Is Your Doctor a Good Listener?

By Carol Levy, PNN Columnist

Many of us have had doctors that we loved. They not only listened, but actually heard us. They gave us their time, attention, and cared -- not only about us, but doing the best they could for us.

They truly follow the intent of the Hippocratic Oath: primum non nocere, or “first, do no harm.”

Then there are the doctors who don't care, and don't even seem to care that we know they don't care. They are quick with us. They don't listen or hear. They have their theories. The facts that we give them about how the pain feels, where it is, etc. make no difference.

I went to a new neurologist. She was very nice, but ignored my pain from trigeminal neuralgia and my long history of surgeries and medications. She decided my issue was “anxiety,” which I never said I had.

She repeatedly asked, “Is your problem anxiety?” I shook my head “no” to answer the question and to show my frustration with her for asking it.

Nevertheless, at the end of the appointment, she asked, “Do you want me to prescribe something for your anxiety?”

Primum non nocere? No. She didn't do harm, but she sure as heck didn't help.

Dr. Norton, my neuro-ophthalmologist, didn't seem to care either, at first. He gave me short shrift by rudely saying, “Stop being so schizophrenic in how you're telling me about your pain.”

Because I was so afraid and worried, I gave him the details in scattershot form, instead of chronological and neatly. After two appointments, he finally understood my pain was real. Suddenly, he cared! The change in him was almost palpable. His words were supportive. He worked to give me hope.

When I first went to the hospital for a pain flare, I was overwhelmed by it. It was spontaneous and constant.  My only hope was that Dr. Norton could stop it.

“Is this ever going to go away?” I asked, my voice tremulous with pain and worry.

“Let me worry about that,” he said. “That's my job.”

His words were a verbal hug. Primum non nocere. He cared about me and would make sure I suffered no further harm. I felt like I was being helped.

Dr. Norton was the face of the caring doctor, the one who follows the oath, who puts his patient first. And that makes all the difference.

As for the doctor who wanted me to say I had anxiety, I canceled my next appointment with her. She was the second neurologist I had seen.  The first was also entrenched in his theories and didn't care about me or the facts.

I was concerned about consulting with a third doctor, fearful I would be accused of "doctor shopping.” I asked my nurse practitioner, “Do you think seeing another neurologist will be an issue?" She shook her head no.

"You have valid reasons for not wanting to stay with them. You need to find someone who will listen to you and deal with the pain," she told me.

And she was right.  I needed another doctor, a doctor like Dr. Norton, (who moved out of state). I need a doctor who works with me, not against me.  Who truly practices primum non nocere.

And that should be the goal for all of us.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here. 

Is Your Doctor a Master or Servant?

By Carol Levy, PNN Columnist

Recently, I heard a doctor on TV say something that seems to be common sense: a doctor must be the servant of his patient and not the master. The Hippocratic Oath says as much, that a doctor should be “a servant of people.”

Though the wording is old-fashioned, the point is well taken. I have experienced doctors trying to act as masters, not servants.

I’ll tell a doctor all of my symptoms, only to have her concentrate on one or two. Then she makes her pronouncement: “This is my diagnosis. This is the treatment I am prescribing.”

If I ask, “What about my other symptoms?” I’ll be dismissed.

“Try the treatment and if it’s not better, come back in six weeks.”

There’s no room for discussion. That’s the way a master would talk to a servant.

Some patients think they are the masters. They’ll say, “No you're wrong. I need and will only accept this medication or treatment.”

It seems many chronic pain patients, more so than others, are of two beliefs: we want the doctor to help us, to diagnose our condition and to end our pain to the best of their ability. That makes them somewhat our master.

But many of us also think we should be the master of the doctor when it comes to what he will give us to end our pain: “I want this drug, this dosage, and this number of pills.”'

I almost never hear someone say, “The doctor refuses to give me the test I want” or “She won't refer me to the specialist I want to see.” Pain patients tend to want those decisions left to the doctor.

In recent years, a major loss for doctors is their ability to be their own masters when it comes to prescribing pain medication, specifically opioids.

The best example I have of this is my own experience from decades ago. My ophthalmologist understood that my trigeminal neuralgia pain was unmanageable. He had nothing to offer that would completely eliminate my facial pain, but he wanted to at least mitigate it. He gave me with a prescription for an 8-ounce bottle of Tincture of Opium.

The first pharmacy I went to couldn't fill it because they didn't carry opium. But the pharmacist didn't look askance at me or the prescription. The second pharmacist I saw also gave me no debate, no questions, and no dirty or suspicious looks. Within 10 minutes, I left the pharmacy with a bottle of opium in my purse.

Of course, we all know that could never happen now.  I don't even know if a doctor can write a prescription for opium anymore. It is hard to be a master of the patient when your hands are tied, and you fear losing your livelihood, freedom or both.

When it comes to opioids, we cannot be masters of our doctor, no matter how much we may want to be. We can't insist that we need an opioid, when by law or fear, a doctor won’t comply.

What we need to accept is that neither doctor or patient should be master or servant of the other. Some doctors may not accept this and some patients may not want it, but the best relationship we can have with our medical providers is a partnership.

