I am always impressed by the ability of physicians to justify their lack of success, in one way or another. And in an article appearing in this month’s JAMA, the author states in the very title that “Zero Pain is Not the Goal”. The author immediately elaborates on this statement.
Simple measures for which 100% is the target cannot define performance for the complex work of health care. Quality does not mean the elimination of death or perfect compliance with guidelines. Efficiency does not mean the elimination of all spending or even 100% elimination of all wasteful spending. And compassion for patients does not mean the elimination of all pain.
I spent a bit of time on Google looking for the appropriate term to describe the quote above. But no matter how much I tried, every term I uncovered was scatological. The fact that a renowned, experienced physician can make such declarations, without any specific references to back them up, is proof of the fact that far too many doctors still feel secure in their divine standing within the community..
Let’s examine these words of the medical gospel. I will start with the following selection “quality does not mean perfect compliance with guidelines”. What the author is trying to do is impose the principle of “reductio ad absurdum”. Basically, one takes an argument to the extreme in order to prove the opposite. The author is attempting to say that it is impossible for flawed humans to achieve perfect compliance. Therefore, one cannot, in absolute terms, associate quality with such perfection.
I personally wasn’t aware of the fact that the only options are 100% compliance with standards of care, versus absolute chaos. There is clear literature that demonstrates the ability to modify physician behavior in terms of washing hands before assessing patients. What physician does not wash his or her hands before moving to the next patient? Based on the literature – most. When computerized systems are implemented to spy on the doctors, handwashing rates go up from pitiful levels to rates approaching 70-80+ percent. And lo and behold, infection rates in the various departments studied, drop by many tens of percentage points, all from enforcement of handwashing.
Should every doctor be the utmost strict about washing hands between patients? Of course. There should be 100% compliance with such a basic standard of care. But if we achieve 80% compliance, we will still see a reduction in infections that is far beyond the effect of any prophylactic antibiotic. As a general principle, when it comes to performing certain procedures, it is not that following the instructions eliminates any and all complications. The result of following protocol is that success rates rise dramatically and complication rates drop precipitously.
I would be concerned that this particular author feels that his “100% rule”, exempts him from a whole range of standard protocols. His repeated argument would be that “even if I do X, it will not eliminate Y, so why bother doing X”. This is clearly a child’s perspective, and is totally unprofessional. And the fact that such a statement appears in a regarded journal, is reason for great disappointment.
The author’s following statement that efficiency does not mean the 100% elimination of all spending, makes absolutely no sense, even when invoking the principle of arguing the extreme. I by no means am an efficiency expert, but I am not aware of any practical definition that speaks to the 100% elimination of costs as the definition of efficiency.
Admittedly, if efficient work eliminates certain steps, then the costs associated with those steps is reduced by 100%. But that’s not how people speak. If you speak about improving the efficiency of a department, or a surgical procedure, or the discharge of a patient, then you are talking about a whole long series of steps, which are added together to measure overall quality of practice.
If you can improve efficiency by just 10%, that can translate into savings of millions of dollars for a hospital and potentially billions of dollars across the country. If physicians were to improve their rates of appropriate antibiotic prescriptions, even by just 10%, the financial and medical and biological benefits would be astounding. Once again, if this is an indication of the way in which my esteemed colleague understands terms like quality and efficiency, it truly frightens me.
The final statement within the quote is that compassion for patients does not mean the elimination of all pain. I agree wholeheartedly that the definition of compassion is not solely related to pain management. I also partially agree that there is a level of pain, below which it is still considered humane to perform a procedure without formal anesthesia.
For example, taking blood from the fingertip of a patient to check a one-time blood sugar does not incur tremendous pain. On the other hand, if this is a procedure that a patient needs to do four or more times a day, every day of the rest of the person’s life, then that adds up to a lot of pain. There are companies that are betting on a multibillion-dollar windfall from devices that eliminate the need for fingertip pin pricks to draw blood to test for diabetes status. I assume, according to the author, that all of these people who want to stop pricking themselves are simply “wusses”.
On the other hand, I have to admit that I have seen many doctors use this type of “verbal anesthesia” when it is just too difficult, or perhaps expensive, to numb the patient. Verbal anesthesia is a term that is not often used in formal discussions but refers to pain management by virtue of the doctors saying to the patient “oh come on, it doesn’t really hurt that much”.
A classic example is the reduction of a dislocated finger. This is not considered a major procedure in the medical world, and is actually very popular amongst young doctors who get to feel like they just “fixed” a broken patient. There are two ways to reduce a dislocated finger, in terms of anesthesia, when speaking about an emergency room situation. One way, would be to give a general medication intravenously or through some other route, that sedates the patient and can even cause short-term retrograde amnesia – the patient forgets the last 5 to 15 minutes. I have personally witnessed patients who asked me when I will start a procedure that I have already completed under the influence of such medications.
