Medicine from the heart . . . Sara Shields

On Thursdays, the Daily Voice showcases selected Thursday Morning Memos, reflective essays about clinical experiences written by faculty, alumni, residents and students of the Department of Family Medicine & Community Health and, occasionally, contributors from other departments. Thursday Morning Memos is UMass Medical School’s homegrown version of narrative medicine, in which the authors process their experiences through writing. To learn more, visit: http://www.umassmed.edu/news/articles/2011/personal_stories.aspx.

 

Sara Shields, MD, a faculty member from Family Health Center of Worcester, writes about how being a family doctor is about "taking care of families." Her story also touches on issues that we all face on a daily basis—a complicated new patient, pain medications, honest frustrations—and yet Sara manages to capture all of this and her own emotions in a story that ends with a clinical success. The provider took her time, did not make assumptions and allowed for creativity in her care to lead to new beginnings.—Hugh Silk, MD

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Vicodin 2 tabs q6hr prn #180

I met her medication list before I met her.

She was one of those patients we all have at busy inner city community health centers where provider turnover and the overwhelming volume of people seeking medical attention can lead to scattered, discontinuous care. She was the long-term patient of a provider who had left the practice a few years back, who had been seen only a couple of times by the interim provider, and now was left floating again without an assigned primary care person. Her daughter and first grandson ended up becoming my patients through our prenatal groups, so I agreed to take her on my panel because after all, that is what being a family physician is supposed to be about, taking care of families.

Soon after I agreed to do this, before this woman could get an appointment to see me, the first request for a narcotic refill arrived. I was a bit surprised by the quantity of short-term opiates requested, and quickly reviewed the e-prescribing list to confirm that this had been the standard amount each month for at least the few years that the e-prescribing had been in place. I made a mental note to review her chart for prior evaluation of her “low back pain” and discussion around pain management options.

The next several visits became a slow, step-by-step process of re-evaluation, 15 minutes at a time. First I had to ask for the three further volumes of her chart that were in storage so that I could begin to figure out what had actually happened a decade or so ago when the narcotic prescribing started. Then I had to comb through each volume to find pertinent notes—from her long term PCP, who had indeed cared for this woman’s whole family and who had clearly documented the all-too-common story of family violence, abuse and suffering that is such a part of our health center’s patients’ lives. The medical evaluation for the original back injury was buried in one of these prior volumes, but I could not find a narcotic contract or any paperwork using the “chronic pain” packet that we had developed a few years ago to more fully assess such patients. I began to feel that dread of taking her on that we all can get when looking at monthly opiate prescriptions, wondering if I would get drawn into the potential for drug seeking behavior.

I decided to set the tone from the first visit, after greeting her and congratulating her on her newly born grandson and the life cycle change that this meant for her. She was cheerful and thrilled about him, and as we began talking about her pain and her medications, as I introduced the idea that this amount of long-term short-acting opiates was probably not the best treatment for her, she was more open than I expected, especially when I kept the focus on “figuring out a way to help you be the healthy grandmother you want to be and your grandson needs you to be.” We agreed that while I was gathering further data, she would continue to get the same amount of opiates that she had always gotten, but with a contract, a plan to use all of the materials in the chronic pain packet, regular toxicology screens, and the expectation that at the very least I would want to move her to a longer-acting medication if indicated.

As the months progressed, little parts of the process began to feel more uncomfortable for me. She didn’t complete the pain packet right away. She missed a couple of appointments. The tox screens were positive every time for cannabinoids, although she adamantly denied using marijuana herself. The tox screens were only sometimes positive for the opiate metabolites that should be present if she were really using the medications several times a day as she described, and as the prescription prescribed. I worried about misuse of these medications every time I signed the monthly dose, and I slowly moved back how many tablets she got each time. This wasn’t without my own guilt, however—her back pain persisted, with the usual equivocal physical examination findings and known abnormalities on her old imaging studies (after all, she had at one point had surgery); the alternatives I offered didn’t seem to help as much as the opiates. Still, at some visits she looked bright, carrying her infant grandson with a beaming expression, willing to keep working on a slow taper of the opiates and to try using non-narcotic medications instead. I reminded myself to think about her four-volume-thick chart, her chaotic family life—this all needed to be a long-term process.

At one visit, as we discussed alternative therapies for back pain, she mentioned that a chiropractor had helped her in the past. I made the referral, grateful that at least some visits are still covered by Mass Health in these days of cost cutting. I finally also remembered the availability of acupuncture in our office, thanks to two terrific colleagues who have been trained and have time in their schedules. It took me a few visits to remember how to refer her for this and to talk over the process, fill in the referral forms, and then wait with her for several months for an appointment. During this time, her life realities stalled further taper as she dealt with teenagers in distress, housing instability, bedbug infestations and other stressful events that exacerbated her overall coping with chronic pain. I nonetheless continued to taper as the tox screens and pill counts still did not quite match up.

Finally her acupuncture appointment came. A week or so after her first treatment, I saw her on my schedule, and tried to pre-plan for getting the latest not-quite-right urine screen results into her chart and practicing what I was going to say about further opiate prescriptions. A medical student was working with me this day, and I gave her the background story, albeit with only the most recent of the four-volume chart to show her.

We walked into the exam room together. My patient was grinning ear to ear, bursting to tell me how she was doing. “The acupuncture was great!” she exclaimed. “The doctor says she usually does only four needles to start, but I was able to do nine!” I wasn’t sure quite what this meant and had not had a chance to talk over the patient’s care with my colleague yet, but I grinned in return, happy for this enthusiasm. As I prepared to talk about the opiates, my patient continued talking—“And I haven’t needed my vicodin since then . . .”

At that point I have to admit I almost stopped listening as she kept on about how she felt and the meditation practices she was doing to get her through the more painful times. I was too astonished that this woman, who must have had 10 years of monthly opiate prescriptions, was suddenly down to none for nearly two weeks, and beaming at me right now (nary a symptom or sign of withdrawal, either). I pulled myself back into her excitement when she jumped up and showed me how far she could bend over now towards her toes (I actually could not remember when I had last asked her to do that or how far she had gone before, but more importantly, she felt better about the progress in her flexibility).

I tried not to squash her enthusiasm, even gave her a big hug to share her joy at this life change. Still, I also said after the congratulations, “You know, I’m SO glad you’re feeling this great. But this has been a long time. Try not to get too down on yourself if you have a few bad days when you want the medications again. That’s part of recovery, ups and downs.” Maybe I’m a bit jaded after too many years of watching relapses or lost opportunities; thinking of that four-volume chart and the story it told of a life of struggle, I also wanted her to anticipate that recurrent bedbugs or bad landlords or stressful kid situations may be tough to get through and that I wanted her to be able to come tell me that without embarrassment.

This day, though, we shared a few more moments of optimism together with the medical student, and I left the room keeping my fingers crossed mentally that maybe, at long last, this woman’s life would be less painful for her. Maybe, with this new grandson, she has been reborn, into a new volume of her life chart that she can write with a different kind of story.