Troubleshooting Pain Management in Patients

        Do you remember when Pain became the "6th vital sign" according to JCAHO? Chances are if you don't, then you have not been practicing medicine long enough. Conversely, if you have been around the block then you know that poorly controlled op & non-op chronic pain can be ascribed or attributed to too many reasons; among them, listed herein are some of the most commonly seen or encountered underlying causes seen in clinical practice:

1. Provider's pain assessments are incorrectly based when only normal VS are presented to them by the nursing staff.

2. During rounds or office encounter patient is non-distressed & is calm-appearing on presentations or exams.

3. Assuming a sleeping or a patient taking a nap is not ever in pain.

4. Assuming the patient is drug-seeking given their PMHx of  "doctor/provider shopping"

5. Assuming the patient is a closet drug user or pusher.

6. Assuming/believing ( “knowing”) procedure or treatment is relatively painless.

7. Assuming the patient is being "manic" given their charted PMHx of Bipolar disorder. 

        Due to the inherent subjectivity of pain being experienced by the patient @ any given time, many providers (including residents) may undertreat the condition due to personal unconscious or implicit biases. It is best to provide an immediate empathetic response such as: "I sympathize with your experienced discomfort and am sorry to hear that you're experiencing pain. Please allow me to look into your pain regimen more closely and make some readjustments, allow me a day or two to see if these changes were helpful. Don't hesitate to let the nurse or me know if there's anything else I/we can do to assist you in finding relief and making you feel more comfortable.

        This frank verbal acknowledgment will ease the patient's fear of being dismissed and underrated as they may have experienced in previous medical encounters. Also assured them, everybody's pain-handling issues are different as you will come to see due to expectations, cultural identity, or even socioeconomic status. Better yet, explain and educate the patient that for his/her benefit you may consider implementing a multimodal pain management approach, or if your interventions are not easing or/ helping mitigate the pain you then may consider ordering or referring the patient to a Pain Management Specialist in order to achieve pain control. Do not forget to add other adjunctive agents such as muscle relaxants, NSAIDs, SSIs, etc. So when we, healthcare professionals (HCPs) use bedside shared-decision making with our patients, then patient satisfaction increases, thus ultimately improving patient trust as a final byproduct.

My Early PAhood Experience

           Looking back on when I began my path to PAhood, I can confidently say it was not an easy one. In fact, it was not even a straight line during those early years— it was more like a circuitous first path before I was able to settle down in my journey. In a word, it was more like a tough, dizzying roller coaster ride, while trying to thrive and navigate or hang on to the rough workplace “terrain” ahead of me.

Surviving an arduous career beginning without an employer’s or co-worker’s support can be daunting. Especially as a young PA graduate. On many occasions, it felt impossible to see the light at the end of the tunnel given the daily struggles trying to fit in while sidestepping difficult departmental or organizational politics or even toxic work-group dynamics. 

It is in these sticky situations where you have to grab yourself by the bootstraps and be patient with yourself and others. Keep in mind that mastering any learning curve is not going to happen overnight, no matter how much indirectly or directly you are made to feel pressured. As the old saying goes: Rome wasn’t built in one day–the same goes for any great careerist.

Do not saboteur yourself by allowing others to minimize you and rob you of your confidence. In due time you will become effective and proficient as you continue to develop your base knowledge and skillset. Experiential learning is an incremental process. Things and fact patterns will become easier to recognize while you continue to forge ahead and mature professionally in your craft. 

        In retrospect, I wish I would have been kinder to myself in those early days. Yet, sometimes we must go through these growing pains either early on or intermittently in a mid-career phase. But, in the end, the bottom line is all about respecting and asserting yourself confidently even when others may not honor your efforts or learning disposition you would like or prefer. Sadly, you may be bound to encounter some of these malignant folks along your path. Be resilient, and remain true to your goals. Be resolute…be focused, and always be measured and you will not be easily derailed by these career derailers. Moreover, and in essence, that is the best-guaranteed way to a very fulfilled PAhood experience.

The Robotic (Automated) Provider

            I think and feel I have a lot to say about how medicine is practiced in this fast-paced business of ours. I've seen it in my own career and in many other colleagues' careers too. In this commentary, I'm going to do something I've never done before or at least didn’t think about it on a deeper level. I'm going to dig deeper into an area of troubling practices, and, I'm going to show you where we have erred and continue to do so in our daily practices. More specifically, what we have become as modern-day clinicians. 

Moreover, why what we or you're doing isn't working as well as you'd like, and what to do instead? I'll show you one root cause of why and where we have abdicated our thinking selves. As medicine pushes for profits, we have been pushed to become “fast thinkers” when providing medical services to the patient community. In many respects, we have become too automated, even in my opinion too protocolized in many instances. Do not misunderstand me, I am not against abiding by following practice or clinical guidelines, or even abiding by organizational protocols. Obviously, they have a role in standardizing medical care. However, be that as it may be we have relinquished our clinical thinking to a robotic mode, or simply the activity of “checking boxes” in our minds.

Cognitive Psychology proves this very clearly. In their lingo, this is known as providers practicing Medical Heuristics (aka rules of thumb). Unfortunately, this unconscious mindset although very convenient for quick decision-making, oftentimes leads us astray in our medical final decision-making activities. Tragically, leading us to medically misdiagnose, or delay the appropriate treatment, as a result the plethora of potential medical errors and adverse outcomes we see occurring across the continuum of medical care. See, this is where we are all doing it all WRONG! Not slowing down to pause & think and look beyond the immediacy or even look at the big picture when making clinical decisions in our daily busy practices. In essence and sadly that has become our Achilles heel.

