Occupational Hazard: Playing the Fool

Occupational Hazard: Playing the Fool is the title of a must read article by Michael W. Kahn, MD.

It starts out with an important question. Maybe this is a question that might be a good way to screen future health care workers - doctors, nurses, paramedics, et cetera.

“Can you tolerate being bamboozled by your patients from time to time?”^[1]

Maybe we should turn the question around.


Is it more important for us to punish some of our misbehaving patients, than to provide appropriate treatment to all of our patients?


Better to punish?


Better to treat?


This is the crux of one dialogue about appropriate pain management.

We deceive ourselves into believing that we can tell who is telling the truth and who is telling a lie. We base this belief on . . . ?

Well, what do we base this on?

Are there any studies that show how to identify the patient telling the truth?

or

Are there any studies that show how to identify the patient is not telling the truth?


Do we demand that our patients have an obvious extremity fracture, just to prove to us that they have pain worthy of treatment?

Why?

If the patient does not have some blatant injury, does that mean that there is no legitimate pain?

Why?

If the patient does not have some blatant injury, does that mean that their pain is not worthy of treatment?

Why?


That looks painful. You may have something for pain.


That doesn't look painful. You get Ultram.^*

I think we underemphasize the prevalence of certain normal errors inherent in medical practice. Surgeons are fooled when they open an acutely painful abdomen only to find a normal appendix: in the days before CT scans, it was said that if that didn’t happen once in a while, you weren’t operating often enough. When in doubt, it was safer (and wiser) to operate than to risk a rupture and peritonitis, even if the diagnosis was “wrong.” Here was an error that wasn’t an error, but rather a predictable side effect of balancing known risks with imperfect information.

I suggest that we apply a similar principle to the prescribing of narcotic painkillers and anti-anxiety drugs. Let’s assume that it’s impossible not to be fooled at least some of the time — that when assessing patients’ sincerity, we should expect a certain rate of false positives.^[1]

We have no ST scan to identify pain.

Since “first, do no harm” remains a guiding principle of care, let’s remember that the harm of missing a chance to help often greatly exceeds the harm of prescribing under a false pretext. Our system of justice is based on the idea that we should let the guilty go free rather than punish the innocent. Could our prescribing habits benefit from the same philosophy?^[1]

Go read the whole article.


Footnotes:


^ ¹ Occupational Hazard: Playing the Fool
by Michael W. Kahn, MD
New York Times.
Article


^ ^* Ultram
Wikipedia entry for tramadol.


Ultram is tramadol, which is just the result of another attempt to come up with a treatment for pain that is effective, but not addictive. The result is a drug that is addictive, but is not effective.

When I hear that a patient is receiving tramadol, it tells me that the doctor believes that the person is a drug seeker, but the doctor is afraid to refuse all pain medicine, so the doctor decides to give something they can document - Ultram.

Ultram = pain relief in documentation only.

.