I’m a Physician Assistant and I play one on TV




A Sad Irony

Allow me to preface this article by saying I’m not against the appropriate use of opioid analgesia when indicated in any age group. While there has been legitimate concern regarding the over prescribing of these drugs especially to pediatric and adolescent patients, it also does not create a generalized scenario where we as health care providers can or should stop using these agents altogether. I completely agree that while using opioids for simple sprains and other similar minor injuries is indeed overkill, that does not mean they should be withheld in all cases. The child whimpering due to a supracondylar fracture, a child with terminal painful cancer, and burn injuries are just some of the cases where these agents should be utilized. Not only should they be used in these instances, I would argue if you are not using them, you need to take a long look in the mirror and ask yourself why you are still in medicine. Part of our job is to ease suffering and if you are willing to withhold proper pain management for significant illness or injury over what may happen in the future, I question why your are still practicing medicine.

That obligatory disclaimer aside, we cannot ignore that over-prescribing of opioid pain medications has become an issue if not an outright epidemic. How many of us know or know of a health care provider who have had their license suspended or revoked for improper prescribing of narcotics? At the same time, we have seen well respected physicians change their views on the dangers of marijuana. We have seen marijuana’s listing as a schedule I controlled substance and it’s label as the gateway drug questioned. I would pose that there is a changing of the guard in respect to what is truly the gateway drug.

It’s not even up for debate that opioid analgesia has proliferated and is ubiquitous. The U.S. uses almost 98% of the world’s hydrocodone [1]. Oxycontin prescriptions rose from 76 million to almost 207 million annually from 1991 to 2013 [2]. What prompted this to occur?  In 1999 claims were made that chronic pain was under treated. In response to that, the Veterans Administration came up with the “Pain as the 5th Vital Sign” campaign. Two years later, the Joint Commission spread this notion throughout the rest of the health care system by instituting pain management standards based of the VA’s campaign [3]. What soon followed was pharmaceutical companies convincing health care providers, patients, and regulators that opioid were safe for chronic non-cancer related pain. Some of the misinformation was so egregious that the makers of Oxycontin plead guilty to federal criminal charges [4]. And what has been the end result? Prescription opioids are the most commonly abused drugs in many states, such as in Connecticut [5]. Patient’s who are addicted to prescription opioids are 40 times more likely to become addicted to heroin [6]. The end result is that prescription opioids have become the gateway drug to heroin as patients look for a stronger high or when then can’t get their opioid prescription.

In the other corner, we have marijuana. The cause of the laughable “reefer madness” and historically known as the gateway to other drugs. There is much I could get into regarding non-scientic reasons for its banning (hemp industry) and possible medical uses but they go beyond the scope of what I’m writing about. Dr. Sanjay Gupta has probably been the most famous physician to verbally reverse his views of marijuana being dangerous. Dr. Gupta points out that Marijuana was place on the Schedule I list in 1970 due to “a void in our knowledge of the plant” per Dr. Roger O. Egeberg then Assistant Secretary of Health. Yet there were studies as early as 1944 that showed marijuana did not lead to any significant addiction medically and did not lead to using other drugs. While reports vary, marijuana leads to addiction in 9% to 10% of users. Compare that to cocaine (a schedule II drug which is supposed to have less abuse potential than schedule I drugs) leads to addiction in 20% of users. Tobacco, which is legal leads to addiction in 30% of users, many of whom die from health issues related to smoking [7]. Look at the other schedule I drugs along with marijuana; Heroin, LSD, peyote, and Ecstasy[8]. Let’s use some common sense here. Yes, I know, it’s not very scientific and we humans have a brain and common sense that allow us to assess situations. I’m sure many of you reading this know others who smoke marijuana. Certainly, there are some who do nothing but, however that is the exception, not the rule. Nearly all the people I know who smoke marijuana can take it or leave it, forgetting they even have it half the time. No one smokes marijuana alone, gets behind the wheel of a car, and commits vehicular homicide unlike with our legalized friend alcohol. If anything, they get hungry, eat, and go to bed. No one overdoses and dies from marijuana alone or needs a reversal agent. Many of those who smoke marijuana have a good education and live a responsible, productive life. If not legalized, marijuana should be at least moved to a lower schedule and have well designed studies done with it if indeed we have had a “void of knowledge” all this time. It certainly has nothing in common with its companions on the Schedule I list and even Schedule II. As our medical culture prides itself so much in “evidence based medicine” it amazes me they have let this void exist for so long.

Part of the problem is that many health care providers fall into one of two camps. They either never prescribe narcotics across the board or use them when appropriate AND with chronic abusers enabling their addiction. The age old habit of viewing an issue with a narrow, binary mindset. There are no absolutes and the answers do not lie in the extremes. Opioid pain medications still have a vital and important role in the treatment of acute short term pain due to certain injuries, post-operative patients, and palliative care for terminal, painful conditions. These patient’s should not be made to suffer for what may happen in the future. However, it’s role in chronic, long term pain management has justifiably come under scrutiny and it certainly should not be used for minor injuries. The sad irony is that while marijuana has been the pariah all these years, prescription opioids have actually become the gateway to heroin and other illicit drug abuse. As such, there have been and are health care providers which have enabled this to happen.

