We welcome this guest blog by Dr. Allen G. Gruber, an esteemed Pain Management physician double board-certified in Pain Management and Anesthesiology. He was the first NIH Pain Research Fellow in Neurology and Anesthesia at the University of California, San Francisco. Besides his B.S. in biology and M.D. degrees, he also holds an M.H.A. in hospital management and health systems planning plus an M.S. in Health and Medical Sciences from U.C. Berkeley. Recently a California primary care colleague attempted to send him a difficult pain patient requiring medication management – his response letter was so juicy, and refreshingly candid, I couldn’t help but ask him to share it here.
Dr. Gruber is about as far from ill-informed as a pain clinician can be. So that you know where this is headed, here is a snippet of Dr. Gruber’s thoughts:
That most ancient Hippocratic charge to provide relief from suffering is, in my humble opinion, epitomized in Pain Management practice and principles. — and— Long ago, my Master’s training in health care administration taught that disparity between authority and responsibility is the first symptom of a sick organization.
PREFACE TO PAINDR.COM BLOGPOST
I have been asked by Pain Management colleagues to share the following e-mail in a larger forum to expose what I believe to be a significant downhill spiral in clinicians’ ability to properly care for pain patients. The e-mail below attempts to describe the merest tip of an iceberg of linked problems that have beset the Pain Management clinical community over the past several years. It also tries to express the increasing emotional anguish I feel while working far to too many hours under far too much stress trying the feed a parasitic bureaucracy (not mostly the government, but more and more the vast corporate bureaucracy) while striving to help suffering people. Recent agenda-driven policy initiatives in form of “guidelines” imminently threaten to cast pain treatment norms backwards by 30 years or more and resurrect and re-brand, in the process, long-debunked myths about pain and pain treatment that a reasonable and rational person might have thought were laid to rest long ago by scientific advances in the neurophysiology and neuropharmacology of the human pain response.
The e-mail was prompted by an request from a local community clinic director and Family Practitioner to accelerate the acceptance of a patient into my practice bypassing a 3-4 month backlog of new patients awaiting care. His patient was not untypical of the “train wreck” patients my practice and reputation seem to attract. Over years, I became a regional destination for patients suffering from complex chronic pain that resulted from multiple traumas and/or ≥ 1 failed surgeries, multiple mutually-reinforcing pain generators, plus multiple and/or severe concurrent systemic disease(s). My use of a “railroading” metaphor is not a prejudice or a judgment upon these very unfortunate people. It is merely descriptive. This particular patient was briefly described to be obese, totally disabled, suffering from multiple causes and sources of pain, on high-dose opiates for many years, currently 200-mcg/hr fentanyl per 48-hrs plus breakthrough pain oxycodone. He had a frequent rate of emergency room and ICU admissions for seizures when he overused his drugs then detoxed when he ran out early, being predisposed to seizures by cerebrovascular disease which, in turn, underlay cognitive impairment which predisposed to poor Rx compliance, detox and more seizures. In short, he was another example of patients who suffer from multiple and mutually reinforcing vicious neurophysiologic cycles that so typify chronic complex intractable chronic pain patients. So it’s obvious that this patient is not ideal clinical material for fitting into the high-efficiency industrial model of medical care that has been thrust upon us physicians over the last 15-20 years.
A key sentiment in my colleague’s e-mail was, “Appropriately, no one at our clinic feels comfortable prescribing these doses and we have referred him to pain management.” Comfortable? Between the lines this reads as “paranoid” about attracting surveillance and sanctions. And, to be fair, how would a Family Physician seeing 30-40 patients per day find the time to tease apart and cope with the bolus of tangled problems embodied in a patient like this?
My colleague has not yet responded to this e-mail in the 2 weeks since I sent it. Perhaps I scared him off? If you want to find out why, please read on…
On 10/13/14 10:55 PM, Allen Gruber, MD <firstname.lastname@example.org> wrote:
Dear E***k —
I very much regret to have to offer you to a cautionary (also cathartic) tale and overdue call to arms. Here’s the reality of the current situation.
I am months behind on screening and scheduling new patients. The usual traditional reasons apply as ever they have: chronically miserable, depressed, multi-factorial, often multi-systemic disease, i.e., train-wreck patients much akin to Mr. H. all take oodles of time to diagnose and treat, especially during the first 3-6 months of measures to stabilize and optimize their regimen. Even when they reach meta-stability, PCP’s most often do not want to take them back for maintenance care, so they pile up in my practice, never to leave, and this always take lots of time (*Tar-Baby Syndrome).
Growing like an aggressive neoplasm has been a rising wave of egregious and obstructive insurance and regulatory interference in the rational practice of my specialty, and in most of the rest of medical practice. This has been inevitable as Big Insurance learned to fine-tune the process of squeezing the most, on-paper, evidence of efficiency for maximum profit retention; and as Gummint-run programs and non-profits were beaten and prodded into C.Y.A. documentation of efficiency and efficacy for self-protection against politically-inspired accusations of inefficiency or “fraud-waste-abuse”. And it remains a sad fact that neither my train-wreck patients nor ethical Pain Management standards of practice come close to fitting in with the dominant and increasingly industrialized model of care being rammed down our throats.
