William J. Watson, MSc, MD, CCFP, FCFP, Staff Physician (Retired), Honorary Consultant, Family Medicine, St. Michael’s Hospital Associate Professor Emeritus, Department of Family and Community Medicine and the Dalla Lana School of Public Health, University of Toronto.
When I checked my day schedule, I saw his name and had a deep sigh.
‘Oh no-not him again” I thought.
As a family physician, this is a true story about, Dale, one of my patients whose trauma history and difficult background transformed both of us. The names have been changed.
The normal day of any family physician is filled with a spectrum of situations and emotions: immense joy, surprise, excitement and sometimes sheer horror, interspersed with challenging dilemmas, stress and at times, humour. We see any number of patients usually 20-40 per day depending on location and practice characteristics, with problems ranging the full spectrum of physical and emotional ailments. And the ages range from birth to death, or as one of my colleagues described ‘sperm to worm’ care.
Usually in the course of medical care, there is a relationship between patient and doctor that develops over time; that relationship based on mutual respect, collaboration and good medical care can become a positive force for both.
But this is not always the case.
Dale was what I call one of my ‘heartsink’ patients-those individuals who I didn’t look forward to seeing and don’t particularly like. I have called them my “heartsink’ patients, because they literally make my heartsink when I see their name on my day-list of patients; perhaps because they have challenging health problems, mental and/or physical, or difficult interactions.from past visits.
Colleagues have shared similar stories about their own ‘heartsink’ or what some would call ‘difficult’ patients. Much has been written in medical journals about how these patients constitute a small percentage of a physician’s practice, but can consume much more of their time. Physicians cite stress and feelings of burnout when they have too many, even to the point of discharging them from their practice.
As physicians, we have been trained to have a professional demeanor and treat all of our patients equally with respect, and, as the psychologist Carl Rogers said, with “unconditional positive regard, along with empathy and genuineness’.
Are we allowed not to like our patients?
“Hi Doc , how’s it goin? Long time no see. I need a prescription”.
Dale was a thin, bearded, wiry, tattooed man in his 40’s who had a back injury while working on a construction crew several years ago. He had been on pain killers for several years prescribed by his former family doctor and became addicted to opioids. After his doctor retired, I took over his medical care and today, was asking me to fill his script for ‘percocets’, a prescription opioid.
Dale visited the office frequently and often claiming that he ran out of his pain meds and needed more. Every visit with Dale seemed somewhat tense and almost confrontational, with his claims of “I’m not getting any help”. Never satisfied, the meeting usually ended in some kind of compromise with a limited number of pills prescribed weekly, always with an overall ‘harm reduction’ approach. This scenario was a requent occurrence in our inner city clinic, and many of my colleagues had similar stories.
For some background context, physicians have a responsibility to provide adequate pain control in our patients with non-cancerous chronic pain, along with the concern about the risks of chronic opioid use including addiction, aberrant drug-related behaviors and death.
In fact, in the 1990’s, there was a major effort by some physicians, sponsored by the pharmaceutical companies who manufactured the meds, to prescribe opioids, specifically hydromorphone (AKA oxycontin, dilaudid) to our chronic non-cancer pain patients, who they believed were not being adequately treated.
Consequently, there is often a tension between physicians and patients with chronic pain conditions who are requesting/demanding opioids, and the very real concerns of physicians about side effects. Over the past 30 years, I have heard the same concerns voiced by many physicians, especially with the increase in opioid-related deaths. Physicians have even experienced burn-out with their addicted patients, and /or asked them to get a new physician.
In Dale’s case, in spite of trying physiotherapy and other drug treatments, nothing was really effective. Over time, Dale had become a loner, with few friends and social interactions, unable to maintain functional relationships, and experiencing increasing anxiety and depression.
“Dale, I am concerned about how many of these pills you are taking. They are dangerous and can kill you if you take too many. They also don’t work after a while, and the effects wear off . Would you consider a lower dose and maybe substitute some other pain meds?”.
And so the battle began.
Dale had no wish to switch to another pain medication saying “Just give me my script and I’ll be on my way. I’ve already tried those other pills and they don’t work.”
It wasn’t the first time I have had difficulty with this kind of patient. What I did not yet realize was that Dale had a history of childhood neglect and trauma, as is often the case in addicted patients.
As a physician, it’s sometime easier just to give the script than to fight with disgruntled drug-seeking patients. While we want to treat our patients’ pain, we are also aware of the very real and significant risk of accidental overdose or death with the use of opioids.
On this particular morning, I had recently read a journal article about the origins of addiction and how childhood trauma was often at it’s root.
After struggling with his care for many months, I decided to ask him about his life.
“Dale, I’m concerned about how you are doing in your life, and why you’re having such difficulty. Do you mind if I ask you a question?
What was it like growing up as a kid?”