  1. https://www.incb.org/documents/Publications/AnnualReports/AR2008/AR_08_English.pdf
  2. http://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127-DAWN-highlights.pdf
  3. Mularski RA, White-Chu F, Overbay D, et al. Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Itern Med. 2006;21(6):607-612.
  4. http://www.newyorker.com/business/currency/who-is-responsible-for-the-pain-pill-epidemc
  5. http://www.nhregister.com/article/NH/20150331/NEWS/150339887
  6. http://www.cdc.gov/vitalsigns/heroin/
  7. http://www.cnn.com/2013/08/08/health/gupta-changed-mind-marijuana/
  8. https://www.dea.gov/druginfo/ds.shtml

Instant Gratification Society (Part I?)

Those of us who work in Emergency Medicine have all had these patients. They present with a complaint that started two years ago and for whatever reason now deem it an issue that needs immediate attention in the ER. I had a patient like this recently who not only had the issue for 2 years, but also had a primary care provider. Not only did the patient have a PCP, they saw their PCP a week before coming to the ER. Their provider also referred the patient for some outpatient studies. The studies were reasonable even though they would unlikely get to the root cause of the patient’s symptoms (an issue I’ve addressed in prior posts). Despite being reasonable, the patient decided to not follow through with the referrals and instead decided to come to the ER demanding the studies be done there because the patient “needed to know today”. I politely went through my normal boundary setting dialogue about how the patient should be getting her outpatient studies done as referred by her PCP and how coming to the ER in lieu of that is an inappropriate use of the ER but it fell on deaf ears as usual. Now none of this is new. We see patients with chronic symptoms all the time as well as patients who have doctors. But to read many of the articles you find out there, whether it be on a news site, “news” site, Facebook or a blog, I have yet to see articles pointing out the issue of middle class, insured patients with primary care providers misusing the ER.

By comparison, I’ve read numerous articles making pariahs out of the uninsured and even those who signed up for health insurance via the Affordable Care Act. Many of us have read that article where the ER physician laments about the patient he sees with asthma who says he can’t afford his inhaler but has money for cigarettes and a brand new smart phone. By itself, a legitimate question but narrow in its view not taking into account a broader picture. Likewise many of us have read about how those singing up for health insurance from the ACA will inundate Emergency Departments for their care and stress out the system. Articles written on this topic target the poor, those without insurance, or insurance via the ACA for using the ER while seemingly giving a pass to the many patients who have private health insurance and doctors and still use the ER for minor and/or chronic issues best served by their PCP. This is both backwards and inaccurate.

Working in an urban Emergency Department on the edge of city all but forgotten by government, we see both inner city and suburban patient populations. I can give somewhat of a pass to inner city patients with or without insurance for utilizing the ER because at the end of the day, access to primary care in the city is limited. Maybe not total absolution at times but one can certainly understand. I know many more people who have insurance through the ACA grateful for it and use their primary care providers appropriately rather than inundating the ER. What I can’t give a pass to are patients who have private insurance and doctors that try to use the ER as a surrogate. The reality is, this happens with great frequency. The examples are numerous. Patient’s with simple common colds who don’t even try to see their doctor or “couldn’t wait to the next day”. Patients who present to the ER expecting a routine MRI of their knee. I even had a patient with a referral from the orthopedic doctor for a follow up x-ray of a fracture written 2 months before coming to the ER. The patient needed to get the x-ray done that night because he had his follow up appointment with the orthopedic doctor the next day. They had two months to get their outpatient x-ray done. Not to mention, those who come to the ER to get their prescriptions for chronic medications refilled.

I’ve read the term “entitled” used when referring to certain patients. When they do, they are usually referring to those without insurance being entitled to not only using the ER for convenient health care but to get fed in the ER and a cab voucher home.  They are not always wrong however they don’t seem to apply it equally. Entitlement is blind to socioeconomic status. We live in an instant gratification society where anyone from any walk of life can and does feel entitled to getting what they want, when they want it. It could be health care, food, shopping, anything.

The reality is, middle class, insured patients who have their own primary care provider misuse the ER just as much if not more than those without insurance yet they are less likely to be called out for it or labeled as “entitled”.

Not with me yet? Well, as vapid as the saying is, a picture is worth a thousand words…

I’m sure one could write an entire article on how wrong this is. This advertisement is certainly not targeting the uninsured, inner city patient populations. It is targeting the middle class person who wants to shop and not have to wait to be seen in the ER. It also sadly demonstrates that people do not understand the term “emergency”. I am certainly empathetic enough to understand that something simple may be perceived as an emergency to a person. However if that perception exists, if a patient truly thinks they have an emergency, they are not going to stop by the mall first to go shopping. Conversely, if you are able to go shopping, you do not have an emergency. This is the medical equivalent to getting the beeper from a restaurant so you don’t have to wait and do nothing while waiting or worse yet, talk to other people. It’s not an emergency, it’s convenience. It’s instant gratification. One could also argue that the advertisement resides at the corner of Instant Gratification Street and Patient Satisfaction Survey Road. That is another topic in and of itself. The demand is obviously there if the hospital is supplying it.