For the past several, months I have been devoting 15-20 hours per work-week exclusively to Rx denials, TAR’s (which often get denied), endless calls & emails with stonewalling Rx-review contractors, insurance adjusters, with distraught patients and — now just in the past week— nearly all of my MediCal patients, who are > 70% of my practice. Of course, this is non-billable time for me and, worse, my income has bottomed because I no longer have the “leisure time” late at night to catch up on chart notes (which are prerequisite to getting paid, as you well know). With ever-shortening intervals permitted between service and billing (now cut to 45-days), more and more of the care I provide is for free. Damn! I’m going to have sooo much good karma from all this selfless dedication that, at death, I’m going to zip straight through all the Bardo states, Purgatory and Limbo directly to reincarnation as a cow. 😉
It’s totally crazy. And… I am totally unsurprised. I have (with my pre-medical career in health care system planning) been presciently watching this deconstruction of Medicine coming on for over 20+ years, and dreading every minute awaiting its arrival, now crashing down around our ears. The only amusement in it has been watching how clueless doctors have been, scurrying around in futile efforts of personal rice-bowl preservation, inevitably failing, as ≈90% of physician standing, authority and —now— even ability to function professionally outside of a large corporation-look-alike business, has been wrenched away one rivet at a time until the vehicle of American medical care is rolling to a wheezing halt, stripped of most of its substance in the pursuit of infinitely greater corporate profit. Check the latest WHO stats on developed countries’ national health care system rankings to see where American medicine is coming to rest.
In civilized socialized=evil countries, patients like Mr. H are put into inpatient programs with multidisciplinary teams that address intertwined systemic disorders per bio-psycho-social principles, which leads in many cases to improvement in life-quality and function. then rehabilitation to a degree made rare-to-impossible in our system. In the frontier backwater of 1882 that is now the once great and admirable US of A medical system, even with the spit-in-the-ocean that is Obamacare, we are rapidly regressing back to the ancient tradition of punishing those who suffer through increasing denial of care. More, cost-reduction measures and rationing are being dressed up as a “solution” to a manufactured national opioid prescribing “crisis” that has quickly been exploited by money-men for the bling it offers in lowering 3rd-party cost for drugs and more profits all around, including the drug-prohibition industry.
The solution to Mr. H’s misery is astonishingly simple under this new regime. The new policies make “pain management” child’s play that any clinic can implement. There’s no longer a need for making referrals to fussy pain specialists who “overprescribe” opiates, each and every one of them (ask a California trial attorney; they’ll confirm it), and are to blame for the massive epidemic of opiate-related deaths that now about equals the number of NSAID related deaths each year (google it; per the CDC it’s true). The PCP (a/k/a prescription control partner designate) simply needs to follow Chapter 1, verse MPRP4059, in the Holy Book of Practice Guidelines, and prescribe 120-mg morphine or equivalent per day for all chronic pain cases. In case of complaint, the patient need simply be handed a form letter with a verbatim quotation from MediCal/PHP *TAR denials that, “…doses above 120-mg (of morphine or equivalent) do not provide more effective long-term analgesia…” (than do higher doses). Never ever. Can’t possibly happen. Don’t even bother to ask for more. No, never mind that decades of basic and clinical pain research have found otherwise. Sorry Mr. H, Mr. Woe, Ms. Misery, but we have given you all you actually need and you’ll have to make do with what you get, or words to that effect. Fagin-like leer and grin is optional, but may garner favor with the Powers who are undisclosed.
If community clinics have collectively acquiesced to this party-line, then that’s how it’s going to be. Too bad it’s going to get worse next month and next year because physicians have most of them been so astonishingly acquiescent and so very afraid that their extremely hard-won permission to help the afflicted may be taken away if they deviate from doctrine. OR….. The community clinics of Northern California might think about saying “no más!”, then apply sweet reason and scientific acumen to reacquaint MediCal and PHP with 40 years of scientific progress in the control of pain, and demand that they cease what is clearly arbitrary Rx rationing that contravenes the spirit and letter of the California Intractable Pain Treatment Act of 1990. More, that they should cease and desist from all micromanagement of medical care across the board, i.e., cease de facto practice of medicine by proxy under the false flag of “resource allocation”, and give up their usurpation of the centuries-long honored role of physicians as pre-eminent in the care and welfare of patients.
There may be other pain specialty providers, in fact there definitely are, who will likely be much faster at accommodating Mr. H’s needs… Well, they may, insofar as numerous injection procedures and very brief office visits with zero-tolerance Rx compliance will help, until he is once again discharged back to primary care. Perhaps something is better than the nothing I can offer in the near-term future.
Allen G. Gruber, MD, MS, MHA, CAQPM
4704 Hoen Avenue
Santa Rosa, CA 95405
What a superlative analysis, Dr. Gruber! Paindr.com thanks you for sharing your views and perspective with our blog followers. And, for the world to see, rather than including a short biosketch, we are hyperlinking Dr. Gruber’s undeniably impressive curriculum vitae in its entirety.
Let’s get some guileless, frank, candid, open, honest, comments from our readers!
- Dictionary.com – A situation, problem, or the like, that is almost impossible to solve or to break away from. Also, tarbaby.
Origin Expand after the tar doll used to trap Brer Rabbit in an Uncle Remus story (1881) of Joel Chandler Harris.
- Urban Dictionary – A dummy made of tar, which cannot be struck without getting oneself hopelessly stuck to it–from the story “Mr. Rabbit and Mr. Fox” by Joe Harris, as told by his fictional narrator, Uncle Remus. Tar baby has become short hand for a situation better avoided than confronted.
Example; The issue of immigration has become a tar baby for president Gearge W. Bush.
- Wikipedia – Br’er Rabbit and the Tar-Baby, drawing by E.W. Kemble from The Tar-Baby, by Joel Chandler Harris, 1904. The Tar-Baby is a fictional character in the second of the Uncle Remus stories published in 1881; it is a doll made of tar and turpentine used to entrap Br’er Rabbit. The more that Br’er Rabbit fights the Tar-Baby, the more entangled he becomes. In modern usage, “tar baby” refers to any “sticky situation” that is only aggravated by additional contact.