Another option is to use local anesthesia and to anesthetize the entire finger. This process takes a bit of time and expertise, and is definitely painful during the injection of the anesthesia. The benefit of this approach is that it becomes much easier to reduce the dislocation, the risk of injury to the small tendons and nerves in the finger is reduced, and most importantly, the patient feels nothing during the actual, otherwise painful, reduction of the dislocation. The patient can be sent to x-ray to validate success of the procedure, and if success was only partial, further manipulation can be performed, still with no pain.
In this particular type of case, it is unnecessarily cruel to reduce the finger without some form of sedation or anesthesia. In this particular type of case, compassion is absolutely related to the elimination of all pain. And in this particular type of case, such elimination of pain is absolutely feasible, should be the standard of care, and should be enforced whenever possible.
The impetus for this particular commentary by the author is the new CDC guidelines for prescribing opioids for chronic pain. I have been very open and honest about my personal medical conditions. I suffer from chronic pain, both in my mouth and along most of my back. This pain has ruined a good part of my life. I have lost the desire to engage in a whole range of previously pleasurable activities, such as going out with friends, taking my wife out to dinner, and going to the gym. I was a very heavy user of opioids until recently, and generally speaking, they did help to significantly reduce my baseline level of pain.
Recently, I have weaned myself from approximately 90% of the opioids I was previously using. Part of this had to do with reducing certain side effects, which were becoming more and more disturbing to me. Part of this also was for the purpose of assessing my situation. I wanted to see how much pain I would have without the regular use of the opioids. I was hoping to discover that my baseline pain would not significantly rise, even after such a major reduction in opioid dose.
The results of this experiment were very negative. There are days, sometimes a series of days, when I do not take a single pill of an opioid. That is a good thing. But every day since I reached my present low usage of opioids, is miserable. I have been doing my best to find ways of distracting myself when the pain oscillates to its peak. But my overall conclusion is that this is no way to live.
When doctors hear patients, with chronic pain, start talking about whether a life full of pain is worth it, the doctors get very nervous and jump on diagnoses like severe depression and worse. Here’s a thought for those doctors who think that a chronic pain patient is depressed when they express a desire to commit suicide. First, control the chronic pain. I personally believe that you will find that the “depression” amongst these patients evaporates in 100% of the cases. Of course, the retort to this, as the author initially argues, is that pain control cannot be 100% efficient; therefore, let’s throw the patient out with the bathwater.
In many cases, reducing chronic pain by far less than 100% will eliminate many of the psychological risks, and may even significantly improve quality of life. I would therefore modify the title of this commentary and call it “Zero pain IS the goal, but when unachievable, consider the following …”.
Compassion in the case of chronic pain is first and foremost recognizing that chronic pain is not going to get better just because you were [by your definition] compassionate to the patient. Yes, there are some patients who experience some psychological relief when the doctor tells them that everything is going to be okay, even though the doctor is lying through his teeth. But when it comes to chronic pain, usually, all it takes is for the first nighttime experience to come along. During those long dark hours, chronic pain is amplified. It destroys a person’s sleep, it eliminates the concept of “rest” from the patient’s mind, it directly causes great despair, and yes, psychologically depresses the patient.
There are dangers with the use of opioids on a chronic basis. There are individuals who fool their doctors into giving them long-term opioids for nonexistent pain. Addiction to opioids is a major problem, but still kills far fewer people than the lack of handwashing by doctors. In the end, chronic pain control is a tightrope that the doctor and patient have to walk together. And as a general rule, you should err on the side of over prescription of pain medication. Leaving a patient in pain is simply contrary to the basic tenets of medicine. Unfortunately, there are nevertheless countless papers on how poorly modern medicine, via physicians, deals with patients’ pain.
To the author of this paper, I say that you are, at the very least, insufficiently sensitive to the status of chronic pain patients. If this author himself suffers from chronic pain, it would have been worthwhile to specify it. I will take the chance and assume that this doctor does not personally suffer from 24/7 significant pain. In this case, I feel comfortable stating that despite his years of medical experience, he has no idea what he’s talking about. Considering how poorly his arguments are formed, as I described above, I suspect that this is yet another physician who simply has no real concern for the welfare of patients and finds any excuse to justify his medical impotence.
These are harsh words. But I am a chronic pain sufferer. And I wouldn’t wish such a doctor on my worst enemies.
Thanks for listening and caring