Now many of you (hopefully) are reading this and agreeing with me. Here’s the rub. You are just as guilty of all this as any patient. I am too. I stated earlier no one is immune to it and it applies to more than just medicine. Every time you hit the drive thru instead of cooking for yourself, every time I use my phone to check Facebook, every time you ask a colleague to right a script, or when I call to expedite a family member to an ER bed, there is some mixture of entitlement and instant gratification at work. What’s solution? As with anything it’s multifactorial and can’t be deduced to just one thing. It is even likely that the solution may be a little different for each of us. As with anything, the first step in resolving an issue is acknowledging it exists, for everyone, not just certain groups.

The Elephant In The Room

This past week I had an patient encounter that left me beyond angry at our own medical profession. While evaluating a patient, I inquired as to her last GYN visit. The patient matter of factly told me she had never been to a GYN doctor and that her primary care physician told her she did not require that until she was twenty one years old. I struggled to maintain my usual poker face when hearing such absurd things and asked my patient to repeat it so that I heard her correctly. She again stated her physician’s twenty one year old criteria to start seeing a GYN doctor. I felt that boring headache starting. The one I get when someone is doing something less than intelligent. Figuring she left out that she was sexually active, I asked if she made that clear to her doctor. Not only had she made it clear, but she advised me that she inquired with per PCP about birth control, specifically the IUD and was told she could not have one because she had not had children yet. Now, I know some of your are thinking “well, sometimes patients aren’t reliable historians”. While this is sometimes true, trust me when I say her attention to detail and her reaction to the very treatable diagnosis left no doubt that her doctor had done her wrong. Not only did he give her gross misinformation regarding women’s care and birth control, he barely addressed birth control at all. To say my blood was boiling is an understatement.

The fact is, most of us have encountered these types of practitioners, usually through their patients. Their misdeeds range in severity from unnecessary x-rays that make us raise an eyebrow, to patient’s literally diagnosed with “the Flu” or “Viral Syndrome” then prescribed a Z-pack (seemingly the panacea of choice patients ask for these days) thereby contributing to antibiotic resistance, to more negligent actions such as my example above. There are practitioners providing poor care, some to the level of being potentially, though not immediately, dangerous. Is it age, ignorance, apathy? A discussion of the why is a bit too broad to address here. I’m more interested in what we do about it when we encounter it and from my experience, it seems very little.

With the exception of fitness for duty exams when practitioners are suspected of working under the influence, I can say I’ve rarely seen a provider’s actions addressed. I’ve heard colleagues and co-workers complain to each other about another practitioner’s actions. I’ve heard people laugh it off and I’ve even heard others make excuses for it. I’ve rarely heard anyone called to the carpet for it. There exists an underlying air that it is improper for one practitioner to ever question another practitioner’s actions. That it is a big professional faux pas. I would think there are many other reasons why. Perhaps the proper channels for addressing an issue are too laborious? Some don’t want to get involved at all, some don’t want to get listed a troublemaker, some are afraid to challenge a fellow practitioner / don’t want to deal the with overbearing egos that are so prevalent in medicine, some don’t want to ruin working relationships, and I’m sure there is a whole host of other reasons I’m not aware of.

The fact is, just treating another practitioner’s patient correctly is sometimes not enough. In doing nothing to address the practitioner’s shortcomings we are just as accountable as the practitioner who errors. Perhaps not legally, but ethically. When we do nothing, WE ARE ENABLERS. We are presented with a situation that if addressed, could prevent numerous other medical issues but instead we do nothing and wait for the the issue to worsen, boil over in it’s respective way, or worse still for the patients, just fade away. When we do this, we become responsible for weakening our own medical system as well as doing a disservice to patients.

Please do not read this and think I’m coming off all high and mighty. I’m not. I’m sure I’ve managed some patient’s incorrectly that no one has ever brought to my attention. Hopefully, it has been very minor things. Regardless, I can honestly say I would rather someone bring this to my attention so I do not continue doing the same thing over and over rather than find out 15 years later or worse yet at the end of my career. If we really care about our patients, we have to care enough to routinely ponder if we are doing right by our patients, be able to set ego aside, avoid hubris, and be open to criticism when it is due. If one cannot, then one should really reassess why they continue to practice medicine.

Psychiatric Patients In The ER

Patients with psychiatric emergencies increasingly use the ER for their care. While the ER can initially assess and address acute psychiatric conditions, these patients ultimately need dedicated psychiatric services to finish out that care. Unfortunately, these services have become scarce leading to psychiatric patients to be boarded in ER’s, sometimes for days. During this time, the patients do not get the care they need, utilize resources that could be used for other ER patients, and contribute to ED workplace violence. While many hospitals don’t acknowledge this issue, one state is trying to find a solution…