These battling internal and external forces for better or worse ultimately drive our decisions. As they say, we win some we lose some. But, I would argue to anyone to take the higher road: pause and reflect consciously upon the decision(s) you are about to embark on...solicit more information or much-needed data before proceeding. How do I know? Simple, I know this firsthand & better than most others because I have seen it from a medical-legal consultant perspective time after time. Primarily when I have served as an expert reviewer in alleged PA med-mal claims allegations. And there it is. In plain English & the spirit of sharing, I just had to remind you (my peers) of this ugly reality. One that lurks unnoticed in our daily practices.

            And from a Risk Management perspective, proactively mitigating your risks is what should be your bottom line. Simply by knowing and understanding how and when to implement these tips would definitively mitigate your potential legal entanglements. You must understand how to consciously sidestep them in your everyday patient encounters, whether it is in the office, ED or urgent care settings, or hospital. At the very least, it's another tool worth taking notice of in seeing for yourself what I'm talking about when you put these techniques into practice. It will give you a better understanding of the legal landmines lurking in the background, not to mention a broader view of your risk exposures. 

Start practicing safely and confidently...don’t take chances by being or becoming an automated provider. Better yet, don't sabotage your own career. Stay present, become an engaged provider, and allow your fast (unconscious) and slow thinking (conscious) to coexist harmoniously when making your final clinical decisions. Your patients will be less inclined to raise any potential medical malpractice claims knowing that you balanced your options before making a rash decision. You owe it to them...you owe it to yourself.

Fatal distraction: Compensation talk---keeping your guard up.

 

            There’s one distraction whether experienced or inexperienced every PA job hunter wrestles with during their job interviews--compensation. Especially, if the amount offered surpasses their anticipated expectation for that job.  For many, metaphorically speaking is as if they were cruising at moderate speed and momentarily taking their eyes off the road just to be jolted by the impact of going off the road and landing in a ditch. Conversely, a “generous” compensation offer (i.e. salary) can have a very similar effect. Therefore, this unexpected derailment can sneak into your mind potentially obfuscating the big final picture during or after the interview.

            During that vulnerable period of the interview process, you must be at your best if not your strongest and/or sharpest. Why? Because it’s very easy to briefly disengage and put yourself at risk of becoming distracted, thus easily forgetting to recall all other important key factors that would weigh in helping you make that final informed decision comfortably.

            Conversely, do not allow yourself to be pressured by the interviewer; resist the urge of accepting the job right on the spot. This could have been a gambit used against you. Some interviewers like to play this card-- a momentary tactic to disarm you and avoid those well-thought-out questions you prepared before the interview.

            So, the best protection against this kind of fatal distraction is to avoid capitulating to blind impulsivity. You must respond with a very thoughtful constrained remark such as: “As enticing, & generous your offer is, I still would like to have 2-3 days to discuss this with”… your significant other and/or family, or your attorney.

             But more importantly, by keeping your guard up and remaining grounded when it counted the most, then the less cheated you would feel if the job didn’t work out for you in the end.   

            In conclusion, never accept or negotiate an employment offer on the spot. No matter how good it sounds to your ears or if it appears on paper. It is best to take time and sort things out after you've taken time to thoroughly consider the pros and cons. Remember, right there and then thank the employer and restate your desire to work for the company or organization. But just as important, if not more so, that you need time to think it over, and even discuss it with your spouse( if applicable) so they can understand you will base your final decision on both monetary and non-monetary issues related to the employment offer.  And don't forget to ascertain the allotted response time given to you.

 

 

A point of Contention in PA Education

        In this commentary, I will discuss my opinion about a recent trend noticed in the PA academic sphere. Many, if not many PA programs are failing our prospective colleagues in their professional preparation to become competent, skillful clinicians. This is based & derived from my own past observations from my own past precepting/teaching experiences and occasional lecture presentations, even to practicing PAs. And w/o much fanfare, I will get to the issue at hand in my next paragraph as shown below. 

My main point of contention is that they believe that the current PA curriculum being taught has no room or need for Clinical Risk Management exposure at this stage of training. As some of their experts–as read recently in a blog– would have you believe. They hold the view that this would better serve as a post-PA school training pursuit in the form of CME through their various venues of teaching/training. 

I would disagree, and here is why: This author believes that these rationalizations are flawed given the push for adding other “nonessential” PA courses into their curriculum; namely Nutritional training and others for our students. This is one of the most common ones discussed in some PA forums. 

            This is the dilemma: they fail to see their pedagogical myopia when it comes to our students and the community at large, by dismissing teaching them how to mitigate and shield their careers from legal landmines encountered in the everyday practice of medicine. For that same reason, I am strongly in disagreement favoring a more tangible “investment in a quality education/course”. One that would have better “return of investments” sort of speak. 

I would further add, this is not only necessary but vital to develop confident clinicians in providing care in a very litigious industry, I believe that identifying and using a set of curricular Risk Management standards in this regard at the national level for PA students is more than a good idea. Not only would it mean they would feel empowered to tackle legal minefields based on sound proved risk management practices & methodologies. But moreover, it would be a step in the right direction towards ensuring sound training for all students, regardless of the particular PA program enrolled. 

I realize and wholeheartedly admit Education is a dynamic field and granted almost every change in the realm of education has a direct impact on us as educators, students, and practitioners at large. Therefore, it is important and incumbent that we be ready to accept this new paradigm and be prepared to learn and use effective new methods and techniques that would not only enhance our PA curricula but would benefit our students in their career journeys. 

With this in mind, we must always entertain relevant educational issues and seek out educational offerings that add and not detract from their careers, rather by elevating their professional development with substantive subject matter exposure topics.