The problem of pain, from the viewpoint of British novelist and theologian C. S. Lewis, is how to reconcile the reality of suffering with belief in a just and benevolent God.
The American physician’s problem with pain is less cosmic and more concrete. For physicians today in nearly every specialty, the problem of pain is how to treat it responsibly, stay on the good side of the Drug Enforcement Administration (DEA), and still score high marks in patient satisfaction surveys.
If a physician recommends conservative treatment measures for pain–such as ibuprofen and physical therapy–the patient may be unhappy with the treatment plan. If the physician prescribes controlled drugs too readily, he or she may come under fire for irresponsible prescription practices that addict patients to powerful pain medications such as Vicodin and OxyContin.
Consider this recent article in The New Republic: ”Drug Dealers Aren’t to Blame for the Heroin Boom. Doctors Are.” The writer, Graeme Wood, faults his dentist for prescribing hydrocodone to relieve pain after his wisdom tooth extraction.
As further evidence of her misdeeds, he says, first she “knocked me out with propofol–the same drug that killed Michael Jackson.” Wood uses his experience–which sounds as though it went smoothly, controlled his pain, and fixed his problem–to bolster his argument that doctors indiscriminately hand out pain medications and are entirely to blame for patient addiction.
But what happens to doctors who try not to prescribe narcotics for every complaint of pain, or antibiotics for every viral upper respiratory infection? They’re likely to run afoul of patient satisfaction surveys. Many hospitals and clinics now send a satisfaction questionnaire to every patient who sees a doctor, visits an emergency room, or is admitted to a hospital.
The results are often referred to as Press Ganey scores, named for the company that is the leading purveyor of patient satisfaction surveys. Today these scores wield alarming power over physician incentive pay, promotion, and contract renewal.
Now hospital payments are at risk too.
Beginning in 2002, the Centers for Medicare & Medicaid Services (CMS) began work with the Agency for Healthcare Research and Quality (AHRQ) to develop a standardized survey of patients’ perceptions of hospital care, now known as the HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) survey.
Press Ganey submits HCAHPS data to the government on behalf of its many clients. At first, the HCAHPS survey was intended as a tool to allow objective comparisons of hospitals on topics important to consumers, including:
- How well doctors and nurses communicate with patients.
- How responsive hospital staff are to patients’ needs.
- How well hospital staff manage patients’ pain.
- Whether key information is provided at discharge.
But since 2007, hospitals that fail to report “required quality measures”, which include HCAHPS results, receive less payment from CMS. The government’s Value-Based Purchasing program bases only 70% of hospital performance scores on actual clinical care, and a full 30% on the HCAHPS survey’s report of the “patient experience of care”–including patient satisfaction with pain management.
“Never deny a request”
A patient who isn’t pleased with the experience of care may give bad marks overall, whether the problem was a long wait or a doctor who doesn’t heed requests for a medication or a test. But any physician who is associated with the low scores will earn the ill will of hospital administrators, who fear reduction of the hospital’s already slim Medicare/Medicaid payments, and of the CEO, whose salary incentive component may be at risk too.
Never mind that Press Ganey scores are often based on small numbers of returned questionnaires, too small to be statistically significant.
Do these pressures affect how physicians deliver care? It would be surprising if they didn’t. A family physician, Dr. William Sonnenberg, wrote recently, “The mandate is simple: Never deny a request for an antibiotic, an opioid pain medication, a scan, or an admission.” He believes Press Ganey “has become a bigger threat to the practice of good medicine than trial lawyers.”
The Atlantic published a recent article: “When Physicians’ Careers Suffer Because They Refuse to Prescribe Narcotics.” The author, Richard Gunderman, highlighted the fallacy in satisfaction scores, noting that “patient perceptions may prove downright misleading.”
Patients often visit multiple emergency rooms and physician offices asking for narcotics, Gunderman reported, and “the problem of prescription drug abuse and drug-seeking behavior is abetted by a robust and growing black market for prescription medications.” Still, physicians are at risk for being hired or fired on the basis of patient satisfaction data, without critical review of the source.
