Says Who??

Verstehen, through shared perspectives


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RESPONSE TO DR. JEFFREY FUDIN’S REQUEST

In Dr. Fudin’s post today, comPASSION Fatigue https://t.co/rilJGgQxFG , he defines Compassion Fatigue as “essentially a form of burnout common to those of us who actually care.” He and his co-author explain the problems of advocating for good care for chronic pain patients while navigating the endless stream of misinformation, outright lies, overreaching legislation and its advocates, and the inability to understand the differences between the illnesses of substance addiction, and the suffering of chronic pain patients. “[W]e continue as a society unable to hold two thoughts in our heads, the suffering of the addict now that rules the day and the suffering of the pain patient has been relegated to a bottom dweller,” the article states.

Since most fail to listen to anyone they do not agree with, and no one seems to care about truth in advertising, chronic pain advocates and their physicians (and pharmacists) grow disillusioned and weary of the task. I urge the reader to use the link above to read this very relevant article, where the authors make a much more articulate argument for the case than I have made here, as well as reporting important new information.

However, it is not my intention to simply report on the article or its excellence. The authors realistically ask a very relevant question: Is anyone out there still playing the game? Are we still actively advocating for chronic pain patients? My answer is difficult to write.

Having been an undertreated chronic pain patient for well over 40 years, as well as a nurse in a county jail who worked with police, substance abuse addicts, and drug dealers, I believe my claim to a broad understanding of the situation to be credible. I am also well trained in both statistical and qualitative research as a result of my graduate degrees. Yet I am repeatedly called out as ignorant, as a probable drug seeker, or as simply being wrong about everything. I do have pretty thick skin, having been an academic dean for several years, and while friends compliment me on my ability to persevere, my parents called it “stubbornness.” But so far, it has served me well.

Again, I hate to quit, or to give up on a good cause. But at my age I have learned to pick my battles. I have only so much energy, thanks to my years of pain and the many disease processes that have resulted from that pain.

At the same time, that last sentence explains exactly why I have chosen THIS battle, and I will not give up or shut up. You may not see me in writing as often, because I am tired and ill much of the time. But I will write, and I will talk, and I am definitely still in the game—just benched to rest a little more often. I am far from being alone in this situation, and I no more want to see hundreds of thousands of others suffer than I wish to suffer myself.

Meanwhile, here is a thanks to Dr. Jeff, and to all the compassionate pain management physicians (especially mineJ) who stay in the game despite all the prejudice, dishonesty and even the honest ignorance and misunderstanding that muddies the waters and stains our souls. Then too, the devastation of the lives ruined and lost unnecessarily because of undertreated or ignored pain, and the new rhetoric that is based on the notion that we are all alike and our pain should be treated the same, accordingly. And let us not forget to acknowledge those compassionate physicians who have lost so much after being targeted and charged by federal agents with no accountability for their actions when they were wrong.

I am beginning to ramble, so I end with this statement: The pain of burnout and the pain of disability cannot end this battle. It is too easy already for many to forget or deny the reality of our existence. Our voices must continue to compel the truth into being.

Talmud quote


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THE WAR ON DRUGS HAS BECOME THE WAR ON PHYSICIANS AND PATIENTS

The following article first appeared May 20, 2014 as a guest blog on Dr. Jeff Fudin’s http://paindr.com/blog/ website under the title Patients with Chronic Pain Syndromes are Not Idiots http://paindr.com/patients-with-chronic-pain-syndromes-are-not-idiots/.

From the early days of human habitation on this earth, societies have revered (and also feared) their healers. Even now, from Africa to South America, and wherever modern medicine is difficult to find, the skills and knowledge of healing have been passed from generation to generation of traditional healers. In rural areas of our own nation, many communities still seek medical assistance from ‘grannies” who rely on local herbs and traditional lore to help their neighbors.

So how has it happened that in the 21st century, one of the most technologically advanced nations on earth appears to be conducting a campaign against modern, trained and licensed physicians that echoes some ancient, primitive fear of the healer? We live in the age of Reason. We understand science, including anatomy and physiology, and understand that healers do not possess magic powers that might either hurt or heal us.

Despite this advanced understanding, we have allowed lawmakers and insurance companies to turn our healers into objects to be bullied, threatened, arrested and tried under charges of murder, with prosecutors demanding a death penalty when they have no evidence whatsoever that such a crime took place.[i]

After years of study and practice, sacrifice and struggle, 21st century physicians enter their professional world with dreams and aspirations already shattered. Many have student loans that limit their disposable income for many years into the future. Many more will find that the option of setting up a practice on their own is an unattainable dream – that they will be working for larger organizations and answering to employers who lack both medical degrees and understanding, where the bottom line is profit driven. All will have to deal with insurance companies that limit what they are able to do for their patients, no matter how much the patient might need the medication or procedure. Those companies have even at times contacted their patients, without the knowledge of the physician, and suggest other treatments or tell the patients to ask their doctors for a different treatment[ii]. Somebody tell me – have the laws against practicing medicine without a license been repealed?

