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12 Articles in this Series
Central Post-Stroke Pain – How Central Is It?
False-Positive Urine Drug Monitoring Results and Aspirin
Medical Marijuana & Pain
More Potential Uses for Low-Dose IV Naloxone
On the Horizon: A Brief Look at Potential Analgesics of the Future
Preview of PAINWeek 2018 - Know Before You Go
Stem Cells & Beyond
Underlying Causes of Small Fiber Neuropathies
Understanding Sexual Pain – A Physical Therapist’s Perspective
Video: Drs. Gudin & Fudin on PAINWeek 2018 and PPM's Future
Where Does the Patient-Centered Pain Practitioner Stand Today?
Why Interventional Tactics Should be Used for Chronic Pain Patients Now, Not Later

Where Does the Patient-Centered Pain Practitioner Stand Today?

Keynote presentation offers a deep dive into finding balance in quality care. A PAINWeek 2018 keynote with Jennifer Bolen, JD, Michael R. Clark, MD, and Kevin L. Zacharoff, MD.


The 2018 PAINWeek keynote touched on the tumultuous, policy-driven environment that has taken pain practitioners from compassionately applying the fifth vital sign to dreading discussions over morphine milligram equivalents and their limitations. Fitting right in with the clever session titles and poster-boards that make this Las Vegas-style pain care and CME conference unique, the presentation was titled “Mistaken Identities: Addict? Clinician? Drug Dealer? Manufacturer?” and delivered by Jennifer Bolen, JD, Michael R. Clark, MD, and Kevin L. Zacharoff, MD, of SUNY.

In this environment, “we continue to chase numbers, and we are getting lost trying to find  our patients—they are the ones suffering the consequences,” opened Dr. Clark. But more optimistically, he pointed out, at the end of the day, “patients are sitting in our exam rooms and our goal is provide them with the best treatment.” By sharing approaches at conferences like PAINWeek, he told the full assembly audience, we can do right by these patients.

The Path Less Chosen

Bolen addressed the clinical audience from a legal perspective, including the dividing lines at play in opioid use, misuse, and abuse, and how to avoid ending up on the wrong side of the equation. Opening communication barriers with patients is one step in the right direction, she advised.

“I don’t think you’re drug dealers. I think your patients have unique healthcare challenges,” she said. As a reformed prosecutor, Bolen noted that she has learned a lot from pain practitioners—their resilience, their commitment, their hard work, and their genuine caring nature. To continue moving through the current landscape, which she described as a very deep channel, pain practitioners simply need improved tools and to know they are not alone, she stated.

Bolen pointed, for example, to the mistaken identify of Dr. JZ Gazzko (author of Pain on Trial) author and his nurse practitioner, who were ultimately cleared of being “drug dealers.” Many other physicians have been charged, and had those charges dropped, and continued to work while others have chosen to walk away.

There are also examples rising up all over the country where patients are changing the conversation, including changing practitioners’ minds about what works or doesn’t work for their individual conditions. Part of this shift -  that is from resistance to resilience -involves keeping the patient at the center of clinical goals, noted Bolen. New best practice, therefore, should include maintaining trust in the provider-patient relationship and explaining in more detail to the patient why certain treatment plans are selected, she explained.

“Tread water and create safety nets for your patients,” Bolen concluded. “Keep them at the center.” Referring again to the touch decisions pain practitioners are facing over prescribing for pain, she said, “You have the ability to go and write the next chapter when you enter your office on Monday.”

The Solidified Identity

Dr. Clark and Dr. Zacharoff continued the conversation by focusing on how providers can shape their identity when working with patients, learning about their field, and practicing pain medicine. “The more confident you are about what you’re doing, the less likely someone else is to interpret it for you,” urged Dr. Clark.

Dr. Zacharoff used a recent JAMA editorial written by a resident about the complexity of being compassionate while also trying follow supervisors’ orders and regulatory guidelines. He noted how such articles and communication from peers can be motivators in pain practice today. He went on to share how practitioners need to accept that both conflict and collaboration exist in pain practice, citing a PAIN 2014 piece. By identifying barriers in the way, providers can break through. “Effective communication is the single most important tool in your toolbox,” he said. This involves communication with patients and with other healthcare professionals. For instance, understanding that other providers are facing similar challenges—whether it’s resources and costs or complex patient cases—simply hearing from one another can make a difference.

In the same regard, patients may not digest everything you are saying the first time you say it, noted Dr. Zacharoff, especially if you are one in a long line of providers they are seeing. So avoid jargon, he advised, and ensure that they understand their diagnosis and their treatment plan. Ask them how they feel. Look out for preconceptions and expectations, but also observe nonverbal cues in your patients, he advised.

Another tip – Dr. Zacharoff recommended NOT reading a patient file before entering the exam room. Viewing a chief complaint, a diagnosis, and a history can easily form a plan in a provider’s head before he/she fully understands the individual’s situation and may lead to mislabeling of that patient. When providers bring in personal and professional beliefs, and patients bring in personal beliefs as well as a prior context of healthcare and pain experiences, the paradigm may not be ideal. Through communication, perhaps the provider-patient dialogue and relationship may shift in a positive way, he advised.

Concluded Dr. Zacharoff, “We must shape the dialogue at the regulatory level, remember the differences between chronic pain patients and substance abusers, recognize our own limitations, and understand the interface between care and risk.”

Overall, the keynoters used a number of metaphors—from mirrors, storms, and hamster mills to villains and heroes—to describe what today’s pain practitioners are facing. Their tone and approach seemed to lift the audience and motivate them to carry on and fight for their chosen careers—and for their patients.



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