Do high patient satisfaction scores correlate with better health? Or higher quality care? So far, the answer is no. A recent study of hospitalized patients showed that many patients prefer “shared decision-making” with their physicians, but it results in longer inpatient hospital stays and 6 percent higher total hospitalization costs.
A prospective study of over 50,000 clinic patients showed that the 25% who were most satisfied with their care had higher odds of inpatient admission, greater total expenditures, greater prescription drug expenditures, and–perhaps most surprising–higher mortality.
Forbes writer Kai Falkenberg, in her article “Why Rating Your Doctor Is Bad For Your Health,” concluded that “giving patients exactly what they want, versus what the doctor thinks is right, can be very bad medicine.”
Today, over 12% of primary care visits and over 32% of emergency department visits involve opioid or benzodiazepine prescriptions, according to the results of a study presented last month at the American Academy of Pain Medicine’s annual meeting, and these rates are steadily increasing.
The study’s co-author, Dr. Ming-Chih Kao, said that between 1999 and 2006 there was a 250% increase in fatal overdoses in the US, and more than half involved more than one drug, usually opioids and benzodiazepines. Patients may lack resources to cover services like physical therapy and mental health treatment, and they urge physicians to prescribe opioids and benzodiazepines instead.
The recent history of opioid use and abuse in the US illustrates how well-intentioned actions so often have unintended consequences. There was a time when physicians hesitated to prescribe opioids even for cancer pain, let alone non-malignant pain, for fear of addiction.
That philosophy started to change in 1986, when Dr. Russell Portenoy published a paper in the journal Pain concluding that “opioid maintenance therapy can be a safe, salutary and more humane alternative to the options of surgery or no treatment in those patients with intractable non-malignant pain and no history of drug abuse.” Pharmaceutical companies began to promote new formulations including OxyContin for the treatment of pain.
A major upswing in the government’s interest in pain management followed in the 1990s, as the AHRQ issued guidelines advocating more aggressive treatment of pain. In 1998, the Veterans Health Administration premiered a national strategy intended to improve pain management for its patients, and defined “Pain as the 5th Vital Sign”. The new strategy required use of a numeric rating scale for pain in all clinical encounters.
The Joint Commission quickly added the achievement of low pain scores to its measures of hospital quality, and issued a major monograph in 2003 called “Improving the Quality of Pain Management Through Measurement and Action.” CMS began to rate hospitals on the basis of patient satisfaction scores, and the rest is history.
Now political pressure in the opposite direction–against narcotic prescription–is escalating, as the Centers for Disease Control and Prevention is urging doctors to use opioids more sparingly. The state of Washington passed a law restricting opioid prescription, and other states are considering similar measures, while patients with chronic pain scramble to find treatment.
In 2010, a new formulation of OxyContin was introduced in order to make it more difficult to dissolve or crush. The result, reported in the New England Journal of Medicine in 2012, was that the selection of OxyContin as a primary drug of abuse decreased, but the abuse of other opioids–including fentanyl, hydromorphone, and heroin–rose markedly.
Physicians are caught in the vise between patient satisfaction surveys and the epidemic of prescription drug abuse and overdose. Government and regulatory intervention, as well-intentioned as it may have been, has only led to worse problems and disastrous outcomes. Fed-up physicians are leaving clinical medicine for jobs in hospital administration, consulting, or industry wherever they can. Is anyone surprised?
Karen Sullivan Sibert, MD (@KarenSibertMD) is a practicing anesthesiologist and associate professor of anesthesiology at a major medical center in Los Angeles. She writes at aPennedPoint, where this piece originally appeared.
doctors….i need your help….the reason i’m forwarding this to you is because i’ve never seen someone like me….my problem is with my alimentary canal,i guess,or probably my stomach.The thing is that when i eat any food…i tend to bring it back like a ruminant animal…..more of like constipation buh it tastes better…and it happens almost all the time….what is wrong with me?am i dying?
Please see your doctor! You may need a referral to a gastroenterologist. Endoscopy to look at your esophagus and stomach may help diagnose your problem, and you also might need a study to look at how your esophagus is functioning. Please don’t delay! Help for your problem is possible.
