I’m an ED physician, so I’m used to patients screaming at me — sometimes with earsplitting demands for heavy-duty painkillers, morphine drips and similar remedies that will numb or “fix” them. I can deal with this. What I can’t deal with is a health system that incentivizes physicians like me to medicate adult patients, especially those at high risk for substance abuse, with little thought given to their long-term wellbeing.
As I write this, a recent incident comes to mind: Earlier this year, a regular heroin user experiencing a medical crisis entered my ED. After going over his medical history, I tried to express how worried I was about him and how we needed to treat him, but he said all he wanted was IV opioids. I talked at length about non-opioid alternatives, but he said opioids were the only thing that would help. At one point he actually screamed, “I know there’s a sign on this wall that says you need to do everything for my pain!”
I explained to him as politely as possible that the law only requires me to medically screen and stabilize him, not medicate his pain, although I was happy to address his pain. He was furious — and ended up threatening all of us, pulling out his IV (and covering the room with blood) and storming out of the ED. That kind of reaction isn’t uncommon, and quite frankly, I was glad none of the staff were injured. The opioid epidemic is so out of hand that physicians and nurses are sometimes attacked by patients who are enraged when they can’t get the drugs they think they need. We are seeing very good doctors, exasperated by their inability to do anything meaningful, completely burn out (no surprise that surveys like this one reveal emergency medicine docs are the most burned-out physicians).
I wonder how many doctors out there would have given this man a prescription for OxyContin or an IV of Dilaudid? It would have certainly been easier than having a conversation about his drug dependency. Also, even if we are willing to have these conversations, we are frequently tasked with treating these patients blind, often times without verified information about their opioid use or other recent hospital visits or care plans — information that can be totally game-changing. But the larger concern at play here is that health systems are actually fueling — and incentivizing — opioid addiction through their policies.
How did we arrive at this moment where patients believe they are entitled to be pain-free at all times?
Our modern-day metrics and “value-based purchasing” were derived with noble intentions but have had profound unintended consequences. Patient-satisfaction surveys put out by non-physician administrators that are filled with questions like, “What’s your door-to-doc time? What’s your satisfaction with services rendered?” It’s like restaurant-satisfaction surveys translated to healthcare. Although we’ve made progress — CMS’ Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Survey removed questions relating to pain in late 2016 — the damage has already been done. Healthcare systems follow government agency precedent, and many are still using satisfaction surveys tied to incentives, and many surveys still include questions regarding pain treatment.
This creates a system that gets you in and out, but not one that gets you healthy.
In order to truly help patients, we need to question such metrics and think more deeply about whether they are truly giving rise to the kind of outcomes the health system is supposed to foster. In our debates over health care, it’s all too easy to forget that the ultimate the goal is healthy people so we can have a healthy society full of people that can go make things, explore mountains and raise healthy kids.
So where does all of this leave physicians who truly want to move forward and help patients embroiled in the opioid epidemic? Can we move past the narrative of “happy patients equals good hospitals?” I wholeheartedly believe we can.
First, we must get rid of tie-in between satisfaction questions and pain. Hospitals should use other metrics to gauge satisfaction and quality of care.
Second, every state should publish opioid guidelines like these. These should be drafted by clinicians, not legislators; it is helpful to have the hospital logos embedded in the document, so patients know we are all on the same page. This makes the conversation with patients much easier because physicians can say, “we are all trying to help you, and to help I need to follow these guidelines.”
We should also do our best to take stock of a patient’s whole medical history, including past ED visits. At Mat-Su ED in Alaska, we rely on a software network solution that pulls together essential patient medical data, including frequency of ED visits in our facility and outside hospitals, and pushes this data into a one-page document ready at the point of care. In reading this, I can quickly see if a patient has been frequenting other EDs or has had issues with opioids or other drugs in the past. This network system recently helped care teams in Washington State reduce ED use among frequent utilizers by 10.7 percent, and reduce narcotic prescriptions from the ED by 24 percent.
Finally, physicians should question the healthcare system with every single decision they make by asking themselves, “what is right for the patient?” Sometimes this means telling a patient, “I care about you, and I don’t want your life to end because of addiction. Let’s look at our options.”
Remember that heroin user I saw who stormed out of the ED? Three days later that patient came back, profusely apologized and asked for help. We admitted him, and he is doing well today.
We are less likely to burn out if we know we’re doing the right thing for our patients in the fight to make a better system — even when they scream at you as a proxy for the health system that has failed them.
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