A delicate balance

Surgeons deal with patients who have pain on a daily basis. But pain is not a simple issue. It begins with nociception: the sensation of tissue being damaged. It causes us to recoil from whatever is causing the damage, whether it is a thorn in the foot or the heat of a fire. It is something that is designed to protect us from injury by letting us know about it quickly. From there, we add layers to the experience. Initially these may be helpful, teaching us to avoid the source of pain, but sometimes they are not. But, sometimes, people develop behaviors to manipulate others to assist them. Sometimes these behaviors even make people feel miserable from pain behavior long after the nociceptive impulse is gone.
Patients with pain behaviors out of proportion to pain and those with addictions make surgeons leery about prescribing narcotics for pain. The legal system reinforces those fears. But, more recently, there are also laws requiring the treatment of pain. And, we must remember, as physicians, one of our tasks is the alleviation of pain.
So, how does this balance work in real life. I would say that most of the time it works pretty well. Most surgeons, and other physicians, become pretty skilled at guessing the amount of pain medication a patient need. Guidelines are available based on patient size, and physicians use their experience to adjust these at times, based on knowledge about the patient.
But, what about when we are wrong? Overdosage can be disastrous, but fortunately, is most often treatable when recognized in time. They can become addicted or sell the unneeded drugs. There can significant penalties for physicians who do, including loss of license or prescribing privileges or worse.
Underprescribing can leave the patient in pain, and sometimes teach a patient to hoard narcotics or seek out other sources. It can also lead to longer hospitalization with its inherent risks and more outpatient visits. And, more states are enacting legislation requiring physicians to provide adequate treatment of pain.
Fortunately, I have never experienced an overdosage as a patient. But, I have experienced undertreatment of pain twice. The first was many years ago, before I was in medicine, when I thought I was tough and declined a narcotic prescription for a fracture. I had never used prescription pain medication before, despite some other injuries. A couple days later, I returned, thinking I would be prescribed the meds I had declined earlier. My chart was not immediately available. I was accused of drug seeking and not given a prescription. I weathered that injury with over the counter medications. And, like many patients, I decided that it was a mistake to decline a prescription, and would accept them, even if I didn't think I needed it. After all, I could decide if I needed to fill it.
The second was more recently. I had an epidural placed that seemed to have no effect, except to cause an allergic reaction to the tape used. In recovery, I told the recovery room nurse that I was in pain, and rated it more than my previous 10/10. Her response was to tell me that since I had an epidural in place, I should have no pain. And when I asked her to get the doctor and suggested that I needed medication, and even suggested a few that I have prescribed in similar situations, she disdainfully suggested to the the doctor that, "she even knows the names of several narcotics." The resident then informed her that I was an attending surgeon at a neighboring hospital. The poor nurse, who hadn't noticed that in her review of my chart, turned bright red. Since the pain was inadequately treated, I was afraid to move. Fortunately, I did not develop a pneumonia or venous thrombosis as a result, but many patients do when they aren't mobilized in a timely fashion.
I recount these two episodes simply to suggest that patients may ask for pain medication for legitimate reasons. I certainly understand the reluctance to overprescribe. But, there are also problems with underprescribing. We must observe our patients carefully so that we can appropriately adjust dosages. It is a delicate balance.

The intersection of medicine and war

New blog on Physicians Practice:
http://www.physicianspractice.com/blog/when-war-and-medicine-combine-physician-reflects

Misdiagnosis

Just had another blog published:
http://www.physicianspractice.com/blog/a-physicians-recommendations-for-avoiding-misdiagnosing-patients

New post On Physicians Practice

Here's a link to another blog, where I hope to be regularly posting:
http://www.physicianspractice.com/blog/after-serious-illness-a-physician-faces-questions-about-the-future

Survivors Day

Yesterday was National Cancer Survivors Day. There were activities nearby. But, the whole idea of survivorship is not to have disease overwhelm humaness. The person is more than the disease.