Said every pain seeker ever…
Had a problem with doctors acting like every patient with ongoing pain is just seeking drugs. I have actually been shoved out of the office while still talking. I have never asked for any medication, I have tried for over three years to get an answer . My PCP sent me to a physiatrist I went because I wanted help finding a cause . I now have a untreated compression fracture of L1 , severe osteoporosis in my spine and chronic L4 impingement, cysts in my superior pubic ramis that one doctor said that means you need a new hip , you just have to live with pain . So I take the pain medication because at this point I have constant pain in my left hip, leg and foot . I have done all the injections and steroids and all that got me was a compressed L1 . So between my PCP not listening or believing a word I say, his last comment to me was I told you already I can’ t help you why are you back and the attitude that chronic pain does not deserve to be treated like any other chronic condition that needs medication I guess my survey will be very poor results. I really find it hard to believe that surgery putting implants in people’s spines is a better choice than adequate pain control with medication. One thing I have learned from this is I will never go to the ER again and most doctors are assholes .
Had a patient leave my ER “AMA” just a few hours ago. It was her THIRD ED visit in 3 days, claiming severe pain and demanding that the ER physician “refill” her chronic opiates because her prior prescription had been “stolen.”
What a surprise, her “pain mgmt.” doc didn’t feel like refilling these a month early. When we advised this lady we would not continue to give her narcotics, she literally leapt from the bed (where she previously was writhing in supposed agony), stomped out of the ER, slamming doors as she proceeded to the administrators area where she demanded that the ER physician be fired immediately.
Fortunately our hospital leadership is quite sane and cares more about having good doctors than kowtowing to lunatic drug-seeking patients. (Yes, I realize I’m in the lucky minority!!).
Press-Ganey can kiss my very large buttocks. I will do the right thing by my patients and I’m sorry if this pisses off some drug seekers. (BTW, the above pt was offered transfer to the facility where her supposed Pri Care doc practices, but she of course refused this).
What a conundrum for both physicians and chronic pain sufferers. How many patients are afraid to ask for medication to relieve their suffering for fear of appearing like a drug addict? And how many physicians are thinking the patient who continually asks for meds may be abusing them? How does one draw the line? An integrative care program may provide alternative methods of treating the chronic pain sufferer; however, many of these modalities are not covered by insurance or medicare. Therefore, they are not prescribed and the patient does not venture out to explore these options due to the expense.
As for the surveys, there are always complainers and unfortunately their voices are given more value than those of satisfaction. Unfortunately, we are a society that seizes on the negative versus staying focused on the good.
Managing chronic pain is fast becoming the largest problem facing humanity, not just for the potential of addiction, but also for the loss of productivity and quality of life for both the sufferer and those around them. Much needs to be done in this realm both to help the physician provide relief for the patient and for the patient to gain control of life itself. Allowing Integrative health programs to be paid for by insurance and medicare seems to be a logical move to me.
nice information thank you for sharing
Thank you for this blog.
Acupuncture and other alternative medicine can be an option.
Most times when patients cease from pain management medicine, they are more likely to go for drugs because most come with different meathodology
When I was in residency, I was taught that part of being a good doctor is being ‘the bad guy,’ the guy who says no, the guy who gives bad news. That is part of the job. If you can’t do that, you don’t have the guts to do the job.
As for patient satisfaction, well most patients don’t know enough to judge whether a doc is doing a good job or not. So take patient satisfaction surveys for that they are worth.
As for Press-Ganey, their methodology was debunked many years ago. I pay them no mind.
Wonderful to have the dilemma under which physicians work being discussed!! The solution is not to have no oversight but rather more transparency and communication as to what is actually going on. What treatments are being offered are they effective an evidence based and what is the cost to patients an society. Yes we must be accountable for what we prescribe and yes we will get bad evaluations from patients we refuse to renew narcotics for because their urine drug screen was positive for cocaine and negative for the medications we prescribed. Yes when they do not get their prescriptions and are on government medical plans with little or no cost to the patient they will repeatedly show up in the emergency rooms. Yes there is a huge lack of mental health care for patients with mental illness and drug dependency. All of these issues will have to be considered in any effort to evaluate quality of care. More public hospitals and inner city care will continue to fare poorly in statistics and more and more physicians will wish to practice in Malibu and or Beverly Hills not in East LA or Watts where perhaps there is more real need. We cannot attempt a solution until we have more transparency as to the problems.
