My patient’s son stood vigil outside her hospital room day and night. His eyebrows were frozen at an anxious angle. Although his mom was healing well from her injury, I could see that he was worried about next steps. He asked staff repeatedly about his mom’s pain management, and reviewed every therapy session she attended.
His mom, on the other hand, was deceptively charming. She was a thin, well-groomed elderly woman who knew how to exact empathy from others. When I looked into her room from a distance she appeared comfortable, lying in her hospital bed covered in a quilt that her son had brought her from home. When I entered the room to check on her, she would grab my hand and wince, telling me that the pain was severe but that she didn’t want any medication. She was quite invested in convincing me that she was unable to go home and care for herself, and that she needed to be discharged to her son’s home. She would not accept others help at home, nor would she go to a skilled nursing facility.
She was doing well in therapy, limited mostly by her macular degeneration (poor eyesight). Again, I watched her from outside her field of vision. I saw her stand without assistance, push her walker across the room, and navigate a couple of stairs. I heard her speak to her son in angry and dismissive tones. When she saw me approach her knees buckled and she crumpled to a padded bench. “I am not safe to go home, doctor.” She said. And her eyes filled with tears – “I am going to fall and no one will know.”
I took her son to a private room to discuss the predicament. I carefully raised the subject of how his mom was doing well physically, and could discharge home safely with home health services, but was angling for a discharge to his house. I asked him some open ended questions and learned that he was her only son, that his mom had been guilting him about quitting his job to care for her full time.
He became tearful – “I have only a few more years to go before I can collect my pension. Mom knows this but wants me to quit right now and move back home. If I do that I won’t have enough money to survive my own retirement. She has no friends and dad died several years ago. She says she doesn’t want any hired help at her house, and she cries when we discuss nursing homes. She says if I love her I will let her live with me. But I don’t have time to help her during the day. What am I supposed to do? She has been doing this to me all my life – getting me to do what she wants!”
I decided to tell him the unvarnished truth.
“I can see that your mom can be quite manipulative, and this has been an ongoing struggle. You need to take care of yourself. The fact that she wants to be with you 24/7 does not prove her love — a loving mom would not ask her son to jeopardize his financial future so that she wouldn’t have the ‘discomfort’ of caregivers in her home. Do not feel guilty about continuing to work. Her insurance will cover the care she needs. It’s ok to say no to her. That’s my professional opinion.”
The son let out an audible sigh. He thanked me profusely for telling him the truth. I told him that it was entirely possible that his mom would fall down on purpose once out of the hospital, to try to get him to change his mind. I warned him not to let her consume his life. She likely had a personality disorder that made her capable of squeezing the very life out of him.
My patient ended up discharging to a very nice skilled facility that her son had pre-screened for her. She was as happy as a wet cat on departure, but I believe it was the right decision for both of them. I just hope that she didn’t succeed in wrapping her emotional constrictor muscles around the neck of her poor son again. I tried my best to save him, but in the end I know that sometimes people have to save themselves.
Most of my patients think about pain medicines in terms of the symptoms they treat. “This is my headache medicine, and this is my arthritis medicine,” they often say. Healthcare providers are more likely to categorize pain medicines by the way they work: some are anti-inflammatory, some affect nerve endings, and others influence how the brain perceives pain. But the truth is that no matter how you classify pain medicines, there is no way to know if they’ll help until you try them for yourself.
Most people don’t realize that pain management is personal. Research is beginning to help us understand why people respond to medicines so differently, and one day we will probably be able to personalize treatment plans more successfully. For now, there are several known genetic reasons why pain medicines are more or less effective for one individual over another. Genes affect:
The number of enzymes that break down medicines and remove them from the body. Some people have larger numbers of these enzymes and therefore require more drug to feel its pain-relieving effects. Others may be strongly affected by even small doses of drug.
Pain medicine receptor variations can make one medicine effective and another (nearly identical medicine) ineffective in relieving pain.
Differences in carrier molecules that transport pain medicine across the blood stream and into the cells that are triggering pain sensations. Some people have fewer carrier molecules to bring the medicine to the site of pain.
The number of “middle man” neurotransmitter molecules that pass along the pain response. Too many of these molecules can reduce drug binding and mute the pain relief effects of some drugs.
