"He's just a drug seeker." This was my signout from Dr. Dispo, an emergency medicine intern. He was going home, and I was taking over the care of any patients of his that still needed disposition, whether to the inpatient floors, a short-stay unit, the psychiatry department, or home.
This last patient on his list was a "frequent flyer" in our ED, a guy who is in all the time with abdominal pain. He'd been last hospitalized the week before with a suspected small bowel obstruction, and Dr. Dispo was sure he just wanted more painkillers because they got him high. "Just get him out of here," he said. "Give him a bus pass and a script for, like, five Vicodin. Then get him out."
The term he used to describe the guy, "drug seeker," refers to people who present with somatic complaints in order to get drugs that might be abused or sold. Not everyone who is seeking drugs is a drug seeker, and it's helpful to think of patients seeking drugs as falling into four categories : fakers; people with undertreated pain; addicts; and people with other psychiatric disease. When I (and most others) use the term "drug seekers," it's really the fakers we're referring to.
Unfortunately, those fakers comprise a large and very frustrating proportion of every primary care and emergency medicine doctor's patient base, and it's not easy to differentiate them from other drug-seeking patients. A robust (if not incredibly evidence-based) body of literature has grown out of the increasing emotional and financial cost of treating these patients, and although there exist some sensible strategies for physicians, they usually require some component of longitudinal care to be effective. Our science in this area is far from perfect.
In the absence of great science, we rely on gut instinct, the utility of which is different based on the experience and training underlying it. A good ED doctor has the instincts to correctly call a spade far more often than not, but a trainee often does not. One of the challenges in telling a drug seeker from a truly ill individual is that people with untreated or undertreated pain can be as belligerent and appear as manipulative as people who are faking pain. The gut reaction to both groups is often to "get them out"; nearly every ED resident I know has a few stories about trying to send home a patient who really should've stayed in.
Now, Dr. Dispo does, too. His patient, on whom he never bothered to get a good history before rubber-stamping him, had a history of metastatic colorectal cancer. The many abdominal surgeries that followed resulted, as they often do, in recurrent, very real small bowel obstructions. Although these don't always require surgical repair, they are often very painful.
I can understand why Dr. Dispo might have initially suspected this patient was a drug seeker: he was requesting narcotics; he was prone to great displays of emotion; he resisted other interventions to treat his pain, such as a nasogastric tube for decompression of his stomach. But a quick peek at old discharge summaries would have revealed that the patient is on chronic narcotics for his cancer pain--he was just asking for more of his home medications. A peek in the emesis basin next to his bed would have revealed that he was vomiting bile, a sign suggestive of bowel obstruction. And a peek at the CT scan Dr. Dispo didn't want to do showed a partial obstruction of the patient's small bowel.
In the absence of great science, we rely on gut instinct. But in this case, there was good enough science, and Dr. Dispo went with his undeveloped instinct, anyway. That's not a problem with the science--it's a problem with the doctor.
- Log in to post comments
Note to Nurse Von (see comment under "donating your body to science" post): THIS is why those of us who know Dr. Signout and trained with her would have her as our doctor any day of the week! And, Dr. S - it's nice to see you tooting your own horn for once! It sure beats fretting about mistakes, doesn't it? :)
Nice piece. I'm as incredulous as you are that the doctor you mention was so cursory in his history and examination. I know that ERs are extraordinarily busy places as I work in a hospital that not long ago claimed to have the busiest ER in New York City, but overlooking a diagnosis of metastatic cancer is rather inexcusable.
I wonder if you, or someone else, might bring it to this intern's attention? If there is a way to give feedback, it sure would be warranted. Not only to deconstruct stereotypes but to inform about appropriate ER triage and care. That's what residency is all about.
Yeah, I probably should've mentioned it to the intern. It certainly might've reduced the amount of hide-chapping I got from him during every other encounter. I'll look into it.
And EGM, thanks for the vote of confidence. Unfortunately, proving this guy wrong took very little work--this is supposed to read like a story about his mistake, not my triumph. But I guess I should take what victories I can get, huh?
And I was that patient! Or someone very similar, in tears from abdominal pain and vomiting. An ER gave me some IV zofran, told me I had an intestinal virus, and sent me home. The fear of drug-seekers get seriously in the way of people in real pain with real problems. I've had abdominal surgery three times for cancer and four times for bowel obstruction, but get scrutinized for addiction when I get mixed up in ERs. Emotional? Right. Pain hurts.
Man, there has GOT to be a better way.
Most ED's have protocols for dealing with drug-seekers, individualized to each person and their specific manipulative ways. I'm not sure why (or whether) they don't also have protocols for dealing with frequent fliers who aren't faking it--people who come in regularly with real pain complaints.
Sorry you've had to be on the business end of this unpleasant phenomenon, Kate.
He needed a good doctor to look into the pain he was in. Good job for not taking the other Dr.'s word for what was going on.
People are suffering in real pain, while physicians are becoming jaded due to the abuse by some. Look and look thoroughly when a patient is repeatedly complaining of pain, perhaps something is being missed.
I do wish there was an absolute way to weed out the "drug seekers" from those that are in real need of relief.
I recently heard of the site from a Signout reader named Benjamin Langer, who himself has a very nice critical piece on intelligent design in the current edition of SCQ. Why I hadn't heard about this publication before, I don't know. I can only hypothesize that I perhaps have been living under a rock.
I think the doctor was a little embarrassed by his emotional display, but personally I thought it was beautiful. I remember thinking, "that's who I would want as my physician.
For the record, a friend of mine is in psychiatry, and he's actually the sanest of our group of friends. I think the overal sanity level of psychiatrists is just a well camoflauged secret.
They don't view dealing with complaints about residents as "their job," and so they throw it in the program director's lap to deal with. There's little point in complaining about it, even though it's crappy.