of the JACHO initiative, but there is evidence of its aftermath.  Sales of opiate based analgesics have increased dramatically (approx 100%)(3).  It is certain then, that physicians have become more liberal in their use of opiates to treat pain.  Of course, the increased problems with chemical dependence, feared by reactionaries but not by the champions of these policies, have come about exactly as predicted (4), (5), (6)).  Even the bizarre predictions became true: that there would evolve a group of ‘professional’ patients who would visit multiple pain clinics, self-reporting chronic pain, garnering multiple prescriptions, and reselling their drugs on the street.  Opiates are dangerous to abuse, and those who care to can easily measure the body count associated with the new era of pain control (4).  Once again, it’s not small…. and it’s far more the direct product of these campaigns than their architects are willing to admit *.  To be fair, it is certain that human nature, human biology, and human avarice are the most important drivers of this problem; these initiatives simply made it worse.  Dare I say that while no one ever died of pain, lots of people have died (in the past few years) from its treatment? Or at least in part as a consequence of these initiatives?

 

Impaired Physicians Part III- Clinical Competence, a Moving Target

Of all impaired physician issues, incompetence is the toughest to manage. The "dry lab" component of competence is obvious; required didactic certifications must be maintained, CME's must be completed, licenses must be active, minimum case numbers must be documented. The problem arises in the crucible of clinical practice. Like everything in life, physician competence resides on a continuum, from inspiring to notorious. Competence changes with time; sickness or senescence, improvement with experience or intercurrent training, and importantly, shifting standard of care. To make matters more difficult, competence can be contextual; I might be an outstanding neuro-vascular anesthesiologist, but weak with liver transplantation. So, how to judge?

The answer is outcomes. As in  evidence based medicine, good outcomes are the proof of good practice. Competence is generally considered adequate from an institutional and leadership perspective if bad outcomes don't "fall out" in Quality Assurance activity. There are sentinel events (major complications) or patterns of lesser complications that serve to focus leadership scrutiny on the affected practitioner. Here is a situation where once again, insight is key.

Being Best At Who We Are

A recent editorial in the Philadelphia Inquirer by Chris Satullo (Aug 19, 2007) caught my eye. He discusses the myriad manners in which one’s pluck and one’s luck interact to result in one’s life story. I was struck how much of my own bio is luck in the context of some pluck. But thinking about it more, perhaps whatever pluck I have applied to my life is really luck….the happenstance of genes, role models, training, NIH study section assignments of my grants, and parenting.

So here I am a professor of anesthesiology at a major medical center, the culmination of a series of unlikely events, starting from the improbability of conception and survival of birth-related asphyxia. Then one summer day Mike Ruscher, in 1967 on his skateboard on the street in front of 115 Windsor Drive, suggests we volunteer as junior ambulance attendants at the local ambulance service. What a cool idea, sure lets do it! This leads by a circuitous path to medical school and then an interest in cardiac arrest associated brain ischemia and acute care medicine. This then leads to a variety of interactions with many other basically randomly encountered life influencing people and experiences and here I am!! If I had not met my health teacher Ted Kondrad in junior high, my buddy Mike Ruscher, Harold Heine in college chemistry, Peter Safar in med school, and numerous others, undoubtedly everything would have worked out differently. Probably much differently. Sometimes I look at my tattooed drug addled Viet   Nam vet biker patients and think how easily that could have been me….just one or two more C’s in college and my lottery number of 92 would have been enough.

Impaired Physicians Part II - Insight

There are two psychological traits that are important to the successful practitioner; empathy and insight. Empathy allows us to identify with the suffering of others; it motivates us to perform at a high level. Insight allows us to process uncomfortable realizations regarding our ineffective, harmful or embarassing actions. "Good judgment comes from experience, and experience comes from bad judgment;" but only if there is motivation to get it right, and insight to allow honest assessment of when we do (and don't) get it right.

