Co-management of pain medication: He was a good partner

Dr. Maren Batalden’s story:

Several months ago, I treated a man in his 40s, a veteran of the war in Afghanistan who had developed both a chronic pain syndrome related to recurrent pancreatitis and a problematic relationship to opioids.  Sometimes the healthcare system had been suspicious of his requests for pain medication. People were nervous, thinking that if they listened to him, and gave him an inch, he’d take a mile, and we would get into a dynamic were we’d never be able to satisfy his needs for narcotics.

I have been thinking a lot about this “co-production” framework for patient care, which invites a more full partnership and more transparency in communication, so I decided to risk putting it all on the table.  “Look, we don’t want you to be in pain.  But it can be hard for us to know whether we are managing your pain or your addiction. You’ll have to help me out with this. You have a high tolerance to narcotics and you have real pain. Let’s figure this out together. What matters most to you?”  Having had a lot of experience in various hospitals, he knew he didn’t want to be on a pump that he could use to dose himself as he knew he might fall asleep and wake up with undermedicated pain; he didn’t want to have to keep ringing the bell to ask the nurse for pain medication that was prescribed as needed or “PRN.”  We put together a plan that involved a combination of long acting and short acting medicines on a regular schedule at doses that he knew would work for him.  

He turned out to be capable of being a very good partner.  The regimen we put together kept him comfortable without over-sedating him.  He did not page the overnight teams with requests for more narcotics. In keeping with parameters I set in our initial conversation, he made no demands for additional narcotics at the time of discharge. I suspect most people want to be good partners with their health professional teams, if we help them understand what we need and want from them and what constraints we are working with.

Often, hospital-based doctors wring their hands behind the scenes in caring for patients like this.  Assuming people with addictions to pain medication will ask for more than they need, doctors feel they have to make decisions by themselves and – not surprisingly – they often don’t get it quite right.  This leads to a lot of back and forth tension about a hospital pain regimen which is frustrating for everyone.

Once you get start looking for ways to improve the quality of the partnership between health professionals and patients, you see it everywhere.

Thanks to Dr. Maren Batalden for her story. Read another of her stories about the co-production of medical care and her article in the British Medical Journal.

Planning hospital discharge with the patient: I wanted to watch him another day

Another story from Dr. Maren Batalden:
A few months ago, I treated an elderly gentleman with cancer who was getting chemo, so his immune system was compromised.  He got a urinary infection and ended up in the ICU [intensive care unit] with sepsis, needing specialized attention to support a very low blood pressure.  He got better surprisingly quickly with antibiotics and fluids.  He came to the regular medical unit late the following afternoon where I became the doctor in charge of his care.  I met him the next morning and he told me he felt fine and was ready to go home.  He’d been quite sick, so I wanted to watch him another day, especially because we didn’t yet have the culture results from the bacteria which caused his infection and we didn’t know which antibiotic would be safe for discharge.

I explained my concerns to him. “When will you have the culture results that describe my bacteria?” he asked.  I said tomorrow.  So he asked, “How about if you give me a dose in the hospital of an IV antibiotic that works for 24 hours, give me a prescription that is your best guess about an antibiotic pill that you THINK will treat my infection, let me go home, and call me tomorrow if we need to change the antibiotics. If we need to change it, we’ll change it then.”  I thought it was a great idea!  He said, “Why should I sit in the hospital waiting for lab results?!  If I feel terrible, I’ll come back.”  He did great!  I called him the next morning; the culture results confirmed that his bacteria was sensitive to the antibiotics I had prescribed. He felt well and continued his recovery without complication at home.

It used to be that when it was time to discharge someone, I figured it was largely my decision to make.  Many patients assume the same.  “You’re the expert, doc.  You tell me.”  But I have come to realize that it’s NOT my decision; it’s a shared decision. I understand what the labs and the physical exam are telling me.  But I don’t know really know how the patient feels compared to his or her usual state; I don’t really know what kinds of supports they have or don’t have at home.  Decisions about whether and when to admit a patient to the hospital and whether or when to discharge have to made together. To my surprise this framework has pretty significantly changed my practice.  I find myself keeping people in the hospital for another day or two, when left to my own devices, I might have discharged them earlier, or vice versa.  The best care, I have come to believe, is always “co-produced.”  

Thanks to Dr. Maren Batalden for her story. Read her article in the British Medical Journal on co-production of medical care.

Co-production of diabetes care: Not doing me justice

Dr. Maren Batalden’s story:

In a diabetes group, a woman who was being seen by one my colleagues said to her doctor:  “Why are you so obsessed with this blood sugar number [Hemoglobin A1c]?!  In so many ways I’m so much healthier:  I’m eating better, exercising, losing weight.  I have a job, and I’m not drinking like I was six months ago.  I feel so good, and so empowered and supported by this group.  But my HgbA1C hasn’t moved yet.  I feel like these measures are not actually doing me justice.”  

Hemoglobin A1C is a blood test which measures average blood sugars over a three month period.  Doctors and patients use it to evaluate the degree to which a person’s diabetes has been “in control” in recent months. Ultimately the HbA1c should reflect the positive changes that the woman above is making, but sometimes it takes a while.  We have to be patient with that process.  Sometimes a person with diabetes needs to focus on some more foundational life changes that will eventually be reflected in the blood test, but may take several months to manifest.

Our efforts to measure and improve health outcomes in chronic diseases like diabetes have become “performance measures” for health professionals by which payers evaluate the “quality” of care being provided. In a subtle way, this has confused us about the nature of health professional work.  We’ve come to see numbers like the Hemoglobin A1c as if they are something that health professionals produce.  In fact, of course, numbers like these are co-produced by patients and health professionals working together.  In fact, blood sugar is largely controlled by people with diabetes – not their nurses and doctors and nutritionists. Blood sugar is determined by the everyday decisions of a person with diabetes -- what they eat and how they exercise.  The doctor is a bit player.  The doctor prescribes medication, helps to decide when it’s time to start insulin, or go up on a dose, and does a little teaching.  But most of the learning happens outside of the clinic, in the life of the person with diabetes in relationship with their families, by trial and error.

If they care about health outcomes for their patients, health professionals need to reframe their work.  Health professionals need to ask themselves not “How can I be successful in lowering my patient’s hemoglobin A1C” but rather “How can I be most useful, most helpful, most supportive to the person with diabetes who is already working in whatever way he or she can to be healthy?”

Thanks to Dr. Maren Batalden for her story.  Read Dr. Batalden's article on co-production, mentioned by the Institute for Healthcare Improvement today.