Organized activites are great to see old friends who have also made the journey, but it is also a time to celebrate life, spend time with children, in nature, reading, or whatever one's pleasures are. As it turned out, an RSVP was required and I had failed to call. The office wasn't open on Sunday.

So we went to a nearby park. The kids played softball and soccer with some newly made friends. I walked around a bit, read a bit, and just enjoyed being outside in beaustiful spring weather. In a way, just being normal is a celebration of survival as well. It is time not focused on patienthood, but rather on personhood.

As I think about patients, I have known those who focused on patienthood and some missed out on life along the way. And those who focused solely on personhood, to the extent of denial of disease, and suffered an untimely end. It is a balance that requires continued adjustment as the disease shifts the foundation on which it is made.

Similarly, physicians must learn to balance work and life. "Medicine is a demanding mistress"  accordng to Osler. For those of us who write, perhaps Chekhov's quote, "Medicine is my lawful, wedded wife, and literature is my mistress," is perhaps more apt. So where is the time for family, friends, exercise, travel. We must somehow carve it out. So there are now a plethora of work-life balance seminars for physicians.

I have spent much of my life as a workaholic physician. My illness has taught me that I can't do everything, and I can't just put things off. I must accept that I am mortal. I must live in the present. I must take the time to be with my children, to watch them grow. I must take the time to write the family stories down that I hope they will want to know. I must take time to see the places I have always wanted to see and share the experience with my children.

Illness is the ultimate seminar on work-life balance. It forces one to reevaluate priorities. I realize that I must now work even harder to achieve balance in the different spheres of my life. But, I want it to be the best life I can have. I want to do the best for my children.

Music in the OR

I don't know whether music was played in the OR for any of my surgeries. Many surgeons like music for all or part of the case. Sometimes, it can be too distracting for critical portions. But, one must be aware of the appropriateness of the music.

Years ago, when I was a resident, we were simply playing a radio. It was Halloween, so the music was macabre. I have long wondered how a patient felt going to sleep with such music. I thought that I certainly wouldn't want to hear such music as I was put to sleep.

More recently, for a dental procedure, I was asked what kind of music I liked. Of course, it was to be done with local, so it did matter to me as the patient. My tastes are quite eclectic, so I let them play Pandora with popular music. It turned out to be the ones my kids know by heart. It was good for me to get a chance to hear more of what they like.

When I am the surgeon, I have liked different genres for different procedures, "heavy metal for heavy metal" when I am doing instrumentation. For other cases, I tend to prefer other genres, classical, folk, classic rock, world, etc. A good friend likes Broadway show tunes for his cases. At times I prefer no music like when approaching or clipping an aneurysm, though I have allowed the residents to choose after the aneurysm has been secured.

Recently, a surgical colleague curated an art exhibition at a medical meeting. Scattered amongst the photographs, paintings and sculptures were pieces of sheet music from Pictures at an Exhibition by Mussorgsky. This seemed so apt for the setting. I only wish it could have been playing to set the mood of those looking at the art.

I do think music does set a mood. And mostly the mood in the OR should be calm and organized. But, sometimes, the tempo should increase, and music can  help with this, too. And, allowing the residents to choose will sometimes tell me a bit about them, as well as sometimes introducing me to a new artist.

Mother's Day

Today is Mother's Day. I returned from a class yesterday to find a bouquet of flowers that my children had picked for me sitting on the table. My son, who has struggled to deal with my illness, gave me a beautiful string art heart that he had made, together with a beautiful letter. My daughter had given me a self profile with bits about Central Asia, where she was born.

We went to a movie. Of my choosing! Wrote a short piece and am blogging again. And it has been a wonderful spring day to spend with the kids. A celebration of life.  And recently, all my checkups have been good, even though I still suffer with a complication of treatment. So, I am looking forward to my life, many years of it, to finish raising my children.

What more could a mother want?