Heal the Whole Hurt

The Hospitalist. 2007 July;2007(07):

July 1, 2007 | The Hospitalist

The emergency physician—also under caseload pressure— decides the easiest disposition is to admit the patient and dump the problem on the hospitalist. “They’re out of their pain medications at home, and when you call the attending you are told that they are drug seekers,” Dr. Weston relates. “These patients take a lot of energy. They can be manipulative. We can’t do right for them. It’s not satisfying. We don’t want to round on them. The way we hospitalists manage these patients sometimes reflects not only the patient’s personality, but our personality as well.”

Hospitalists don’t just treat these patients’ pain, they also address their suffering, he says.

High-quality pain management is multidisciplinary, Dr. Weston notes, because pain is multifactorial. The hospitalist occupies an important coordinating position and is charged with responsibility for the whole person during that patient’s brief hospital stay. But there are limits to what the hospitalist can accomplish. A palliative care team or an acute pain service can make important contributions to hospitalized patients’ pain. So can social workers, psychologists, pharmacists, and chaplains. But it is the hospitalist’s responsibility to coordinate these pieces of the pain puzzle for patients on service.

In many hospitals, the palliative care service has been set up to consult on pain, suffering, and clarification of treatment goals for patients nearing the end of life. These services vary from institution to institution in terms of whether they prefer to focus on end-of-life issues or are comfortable fielding other kinds of chronic pain questions. Acute pain services equally vary in terms of whether their focus is primarily on surgical pain “interventions” or on a multidisciplinary approach to pain management.

Ideally, Dr. Weston says, a major hospital would have both services available as resources to the hospitalist. Or, if there is only one of them, it should have a broad approach to pain management. Otherwise, it is up to the hospitalist to pull together a virtual pain team to provide a multidisciplinary response to complex pain.

“I am also board certified in hospice and palliative medicine,” Dr. Weston says. “I can use my medical knowledge to try to get the patient comfortable on oral meds so that they can go home. And I can personally make an appointment for them within 48 hours of discharge with their attending physician or a pain specialist. But for too many patients, this connection never happens.”

“Pain management in general is a hard thing to deal with,” adds Lauren Fraser, MD, regional chief of the department of hospital medicine for Kaiser Permanente Colorado in Denver. “It’s frustrating because you want to do the right thing,” she says. “We need first of all to rule out anything we can fix that might be causing the pain. Then we’re dealing with the patient’s quality of life and the disabling effects of pain. Each patient and family has a different need, and when you meet with them one-on-one you’re dealing with all of it.”

Dr. Fraser doesn’t have access to an acute pain service in her current setting, “although we have interventional folks to put in the PCAs and epidurals. We generally are able to get the services we need, although there would be an advantage to having an identified multidisciplinary pain service to provide the coordination.”

Tips to Manage Pain

Investigate all inpatient and outpatient pain resources in your community. Collect business cards and brochures and develop personal relationships with pain specialists. A multidisciplinary outpatient pain clinic can be a huge resource. Ask someone from the local integrative medicine center to speak at a brown bag presentation for hospital staff. Sometimes other specialists (neurologists, obstetricians/gynecologists, surgeons) may have insights on underlying pathology for a pain case that isn’t responding as expected.
Develop effective communication links with attending physicians and find ways to make sure they receive specific communications by telephone and fax about how their patient’s pain problem was treated in the hospital, what medications are in your discharge orders, and what you recommend in terms of ongoing pain treatment. If possible, make an appointment for the patient’s next visit to the primary physician or the pain clinic before the patient leaves the hospital.
Ascertain the extent of the palliative care and/or pain service at your hospital, if it exists, and find out the extent of its services. Learn when to call for help with difficult cases, such as when pain doesn’t respond as expected to first-line treatments. Learn from the anesthesiologist when certain interventions are called for and gain comfort in requesting them.
Find ways to participate on the palliative care or pain service at your hospital, such as by attending team meetings or serving on an advisory committee. Qualified hospitalists may be able to play a larger role by rotating through the service as attendings.
Create a virtual pain team in the hospital if there is no formal pain service. Find a nurse, social worker, pharmacist, chaplain, physical therapist, and other professionals who have an interest in pain management and will meet regularly to solve difficult cases. Consider the availability of and institutional receptivity to complementary modalities such as acupuncture.
Collect data to show the extent of the pain problem, particularly for patients who keep recycling through the ED with chronic pain complaints. How much do they cost the hospital? How much would the hospital willingly spend on a pain service that could help manage these cases better and faster? Work with other hospitalists to bring attention to these issues.
Make pain management a formal focus for institutional quality improvement activities. Involve multiple disciplines on a pain management task force charged with suggesting improvements for the difficult pain challenges seen in your hospital and applying evidence-based pain management to the hospital’s routines. Does the hospital have a pain policy, pain protocols, and standardized order sets? Is there a pharmacy and therapeutics committee or other body that could spearhead the development of such policies?