6.1: Consistently demonstrate compassion, respect, honesty, integrity, accountability, altruism, prudence, social justice, and commitment to excellence in all professional and personal responsibilities.
Providing care to patients with opioid use disorder during the opioid epidemic is one of the most difficult challenges for internal medicine physicians. In my clinical experience, I have seen loss of trust lead to communication breakdowns, inconsistencies, and emotional tension for patient and provider. As I strive to provide the highest quality patient care to each of my patients, achieving patient-centered care in this setting has been difficult.
My first memorable interaction with a patient suffering from opioid use disorder occurred during my third-year general medicine rotation. The patient was admitted for a kidney stone which caused him excruciating pain. He demanded high doses of IV opioids and became enraged when my attending recommended against opioids. I felt bad for the bedside nurse who spent the entire day sympathizing with the patient, yet stopped short of providing relief by opioids. I felt bad for the patient, who became addicted to opioids initially prescribed by his doctors. And I felt bad for our attending, who spent nearly an hour delineating why we needed to trial non-opioids first and refusing to engage in a bargain for medications. Unable to reach a common ground, he had to excuse himself to see a sick patient. I wondered if I had the reserve to withstand this tension on a daily basis. Returning the next day, we fortunately found some common ground. Although it cost time from the day, the persistence proved worth the effort.
Hoping to learn more about managing pain for patients with opioid use disorder, I enrolled in MAT waiver training. The program helped me to better understand the public health impact of opioid diversion. I completed the training so that in the future I can facilitate care for patients who are candidates for this treatment.
I returned to the general medicine wards for my fourth year sub-internship. This time, I aimed to take more responsibility communicating with difficult patients and resolving conflict. Many of our patients struggled with addiction to alcohol, heroin, and cocaine. When I presented a patient with a documented history of polysubstance abuse, my attending encouraged me to consider using “substance use disorder” as a more patient-centered term.
One of our patients who had used IV heroin in the past was given a PICC line for outpatient antibiotics. She spent days waiting to be placed in a facility, and we tried to alleviate her anxiety. Then one day, without warning, she disappeared from the unit. We were shocked to hear that she had snuck out in the middle of the night after receiving the PICC line. It felt like deception. How could we possibly trust our next patient?
Later that week, I evaluated a patient with hidradenitis suppurativa and a history suspicious for cocaine use. She was in the process of finding a new primary care physician. When I saw her, she was in excruciating pain and yelled that she didn’t want to be bothered by medical students with redundant questions. I attempted to reason, but she demanded I leave the room. The resident decided to provide oxycodone for breakthrough pain given her severe flare of hidradenitis.
I thought about finding a new patient. I sensed this would take up my time and energy. But knowing her case, I decided to take ownership and revisit her the next day. We made some progress and I learned that she was having difficulty finding a primary care physician. Outside of the hospital, she could not access opioid analgesics without a primary care physician. We would have to work with case management to keep her pain under control after discharge.
A new attending started on service the following day. I respectfully introduced our patient, who thankfully had allowed me to examine her that morning. Just as we were leaving the room, the nurse asked if we were in agreement with oxycodone for breakthrough pain. The attending told her to remove oxycodone from the list and then quickly moved on to the next room. The intern was upset about this, because she had previously set different expectations for the patient. The nurse now had to withhold analgesia from a suffering patient. I could understand our new attending’s discretion to provide therapy, but the discrepancy in plans put stress on the team and patient. With this change in course, the patient perceived that we lost trust in her.
Later that day, I checked on her and she asked me sadly, “Why does everyone keep avoiding me when I ask why I can’t have something more for pain?” It seemed like everyone was sideskirting something, saying they didn’t know or they weren’t sure. “I just want someone to please give me a straight answer.” I felt convicted to provide an honest response, even though I wished I could defer her to the residents. I promised her I would check with the residents and return soon with an answer.
I had to think for awhile about how to phrase this and keep our team and our plan and our patient’s goals in alliance. I also wanted to show her courtesy, respect, and honesty as far as possible. I asked my intern for advice.
I explained the situation in big picture terms first. With the opioid epidemic in Ohio, doctors were changing the way they prescribed opioids. To protect people from addiction and prevent diversion, we had to rethink the ways in which we manage everyone’s pain in the hospital. This change made it difficult to speak in a straightforward way about what’s considered “okay” to prescribe. Sending her home with a long course of oxycodone was not an option. We needed to set her up with a PCP to manage her pain.
I thought she would be upset, but she listened carefully and then told me that she had a daughter with substance use disorder and understood our caution. Once I ensured her that we would set her up with a new PCP quickly after discharge, she was on board with the plan. She agreed to trial the nonopioid analgesics and steroids for another day and inform us if the pain worsened. I reassured her that we would find her a primary care physician to follow up with.
Reflecting back on this experience, I realize that I am never going to know how the patient will respond. Maybe they will yell at me, maybe they will agree with me, or maybe they will lie to me to take advantage of the health system. It’s hard to trust after being lied to and yelled at. Regardless, my job is to be there for the patient, build trust, communicate honestly, and provide excellent interdisciplinary care.
Building trust and communicating honestly are difficult when you implicitly or explicitly don’t trust the patient. We may question whether the patient is telling the truth or willing to comply with recommendations. But my responsibility as an intern is not to discern whether the patient is truly in pain or lying. Rather, my responsibility is to care for their medical needs. By sticking around even after I was yelled at by the patient, the patient knew I was still dedicated to providing her care. With those small steps of building trust and honest communication, we found common ground that allowed us to make another small step in progress with her care. Through diligence and honesty, we can build steps towards common ground.
Having a network of allied health providers was critical for successful treatment in all of these scenarios. When communication within our care team faltered, the patient could tell that something was amiss. To give patients the best possible chance of regaining health and autonomy, they need to establish longitudinal care with a health provider. This requires a multidisciplinary team including nursing, social work, case management, and physical and occupational therapy. I completed an advanced competency course on interdisciplinary case management for underserved populations. Working together on simulated cases taught me how to leverage the strengths of an interdisciplinary team.
Since this rotation, I’ve strengthened my skillset to better care for patients with substance use disorder. Honesty with our patients is essential, and so I look to my seniors for ways to respectfully navigate difficult conversations about drug addiction. I use “substance use disorder” to promote patient-centered clinical discussions. During my palliative care rotation, I further strengthened my communication skills with patients suffering from chronic pain and learned additional strategies to optimize pain management. I earned high marks from my attendings for my professionalism and rapport.
During my intern year, I will continue to strive for honesty, integrity, compassionate care, teamwork, and patient centeredness during difficult patient encounters. My specific goals are listed below:
- For patients admitted with significant pain, set expectations for pain control while in the hospital at first encounter
- Consider non-opioid analgesics, therapy, and integrative medicine to manage pain before initiating opioids (with exceptions for patients with clear clinical indications for opioids and patients pursuing palliative care)
- Be patient and diligent with patients who yell at me during an initial encounter
- Always check and document an OARRS report for patients receiving opioids
- Ensure that every patient has a timely follow up plan with an outpatient provider who can manage their pain prior to discharge
- Understand hospital policies on opioid prescription by the first day of internship
- Know where my patients can receive prescriptions for pain medication by the first week of internship