Unfortunately, neither empathy nor insight are required to succeed in medical school and residency. In training, empathy can be replaced by fear; fear of disapproval or dismissal. And insight can be replaced by external direction; the non-insightful are frequently good at following instructions. At least, those that aren't (true sociopaths and the like) don't usually make it into medical practice.

Impaired Physicians

The public imagines that doctors protect each other. The reality is far more complicated. Medicine, at least hospital medicine, is a fishbowl. If Doctor Y turns up for rounds with a black eye on the fifth floor, we are likely to hear about it (in gossipy tones) in the OR that same morning. Think of a hospital as a big cubicle barn without the barriers. Nevertheless, disciplining physicians is tricky business.

First, my credentials. I have served as Chief of Staff at two hospitals, and have been in hospital leadership for two decades. I have had death threats against me and my children, almost certainly as a consequence of physician disciplinary activities during my time as chief of staff. I have been involved in dozens of disciplinary actions at all levels, and in retrospect, I've been generally satisfied with outcomes for patients and physicians.

"There's a lot of stuff goes on."

  -Tony La Russa


A favorite anesthesia blogger, T of Anesthesioboist, recently compared anesthesia to cooking. Not an inapt comparison, but I've always thought anesthesia was most like...baseball. There are the obvious reasons (I'm a guy, I was a baseball fan, baseball is like all of life..); no, wait-hear me out on this one.

Anesthesia is like playing right field.

Firstly, batting is like an anesthesia induction or emergence (or like coming off bypass); it is an acutely intense activity which requires complete concentration on multiple rapidly changing variables in the midst of distraction, if one is to be successful. It is an intensely physical activity (go ahead-try to manage a cardiac induction with a broken finger or sprained ankle) with relatively narrow tolerances. Hitting and anesthesia are completely honest activities; there is no pretend, and little that is relative; either you got it right or you didn't.

The maintenance phase of anesthesia is like playing right field; although it looks relaxed, it's anything but; peering in for signals as to positioning, scrutinizing the batter's stance for clues to his intentions. Examining the baserunner's positions; who's fast enough to tag up and beat a throw, who's slow. Ignoring or engaging the crowd. Preparing to move to a hit ball...every pitch is an exercise in focused watchfulness and pre-positioning. That's the price of playing in the big leagues. And being a "gold glover" means virtually never committing an error; One mistake in a thousand plays is barely good enough. The chances that any given pitch will result in the need for decisive action by the right fielder are low; maybe routine fly balls two or three times a game. Once every five or ten games maybe a big move; shag a fly and a long accurate throw to the cutoff man. Once or twice a season, the game hinges on your move; hero or goat? And if you get it right, the pitcher might come by in the locker room and thank you for saving the game; or, more likely, he might be too busy talking to the press about "his" win.

We’re from the government, and we’re here to help.

   Everyone knows that this statement is generally untrue. It’s a whopper, right up there with “the check is in the mail” and “I’ll respect you in the morning”?   When is this true? Ironically, most often, when members of the armed forces are conducting operations ordered by their Commander-in-Chief (humanitarian or combat missions).  When is this not true? Well….

    As a group, proponents of health care reform advocate a greater government role in the provision of health care.  The more limited proposals advocate some combination of greater regulation and more extensive participation (e.g. expanding Medicaid).  More ambitious proposals would produce explicitly or functionally socialized health care. As we deliberate about the options, it is worth remembering that the US government in already in the business of health care,

    Not only is the US government already in the business of health care, it in fact runs 3 large health care systems in parallel.  The first is the military health care system, which in fact is a hybrid system of military hospitals specializing in the care of combat casualties and an HMO that specializes in procuring care from the lowest bidder (and if you have any friends in the service, you can ask them how it works).  The second is the Veteran’s Administration, which is one of the largest, if not the largest, vertically and horizontally integrated providers of health care on the planet.  The third is of course the Medicare system, which has been a growing force and shaping healthcare since its inception.  Only a few visionaries predicted the role that Medicare would have in shaping health care when it was proposed.