Doctors need to do a better job explaining why they prescribe something. And, if it is an opioid, why the amount and dosage is less than what we may want.  And we, as patients, need to understand that we can’t insist on what a doctor is unwilling to provide.

For partnerships to work, both sides need to come to a mutual understanding of what can and can't be done. Sometimes that means being disappointed. But disappointment that is based on mutual acceptance and respect can help mitigate the negative, allowing for a much better relationship.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

‘First, Do No Harm’ Doesn’t Mean ‘No Rx Opioids’

By Dr. Lynn Webster, PNN Columnist

Many physicians say their ethical duty is to "First, do no harm." This principle is often mentioned in the context of prescribing opioids. Some people even believe that prescribing opioids to treat people in pain violates the Hippocratic Oath, because, they say, a doctor’s first obligation is not to do anything that could make things worse for a patient.

However, that is a flawed oversimplification of the "First, do no harm" directive.

As N.S. Gill writes in Thoughtco, many people believe that “First, do no harm” is a quotation from the Hippocratic Oath. They are mistaken. More importantly, the creed does not say that doctors must never provide a clinical intervention that might trigger some degree of harm. If physicians had to live by such a code of ethics, they would be unable to offer almost any medical treatment, since they all carry some risk of harm.

As the Harvard Health Blog points out, ensuring that you always "do no harm" would mean no one would ever have lifesaving surgery. Doctors wouldn’t be able to order CT scans, MRIs, mammograms, biopsies or other tests that can turn up false positives; draw blood for fear of bruising or provide vaccines that may cause side effects. Even aspirin is a potentially dangerous treatment for some people. To avoid risk altogether, doctors would have to limit themselves to Band-aids and soothing words.

The Double Effect Philosophy 

“First, do no harm” isn’t about standing by helplessly while someone suffers needlessly. It is an ideal that is better explained by the principles embedded in the philosophy of the Double Effect. 

According to the Stanford Encyclopedia of Philosophy, the Double Effect doctrine means that an action is acceptable if harm occurs in the course of trying to make a positive difference. An intent to do good or help must be the underlying motive. However, the intention to do good by itself is insufficient. The possible good from the action must sufficiently outweigh the potential for harm. 

Often, the Double Effect guideline is used to explain why physicians prescribe opioids even knowing they can pose risk to patients. Doctors prescribe opioids -- sometimes at very high doses -- with the intent to relieve pain (which is “to do good”), because there are few other options available or affordable, and the risk of harm is manageable for most patients. 

This trade-off in decision-making is true for all medications and interventions, not just for opioids. Opioids are not evil agents, despite their checkered reputation among some laypeople, physicians and lawmakers. 

Not Using Opioids Can Causer Harm

Most patients nearing the end of their lives, their families and clinicians who treat terminally ill patients place a priority on a peaceful, pain-free death. Opioids are frequently necessary to fulfill that desire, despite their potential to hasten death. 

Providing opioids to ease end-of-life suffering passes the Double Effect test, but it is still controversial. Furthermore, end-of-life-care is only one area for which some experts question the use of opioids. Some people believe that opioids should never be prescribed because of the harm they may cause, regardless of their potential benefits to patients. 

But not using opioids can also cause harm. In an American Journal of Law and Medicine scholarly essay this month, Kate Nicholson and Deborah Hillman argue that there is a special duty to a subgroup of patients who are already receiving opioids: doctors must not harm them with forced tapering.  

There is also harm, Nicholson and Hillman say, in not treating pain in patients. Based on a Human Rights Watch study, they believe that doctors who deny patients the care they need "in an effort to protect their licenses or stay under the radar of law enforcement" may be violating their patients' human rights. 

Nicholson and Hillman point out that "First, do not harm" has a different meaning for policymakers than for physicians. Policymakers have a responsibility to ensure that society isn't harmed by opioids. However, the authors contend that policymakers have an even greater duty to "do no harm" by respecting the doctor/patient relationship when considering the societal impact of opioid prescribing.  

The patient's need for pain medication, they believe, should be prioritized over society's need for protection against the harm that misused or diverted opioids can cause. 

Our Ethical Responsibility to Patients 

As physicians, we are trained to heal. We become healthcare professionals because we want to provide compassionate care to the sick, the frail, and the dying. We swear an oath to use our best judgment to evaluate the risks and potential benefits in all interventions. Intending to do good, even knowing that adverse effects can occur with every intervention, is our ethical responsibility. 

A mischaracterization of the phrase “First, do no harm” must not prevent providers from caring for people, or prevent policymakers from allowing physicians to treat their patients. That treatment must include providing patients with medication that can adequately provide pain relief with acceptable risk.  

The physician's ethos must always be based on what is best for the patient when all factors are considered -- not on arbitrary guidelines that impose a one-size-fits-all philosophy.  

This column has been revised and updated from a version that appeared in the Salt Lake Tribune on December 10, 2017.

Lynn R. Webster, MD, is a vice president of scientific affairs for PRA Health Sciences and consults with the pharmaceutical industry. He is author of the award-winning book, “The Painful Truth,” and co-producer of the documentary, “It Hurts Until You Die.” You can find Lynn on Twitter: @LynnRWebsterMD