When pain is severe, prescription medications may be necessary. However, mild to moderate pain may be effectively managed with over-the-counter (OTC) medicines. I believe in the start low, go slow approach to finding the smallest effective dose of pain medicines. I always recommend that my patients read and follow all the instructions on the Drug Facts labels to make sure that they don’t accidentally overdose on active ingredients.
When I choose a pain reliever with my patients, the first thing I think about is potential side effects. Some medicines (such as non-steroidal anti-inflammatory drugs like ibuprofen and naproxen sodium) can be hard on the stomach lining, or cause bleeding in people who are at risk for it. Other medicines (such as acetaminophen) can harm the liver if used in excess, while prescription pain medicines can cause constipation and drowsiness. The best pain medicine to start with is one that is least likely to cause harm to the specific person.
The next thing I ask is whether or not the medicine has worked for the patient in the past. Previous experience is one of the best indicators of future success. Since I know that my patient has a unique, genetically determined number of enzymes, transporters, and receptors, previous experience with pain medicines will give me a good idea of how well they will tolerate it again, and if it will be effective.
Finally, I consider the type of pain that they are experiencing. If the pain is caused by inflammation (from an injury, surgery, or arthritis) I’ll consider a medicine with primarily anti-inflammatory properties. If the pain is caused by tension (such has headache) or complicated by fever, I may consider acetaminophen first. If the pain is coming from a nerve (such as sciatica or neuropathy) then I’ll use pain medicines that work for nerve pain specifically. If the pain is complicated by depression, I may discuss additional medicines and approaches.
Sometimes, combinations of medicines are significantly more effective than one medicine alone at treating pain (this is why some prescription pain relievers are combinations of an opioid and acetaminophen). When using more than one pain relief medicine, it is important to compare active ingredients in both prescription medications and OTC products to make sure that accidental overdoses do not occur. I also recommend consulting with a healthcare professional if there are concerns about drug interactions or if the patient is already on a significant number of prescription medications that could interact with his or her OTC pain medicine choices.
The bottom line is that science is still catching up to pain management. Perhaps one day a simple blood test will help us to determine the very best pain medicine regimen for a specific patient at a given time. But until then, adopting a strategy of careful trial and error (avoiding unwanted side effects, using the lowest effective doses, and consulting a physician when pain is severe) is the only option. Don’t worry too much about whether a specific medicine is “best” for your pain. Pain management is very personal, so you will need to discover your own best solution.
Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.
Millions of Americans use over-the-counter medicines; in fact, about 35% of Americans use OTC medications on a regular basis. A recent national survey of 2,038 U.S. adults suggests that many Americans are not in touch with the risks associated with OTC medications, and don’t feel compelled to review OTC drug facts labels carefully. As I have discussed on this blog previously, excessive medication use (regardless of whether they are prescription or OTC) can be dangerous.
Some of the survey’s key findings include:
- 2 in 5 respondents believe that OTC dosing instructions are suggestions, not directions
- While all age groups find it important to read the label on OTCs they are taking for the first time, significantly more millennials say it is still important to read the label on OTCs they have taken before (82%), whereas only 54% of older Americans over age 70 agree
- 75% of those over age 50 believe that it’s not possible to overdose on an OTC medication
- 25% of respondents feel it’s ok to not read the drug facts label if they’ve taken the medicine before
On the brighter side, some consumers are doing a little better than others at taking OTC medicines as directed and these differences are very apparent if we look at age, gender, and ethnicity.
For instance, the survey revealed that more women believe it’s important to read an OTC label than men (81% compared to 62%), and that African Americans and Hispanics are more likely to know active ingredients (72% and 66% respectively) than Caucasian (58%) consumers. Perhaps most surprising: younger generations (ages 18-49) seem to be more aware of the risks of OTC overdosing than older generations, while ethnic minorities are more likely to read an OTC label a second time than Caucasians.
The results of this survey are driving a new “Every Label, Every Time” campaign by Johnson & Johnson Consumer Healthcare, McNeil Consumer Healthcare Division in an attempt to raise awareness of OTC appropriate use. I applaud them for continuing to educate on the appropriate use of OTC medicines, and I sincerely hope that we can shift our culture from casual to conscientious when it comes to drug consumption as a whole.
To that end I hope you’ll join me in encouraging everyone to be careful with their medicines and read every label, every time.
Disclosure: Dr. Val Jones is a paid consultant for McNeil Consumer Healthcare Division.
