Note: This is Part 2 of The Hospitalist’s series on pain and hospital medicine. Part 1 appeared on p. 45 of the April issue.
Welcome to Part 2 of our three-part series on managing the pain of hospitalized patients. Last month’s article presented the context for pain management in the hospital—a core competency identified by SHM. It emphasized techniques for assessing patients’ pain, ranging from a zero-to-10 pain score to more complex pain histories addressing type, source, duration, and intensity as well as psychosocial and spiritual factors.
Part 2 delves into some difficult cases and dilemmas of pain management—situations that can take hospitalists out of their comfort zone and challenge their confidence in managing their patients’ pain.
Some of these dilemmas arise from misconceptions about pain and pain treatments and from the fact that, historically, physicians have not been well trained in optimal pain management. General barriers to pain management in the U.S. healthcare system, as identified by the National Association of Attorneys General, include patients’ beliefs, physician and institutional practices, restrictive state polices, and racial and socioeconomic disparities.1
Many of these issues relate specifically to the most common treatments for severe pain, opioid analgesics, which have all sorts of negative associations based on misconceptions about abuse, addiction, and overdose. In other cases, physicians face real challenges in balancing analgesic benefits with side effects and in determining the right medication, dose, and schedule to meet the patient’s need for pain relief.
Hospitalists confronting difficult pain cases work under the added pressure of trying to bring their patients’ acute illnesses under control so they can discharge them to a lower level of care as soon as prudently possible. This time pressure, along with demands arising from the rest of the hospitalist’s caseload, may impose limits on what can be accomplished in difficult situations or with medications that require time to stabilize.
Challenges also arise when the customary approach to pain management—the drug and dosing schedule the hospitalist is most comfortable using for most patients—fails to bring the pain under control. This is often a red flag for the need to try something new, says Stephen Bekanich, MD, a hospitalist at the University of Utah Medical Center in Salt Lake City and a consultant on the medical center’s palliative care service. In some cases, that means calling in a specialist in pain treatment, palliative medicine, psychiatry, or substance abuse.
“You need to work into the equation that there are pitfalls and caveats to everything we say about pain,” Dr. Bekanich observes. “Plus, the common pain treatments are controlled substances, with obvious legal implications and a professional duty for physicians to handle them safely and appropriately.”
When Dr. Bekanich finds himself confronting a difficult pain situation that has caused a conflict with a patient, he often involves one of the hospital’s customer service patient advocates. They are trained to mediate disagreements between patients and the treatment team.
Is This Patient’s Pain Real?
Physicians sometimes wonder if their patients’ reports of pain are accurate. Is the pain really as bad as the patient says it is? “Residents, frequently, are more skeptical of patients’ claims of pain, doubting whether they are truly experiencing that level of pain,” reports Jean Youngwerth, MD, a hospitalist, palliative care consultant, and fellowship associate program director at the University of Colorado Health Sciences Center in Aurora.
“I tell my residents that malingering is rare, and those few cases where it happens really tend to stand out,” Dr. Youngwerth says. “I also tell them that our default position is always to trust the patient, unless given a good reason not to. I have been burned more often when I questioned my patients’ reports of pain than when I didn’t.”