Clinician Tip o' the Month - December 2023

I’ve found for most clinicians there are a few challenging patient scenarios. By that, I mean situations which make us uncomfortable as they can lead to confrontation and dissatisfaction on behalf of the patient. This, in turn, can leave us not feeling particularly “warm and fuzzy” as clinicians. Over the years, questions from clinicians and my own struggles often center around prescribing opioids and antibiotics. Let’s start with the opioid dilemma and address the antibiotic issue during a subsequent tip.

It’s not rare for patients to ask for pain medicine. However, it is rare that this request does not raise a red flag for us. The tragic results of the “opioid epidemic” demand that we carefully consider these requests and are conservative with our prescribing habits. This can be at odds with our desire to reduce pain and suffering, leaving us somewhat torn about what is the best choice in those settings when we do feel that the patient is truly uncomfortable as the result of a more obvious condition, such as physical trauma.

Alternatively, and probably more complex and more common, are the situations where we don’t believe that narcotic pain relievers are appropriate; yet, the patient, significant other, or family member is assuring us of the need for this solution. How do we respond when being pressured in this way, knowing clearly that, unless opioids are prescribed, the patient will not be happy, nor pleasant, and could even become abusive, generally verbally?

I would argue that the stakes are higher now with patient satisfaction being such a driver of “quality.” It’s most likely that if the clinician and patient don’t see eye-to-eye on this outcome, then the patient may choose to make this known through responding to surveys and/or social media. I’ve also seen clinicians struggle with this when they assume care for another clinician’s panel, after the clinician, who had been chronically prescribing opioids for some patients, has left the practice.  The new clinician is now in the position of having to consider rejecting or fulfilling requests for continued pain medicine which had been provided by the previous clinician, often within the same practice!

So, how can we navigate these scenarios with as little fallout and stress as possible? I don’t believe that there’s only one correct response, but there are some tenets that improve the likelihood of an acceptable outcome for the clinician and patient.

• Strive to remain non-judgmental and treat all patients with respect. This will be conveyed to the patient and allows us to provide alternative solutions in situations where we are not going to provide an opioid prescription.
• We can still provide care and empathetic counsel/advice. For example, a referral to pain management or other clinicians expert in managing patients with addictions is a way in which patients may be provided with a viable, safe option. Whether or not we provide a temporary, limited prescription is up to each individual clinician (or possibly a clinic protocol) once they have assessed the clinical situation.
• Turning down the patient’s request can be delivered as a harsh refusal or as a less confrontational response. For example, a response such as “No, absolutely not. Pain medication is not appropriate and is highly addictive!” sends a very judgmental, inflexible response and invalidates the patient's subjective symptoms and concerns. Alternatively, by explaining that I am not comfortable prescribing this medication, I send a very different message. No one can argue whether or not I am “comfortable”—this is my own emotion. So, for example, saying something like, “I’m not comfortable with prescribing or refilling this, sorry,”.  Not infrequently, my patients have responded in ways like: “No, that’s ok,” or “Ok, that’s alright, I understand,” seemingly knowing and not wanting to put me in a compromising position. Then, together, if they’re amenable, we explore alternative approaches, or they choose to pursue their original request elsewhere.

Trust your own comfort level and intuition and approach those situations from a caring perspective; this provides the opportunity for the optimal results for clinicians and patients alike.