This article appeared first in “The Conversation” on April 25, 2018, under the title “Why it’s so hard for doctors to understand your pain”. 

We’re all human beings, but we’re not all alike.

Each person experiences pain differently, from an emotional perspective as well as a physical one, and responds to pain differently. That means that physicians like myself need to evaluate patients on an individual basis and find the best way to treat their pain.

Today, however, doctors are under pressure to limit costs and prescribe treatments based on standardized guidelines. A major gap looms between the patient’s experience of pain and the limited “one size fits all” treatment that doctors may offer.

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Max Thomas

Someone close to me suffers from both mesothelioma and Parkinson's disease. I understand the pain by way of metaphor. It is like a sea with islands of different shapes and sizes representing the various types of pain. Some treatments or doses flood over the lower-lying 'islands' while other pain peaks continue to 'break through' the surface. The treatment consists primarily of opioids in one form or another. The prospect of the peaks becoming higher is very troubling but there seems to be little to offer ...Read More

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Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

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altadoc

Thank you for sharing your thoughts on the specialty. I know for myself, it is so easy to get overwhelmed and bogged down by the day to day commitments and stressors, that it can be hard to step back and take the 20 or 30,000 ft view of medicine and anesthesiology. Would love to hear more about the discussion and find a way to be involved in shaping our future!

Eduardo

Very useful and scaring description! I see it so intricate that it's many diversified steps involved, exposes many places to have an accidental mistake with no clear responsible or even detecting easily where in the line the error happened. Isn't it expensiver than the old one man model? Thanks!

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Avoiding #metoo in medicine

Let me say first that any woman who has ever been harassed or assaulted should NEVER be made to feel that it is her fault. It is always the perpetrator’s fault. Men can be boors, or worse, and testosterone can be toxic.

I went to Princeton University at a time when the ratio of men to women was 8:1, graduated from medical school in the 1980s, and raised two daughters. I’ve had ample reason and plenty of time to think about strategies to deal with harassment, parry a verbal thrust, and maneuver out of a potentially humiliating or harmful situation.

We’re lucky in medicine that we have intellectual qualifications — board scores, professional degrees — that are our primary entryway into medical school and residency programs. We’re not being judged PRIMARILY on our looks. Yet many social media comments recently have underscored the fact that some women in medicine have endured ridicule, harassment, and even assault in the course of their careers. It makes sense to explore any tactic that can help other women avoid similar painful encounters.

Here are some tips — learned through long experience. My hope is that they might help younger women in medicine feel less like potential victims, and more like strategists in a behavioral chess game.

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Zoe

As a young physician working in the emergency department I found this to closely mirror the habits I've adopted. Some of it I think is basic professionalism, and it never hurts to remind people that acting professionally does help people treat you in a professional manner. But some of it is boots-on-ground practical advice about navigating some of the terribly inappropriate things that happen when you are a woman working in the settings we work in. I think you made it clear that it would ...Read More

Laura

Carrying oneself in such a way as to command the already-deserved respect is not, on its own, a bad suggestion. However, your suggestions to "Pretend you didn’t hear it; pretend you’re busy writing a note or checking your phone," are backward. I agree with your points above that it's helpful to provide women with a pre-planned response to help them avoid looking embarrassed or fearful. However, that doesn't mean that we should be teaching women to accept men's inappropriate behaviors. With these words, you are, ...Read More

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When you tell anyone in healthcare that “sedation” to the point of coma is given in dentists’ and oral surgeons’ offices every day, without a separate anesthesia professional present to give the medications and monitor the patient, the response often is disbelief.

“But they can’t do that,” I’ve been told more than once.

Yes, they can. Physicians are NOT allowed to do a procedure and provide sedation or general anesthesia at the same time – whether it’s surgery or a GI endoscopy. But dental practice grew up under a completely different regulatory and legal structure, with state dental boards that are separate from medical boards.

In many states, dentists can give oral “conscious” sedation with nitrous oxide after taking a weekend course, aided only by a dental assistant with a high school diploma and no medical or nursing background. Deaths have occurred when they gave repeated sedative doses to the point that patients stopped breathing either during or after their procedures.

Oral surgeons receive a few months of education in anesthesia during the course of their residency training. They are legally able to give moderate sedation, deep sedation or general anesthesia in their offices to patients of any age, without any other qualified anesthesia professional or a registered nurse present. This is known as the “single operator-anesthetist” model, which the oral surgeons passionately defend, as it enables them to bill for anesthesia and sedation as well as oral surgery services.

Typically, oral surgeons and dentists alike argue that they are giving only sedation – as opposed to general anesthesia – if there is no breathing tube in place, regardless of whether the patient is drowsy, lightly asleep, or comatose.

The death of Caleb Sears

Against this backdrop of minimal regulation and infrequent office inspections, a healthy six-year-old child named Caleb Sears presented in 2015 for extraction of an embedded tooth. Caleb received a combination of powerful medications – including ketamine, midazolam, propofol, and fentanyl – from his oral surgeon in northern California, and stopped breathing. The oral surgeon failed to ventilate or intubate Caleb, breaking several of his front teeth in the process, and Caleb didn’t survive.

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I am so sorry to hear about Caleb Sears, I can only imagine the pain that family felt. I trust my dentist at Molar Bear Pediatric Dentistry in Houston, TX 77084 because they understand the lethal limits of anesthesia and its comforting to know that my child is in good hands. But as a parent, I still try to educate myself beyond the doctor's word.

Rob

Today's deep thought: Why is it that dentists and oral surgeons are considered good enough to "multitask" by being allowed to give the anesthetic and perform the procedure, yet they are not good enough to be exempt from cellphone while driving laws? For those who believe in the illusion of "multitasking"...May I suggest having a look at the Monkey Business Illusion: https://m.youtube.com/watch?v=IGQmdoK_ZfY Thanks for a great article. In my opinion, those who give anesthetics, should follow the highest standards of practice in the field. Separating the anesthesiologist from from ...Read More

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The real surprise – to me, at least – came more than halfway through Dr. Atul Gawande’s keynote address at the opening session of the American Society of Anesthesiologists’ annual meeting in Boston.

Much of his talk on October 21 celebrated the virtues of checklists and teamwork, topics that have turned into best-selling books for the well-known surgeon and professor of public health. “We are trained, hired, and rewarded to be cowboys, but it’s pit crews we need,” he said.

Then Dr. Gawande posed this question to the packed room: “What are the outcomes that matter?”

He answered his own question somberly. “The most unsafe operation is the operation that shouldn’t be done,” Dr. Gawande said. “Does the operation serve the patient’s goals or not?”

“We’ve all been there,” he continued. “Taking people to the operating room and wondering what we’re doing.”

Those are comments I’ve heard from anesthesiologists many times before, but I never thought I’d hear them from a surgeon.

Flogging the dead

For any of us who practice anesthesiology in a major hospital – doing cardiac, thoracic, or liver cases, for instance – there are days when all our efforts are spent on behalf of a patient whose health is unsalvageable. “Flogging the dead” is a phrase sometimes used to describe prolonged and futile care in the operating room or ICU.

Sometimes aggressive interventions are driven by a family that wants “everything” done, because in their innocence the family members have no idea how terrible and dehumanizing the process of postponing death can be.

In other circumstances, however, the decision of whether to do surgery is driven by the mission and the financial motivation of the health system to provide care. If care doesn’t occur, if the surgery isn’t done, no one gets paid.

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What,If the patient or the relatives sue the doctor that a particular line of treatment which offered a possible cure has been denied to them?.the decision making in patient care has shifted to patients and relatives knowledge of the possible lines of therapy available.

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