The fear of being sued can make you miss discovering the patient's real problem.
As I stepped off the elevator onto the medical floor, a nurse whispered to me, "Watch out, Doctor Porat. Miss Carter's a district attorney."
Helen Carter (not her real name) had arrived at the ED six days before, complaining of progressive pain and fatigue that was causing severe debilitation. Only 34 years old, she had recently returned to Colorado Springs to live with her mother and stepfather. She said she was a district attorney in a small city near Denver.
A workup done a year earlier at the University Hospital in Denver hadn't found the etiology of Helen's symptoms, which included persistent pain, anxiety, and depression. Our ED doctor, concerned that he didn't have an adequate diagnosis, had requested an "observation admission" and turned her over to my hospitalist partner. Now it was my turn to see her.
Two rheumatologists had consulted on Helen, and found no evidence of arthritic disease. An oncologist had seen her, but found no sign of hematologic or oncologic disease. A pain medicine specialist had also signed off, recommending that Helen should be quickly tapered off the OxyContin she'd been taking every six hours, with oxycodone for breakthrough pain. The prescription was from a doctor she'd seen in Denver.
Reading Helen's chart left me troubled. Clearly, she hadn't needed an inpatient workup. In fact she wasn't ill enough to be in the hospital at all. It was probably the fact that she was a prosecutor that had scared everyone into doing unwarranted workups.
Debating the need for opioids When I got to Helen's room, her mother and stepfather were there with her. Helen immediately complained that the OxyContin was no longer relieving her pain, so she wanted the dosage increased. I told her that if it wasn't working, we should reduce it since it could be addicting. Helen quickly changed the subject: "The Demerol is working for me," she said. "Can we just use that instead?"
We talked about other pain management options such as massage, acupuncture, cognitive behavioral therapy, and other pharmacologic treatments. Helen said she had already tried those options, and only the Demerol seemed to work.
Now, I have a part-time job as a palliative care physician at a local hospice, and I've never once needed to use Demerol to control pain. Even with dying patients suffering severe pain, I've always been successful with other options. I tried to explain that to Helen, pointing out that Demerol is being taken off the formulary in many hospitals because of its addictive nature and its dangerous side effects.
"But my other doctor has been prescribing it," she insisted, "and it works for me."
That's when I realized that I was discussing Helen's therapy without first doing my own history and physical. So I backtracked, and asked her about her symptoms. She gave me a 20-minute description of her pain and other symptoms. Her mother interjected frequently with her own opinions about Helen's condition, and how Helen's doctors weren't doing enough to solve her problem. "We're not leaving this hospital until we find out what's wrong," she exclaimed.