My patient was an elderly farmer with severe vascular disease. He had advanced leg artery narrowing, had survived multiple heart attacks, and was admitted to the hospital after a large stroke. He was incredibly cheerful, vibrant, and optimistic. He had a very large, loving family who took turns attending to him, and encouraging him with each small improvement in his leg and arm strength. They knew his neurological exam better than his doctors.
I was amazed at his recovery, given the size and location of his stroke (and his advanced age), I had suspected that he would end up wheelchair bound. But he was determined to walk again and get back to his gardening as soon as possible. His children told me that he was very stubborn and was a true “fighter.” As their patriarch, he carefully questioned each of them about their goings on, making sure that they were each on track with grain harvesting plans, animal feedings, and various farm-related projects. His life had meaning and purpose, and the hospitalization was merely a change of venue for his daily instructions.
Because my patient was so motivated, I offered to bring him to his physical therapy session early one day. To my surprise, he firmly, but politely declined.
“I have an appointment with my family in my room.” he said.
I wondered if they were going to discuss advanced directives with an attorney, or something of similar seriousness.
“Oh, I see. Well we will come get you at the regular time then.” I smiled and left the room.
As I walked down the hall back towards the nurses station I recognized various members of his family proceeding towards his room, dressed in what appeared to be their “Sunday best.” There must have been at least 15 people in the group, ranging from tweens to adults. They were smiling and upbeat.
Minutes later I heard wondrous a capella choral sounds wafting from the patient’s room and filling an entire wing of the hospital. All motion ceased. Therapists stopped pushing wheelchairs, exercises paused, patients with walkers stood silent in the middle of sterile, tiled floors.
My patient had delayed his therapy session for something far more important – a live chorus of loving family, singing for him in a private exhibition that managed to touch us all.
The music I heard that day taught me a very important lesson. Some people know how to live their very best, wherever they are. Even a life-threatening condition in a hospital setting cannot dampen the human spirit.
May we all aspire to have such a spirit.
Hospital culture is largely influenced by the relationship between administrative and clinical staff leaders. In the “old days” the clinical staff (and physicians in particular) held most of the sway over patient care. Nowadays, the approach to patient care is significantly constricted by administrative rules, largely created by non-clinicians. An excellent description of what can result (i.e. disenfranchisement of medical staff, burn out, and joyless medical care) is presented by Dr. Robert Khoo at KevinMD.
Interestingly, a few hospitals still maintain a power shift in the other direction – where physicians have a strangle hold on operations, and determine the facility’s ability to make changes. This can lead to its own problems, including unchecked verbal abuse of staff, inability to terminate bad actors, and diverting patients to certain facilities where they receive volume incentive remuneration. Physician greed, as Michael Millenson points out, was a common feature of medical practice pre-1965. And so, when physicians are empowered, they can be as corrupt as the administrations they so commonly despise.
As I travel from hospital to hospital across the United States (see more about my “living la vida locum” here), I often wonder what makes the pleasant places great. I have found that prestige, location, and generous endowments do not correlate with excellent work culture. It is critically important, it seems, to titrate the balance of power between administration and clinical staff carefully – this is a necessary part of hospital excellence, but still not sufficient to insure optimal contentment.
In addition to the right power balance, it has been my experience that hospital culture flows from the personalities of its leaders. Leaders must be carefully curated and maintain their own balance of business savvy and emotional I.Q. Too often I find that leaders lack the finesse required for a caring profession, which then inspires others to follow suit with bad behavior. Unfortunately, the tender hearts required to lead with grace are often put off by the harsh realities of business, and so those who rise to lead may be the ones least capable of creating the kind of work environment that fosters collaboration and kindness. I concur with the recent article in Forbes magazine that argues that poor leaders are often selected based on confidence, not competence.
The very best healthcare facilities have somehow managed to seek out, support and respect leaders with virtuous characters. These people go on to attract others like them. And so a ripple effect begins, eventually culminating in a culture of carefulness and compassion. When you find one of these gems, devote yourself to its success because it may soon be lost in the churn of modern work schedules.
Perhaps your hospital work environment is toxic because people like you are not taking on management responsibilities that can change the culture. Do not shrink from leadership because you’re a kind-hearted individual. You are desperately needed. We require emotionally competent leaders to balance out the financially driven ones. It’s easy to feel helpless in the face of a money-driven, heavily regulated system, but now is not the time to shrink from responsibility.
Be the change you want to see in healthcare.