Always doing “The Right Thing” is often unpopular and definitely not easy, especially when stakes are high, like in politics and medicine. The MOST important characteristic of a quality professional, is integrity.
My spinal stenosis doc says that opioids only work for one day–the first happy day–and that one has to then go for tiny amounts of steroids off and on for the remainder of life– like 5mg pred per week or articular shots per 6 months. So far it’s worked fine for me.
I was a path resident at Cedars in the Pleistocene era. My daughter and son in law were oncologists at Cedars.
@Gunderman is terrific. Case in point his last essay for THCB —
The boundary between acute and chronic pain isn’t always that neat or clear. In my business, which is anesthesia for high-risk adult patients, it is more and more common to see patients who are habituated to VERY high doses of OxyContin or methadone coming in for surgery. This can often be spine surgery, but chronic pain patients develop other problems too, like cancer or diverticulitis. The worst problem are the ones who are already on Suboxone. There is no way to make these patients happy–we’ve even had to put them in the ICU on ketamine infusions. I took care of a patient not that long ago who was on so much methadone that she developed widened QRS complexes intraop–the herald of torsades. Luckily it responded to magnesium. So the problems of outpatient management and in-hospital management are intertwined, and I didn’t make an effort to separate them in this piece.
I think the Gunderman and Falkenberg pieces are right on the money. Lay journalism may simplify issues for clarity, but the fundamental points aren’t misstated.
Grand Rounds speaker at UCSF yesterday (Alexander Smith MD-geriatrics) decried lack of good drug solutions for non-malignant pain in dying seniors. ” We just do not have the right drugs for pain management in frail seniors.”
He mentioned that Vit D deficiency often has marked proximal muscle weakness and extensive pain. I think he said truncal and lower body pain. I did not know this. “People need a lot of Vit D to get a drug level of 30ng/ml….
like 1500-2000units per day.” 30 seems to be what they are shooting for. ..because parathormone levels flatten out at that level.
I don’t think there’s conflation. I think she’s using her data wisely. It just happens that her data uses bad journalists instead of bad outcomes.
On the other hand your point could be viewed as an attempt to invalidate a hypothesis that’s pretty sensible when you get right down to it
a). by tightly regulating certain bad substances without looking at the long term consequences of our decisions, we’ve created a pain management problem for ourselves that’s extremely serious
b). we’re asking patients to rate their satisfaction levels, which is a not bad idea on paper, less practical in real life.
c). we’re increasingly paying people based on said ratings, and in effect rewarding the wrong things, incenting bad choices.
d). the media is covering the story badly, and typically missing a + b + c
a + b + c = a problem for physicians
no, not at all. highlighting in vs outpatient mgt of pain. difft.
Funny, we have a problem with antibiotic overuse in this country, in addition to narcotic abuse. Why is that? Could it be intrusive government intervention?
What a schizophrenic society we have. On the one hand we have a war on drug use, and stricter requirements from state governments on narcotic use, plus cries against overuse of imaging and testing. On the other hand, we have a satisfaction survey for reimbursement FROM THE GOVERNMENT based on use of prescriptions and testing.
Has anyone from CMS or related institutions looked at the absurdity of this?
Let physicians practice medicine based on good medical evidence and caring for the patient for Pete’s sake and get rid of these idiotic surveys.
Looks to me like she cited an example of how bad reporting gets the pain management story wrong by oversimplifying a complex story – but wait, in your view this makes HER the bad reporter? Interesting theory.
Your conflating inpatient, acute pain, with outpatient chronic/subacute pain. Very different indications.
HCAHPS has implications (whats given at time of discharge), but the use of narcotics post op, or for renal colic or sickle pain very different from outpatient lower back pain or “pain syndromes.”
It is quite easy for a patient to become so used to pain meds that, when they are withdrawn, residual discomfort is subjectively perceived as greater pain than it actually is. That can lead to drug-seeking behavior, especially without follow-up medical counseling after narcotics are withdrawn.
The current pain scales are subjective, and that is a key issue. It would help if there was a reliable metric for actual pain and an accompanying protocol for paid med withdrawal.