And that is not the worst of it. Today, a physician who tries to treat patients according to the knowledge and skills that they worked so diligently to earn is now at risk of losing everything—their licenses, their homes and families, and even their own lives. ALL THIS, NOT BECAUSE THEY HAVE DONE ANYTHING WRONG!!! On the other hand, they can’t seem to do anything right. If law enforcement doesn’t destroy them, they are in danger of being robbed or even killed by drug-seeking patients. [iii]

I could easily believe that it is the failed war on drugs that has created the need for law enforcement to redirect our attention by turning the war against physicians – and their patients, who will suffer without medical care. Sociologists like myself frequently inquire “Who Benefits?” when deciphering seemingly irrational social behaviors. In this case, the lawmakers and enforcers themselves would look like people who would benefit from a better public image by this redirection of the public’s attention.

They say it is because the physicians prescribe too many “pills”, and turn their patients into addicts. Not true. Only a small percentage of patients who follow the orders given by the physician become addicted – addiction is a disease that occurs most often when drugs are abused, against medical advice. Most abused drugs do not come from physician’s prescriptions, but from families, friends, unsecured home supplies, or drug dealers.[iv] Dependency may occur, on the other hand, because people must depend on the medications that help them. Physical dependency is not unique to opioids alone, and can be resolved by tapering when the need for the medication is over. A similar approach is needed with several medication classes such as antidepressants to avoid serotonin withdrawal or beta blockers to avoid hypertensive crisis. Because lawmakers and others often incorrectly blend the lines, differences between physical dependence and withdrawal, we allow people and organizations with vested interests to feed our fears and turn us against the only people qualified to help us.

It is no wonder that over 80% of practicing physicians are reported to have stated that they do NOT want their children to become physicians. It is no wonder that more than 400 physicians are reported to commit suicide, annually.[v]

Why are they targeted, when they are not the problem? Let’s look at the real problem here: Addiction is real. Drug-related crime is real. Drug cartels that launder their profits and use some of the “cleaned” money to lobby politicians are real. Even MD degreed providers who misuse the privilege and set up “pill mills” are real (I refuse to call them physicians). There are solutions to all of these problems, and none of them include punishing physicians and other licensed clinicians with the goal of securing political points. We must stop making the problem worse, and focus on the real lawbreakers. We do know who they are!!

I write this letter, ironically, perhaps, because I am not able to take pain medications or many other drugs that could mitigate against the chronic pain that I have lived with for more than 45 years. Like many older people (who, by the way, may be less likely to become addicted to drugs because of the changes age brings to our physiology[vi]), chronic pain (from degenerative disc disease) has exacerbated other illnesses and ultimately severely limited my life. I have written this letter in gratitude for the four physicians who compassionately and patiently took the time to untangle and address the mingled symptoms that I presented with a few months ago, and who have given my life back to me despite my limited ability to process medications. (And yes – one of those four physicians is a board-certified pain management physician. There are other ways to manage pain when patients cannot take drugs.) With some understanding of what it must take to hold on to that compassion and professionalism in an irrational and vengeful world, I declare that these physicians, and physicians like them, are the true heroes of our day. We need to let them know.[vii]

ENDNOTES

[i] Trial Verdict: Dr. Baldi Not Guilty on All Charges http://whotv.com/2014/05/01/baldi-trial-not-guilty-on-all-charges/
What are Patients to do when Law Enforcement Closes Clinics? http://missoulian.com/news/state-and-regional/ravalli-county-health-officer-says-patients-of-raided-florence-clinic/article_cf2e1690-bac0-11e3-848e-001a4bcf887a.html
Ex-doctor faces families in murder preliminary hearing http://www.news9.com/story/25395877/ex-doctor-faces-victims-families-in-murder-preliminary-hearing

[ii] Here I cite my own experience with the insurance company that covered my last place of employment. Over a period of several years, my colleagues and I received messages from the insurance company about changing our medications – such as when I was on a prescription medication for GERD, the company insisted that I must discontinue it and take an OTC medication because unless I did, they would discontinue payment on the prescriptions. We were also advised in frequent mailings to discuss alternative treatments with our physicians.

[iii] The damage done by the war on opioids: the pendulum has swung too far http://www.dovepress.com/articles.php?article_id=16781 …
Killing Pain in Perry county http://www.kentucky.com/2009/12/12/1056711/killing-pain-in-perry-co.html

[iv] “For this crisis physicians take the brunt of the pundits’ blame, despite the fact that more than two-thirds of the diverted medications are acquired from family, friends, and acquaintances – not from a prescription by their doctor. http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

[v] Pain Physicians Have High Rates of Burnout http://goo.gl/P3z1cY
Dr. Gary Shearer: Suspended Northern Kentucky pain doctor dies of ‘suspected suicide’ http://www.wcpo.com/news/local-news/boone-county/florence/dr-gary-shearer-suspended-northern-kentucky-pain-doctor-dies-of-suspected-suicide

Physician Suicide http://t.co/4vhF63eD6NReferences from this article:
1.Adams D. Physician suicide: searching for answers. American Medical News [serial online]. April 25, 2005;Available at http://www.ama-assn.org/amednews/2005/04/25/prsa0425.htm.2.Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. Jun 18 2003;289(23):3161-6. [Medline].
3.Hawton K, Malmberg A, Simkin S. Suicide in doctors. A psychological autopsy study. J Psychosom Res. Jul 2004;57(1):1-4. [Medline].
4.Holmes VF, Rich CL. Suicide Among Physicians. In: Blumenthal SJ, Kupfer DJ, eds. Suicide Over the Life Cycle. Washington, DC: American Psychiatric Press; 2004:599-618.
5.Middleton JL. Today I’m grieving a physician suicide. Ann Fam Med. May-Jun 2008;6(3):267-9. [Medline].
6.Noonan D. Doctors who kill themselves. Newsweek. Apr 28 2008;151(17):16. [Medline].
7.Petersen MR, Burnett CA. The suicide mortality of working physicians and dentists. Occup Med (Lond). Jan 2008;58(1):25-9. [Medline]. [Full Text].
8.Worley LL. Our fallen peers: a mandate for change. Acad Psychiatry. Jan-Feb 2008;32(1):8-12. [Medline].
9.Balch CM, Oreskovich MR, Dyrbye LN, et al. Personal consequences of malpractice lawsuits on American surgeons. J Am Coll Surg. Nov 2011;213(5):657-67. [Medline].
10.Hendin H, Maltsberger JT, Haas AP. A physician’s suicide. Am J Psychiatry. Dec 2003;160(12):2094-7. [Medline].
11.Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).

[vi] “indeed, bad choices, bad behavior, and drug misuse lead to crime, accidents, social instability, and addiction. The developing adolescent brain is particularly susceptible to addiction, while the elderly brain is practically immune.” http://jamespmurphymd.com/2014/04/25/the-dream-of-pain-care-enough-to-cope-the-seventeenth-r-dietz-wolfe-memorial-lecture/

[vii]“ Unless patients wake up and fight for the providers of care, we are headed for the sickest system in the world.” http://www.kevinmd.com/blog/2014/03/dissatisfied-doctors-provide-good-patient-care.html …


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Has the War on Doctors been Lost?

According To Margalit Gur-Alie (founder, BizMed), “There really is no war on doctors. There is a war on patients, and doctors are merely collateral damage [emphasis mine]. You [doctors] are an exploitable asset, to be bought and sold like cattle…” http://www.kevinmd.com/blog/2014/06/really-war-doctors-theres-war-patients.html. In this ingeniously constructed article, Gur-Alie turns the entire idea of “social capital” –- heretofore a positive concept within which we value human dignity, and also show how the poor and oppressed of the world can become the authors of their own freedom-—on its head.

Assigning the term “social capital” to patients, doctors (formerly wealthy and powerful, by inference) as social capital are nullified at worst, and become mere agents of the “owners” of production –- in this sense, the insurance companies, and probably beyond them the international economic cartels that control them –- doctors whose sole purpose is to maximize the productivity of the “covered lives” assigned to them.

The article is interesting on several levels. One of the benefits of growing old is that you get to watch old theories die and be reborn in new calls to action on behalf of a new chosen population. In this neoMarxist work, we see the Bourgeoisie (both new “owners” and the old “owners” – doctors) on one side, and the Proletariat (workers, or patients in this case) on the side populated by the oppressed. The final section of the paper is a manifesto, calling the (workers of the world) patients to arm themselves with knowledge, and unite to save themselves.

I’m all for it! To a sociologist, this is conflict theory doing its job. My problem with the article is that the conflict perspective is only one of the many that are useful for understanding any complex social issue. Like any perspective used alone, it can narrow our understanding of the issue to the point of defeating its own cause by essentially disregarding facts that don’t fit in its worldview, even while stating them. In this article, for example, Gur-Alie claims that there is no war on doctors, then spends the first four paragraphs of the article exposing what has happened, and is continuing to happen, specifically in order to disempower the medical profession as a whole.

By implication, the author is saying that the war on doctors began when the first HMO opened its doors, and is proceeding as scheduled to the inescapable “new world order” in which doctors will be mere employees, judged only by their financial productivity (like piece-workers in a factory?). Here is where I have trouble understanding whether the author sees this as a bad thing, or merely a fait accompli.

At any rate, whether near its end or only begun, there is a war on doctors. And, as so clearly outlined by Gur-Alie, on patients as well. It is manifest in the current drug wars, and in the attempted coup being conducted by insurance companies to claim ownership of medical practice.

This war may become as life-threatening as any fought with the more conventional weapons of destruction.