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Chronic Pain, Malingering and the Difficult Patient

Posted Aug 26 2008 11:11am
There have been some recent storms in medical blogdom over physicians refusing to prescribe pain medication. It seems some patients, especially someone named 'Anonymous Anonymous,' have taken exception, vomited vitriol and demonstrated that action and reaction are most visible at the point of conflict.

Consider the following:

Scalpel or Sword original Letter From a Chronic Pain Sufferer and a response in the Angry Migraineur.

White Coat on The Great Pain Debate and an observation in Disturbing Conversation .

Dr. Val's November post critical of physicians.

Consider understanding posts by a nurse and an English EMT

Let's call these people difficult patients; crazy or not, we need to deal with them. Here are a couple of great articles on the Difficult Patient in AFP , FPM and Medical Economics . There is a difference between the malingering patient (the one who storms out of the ER to get a heroine fix at her sister's) and the somatizer (often an unhappy middle-aged woman with abdominal pain migraines and a high depression score, but no insight).

We all know and hate the malingerer. In fact, it can even be fun to catch them in the act and watch them as they play up their dignity and indignation, as they slink out knowing not to mess with you again. But the somatizer is a type of difficult patient who we sometimes lump in with the malingerer. This person, I have some sympathy for, although rarely the patience to deal with effectively. They will counteract your every action, negate all help and have probably been their own worse enemy since long before you ever met. Sometimes all you can do is make your suggestion, smile and say you're sorry for what they're going through. Sometimes that's all their looking for, a sympathetic ear.

I even wonder about the people with real disease, such as sickle cell, who come in with marginal crises on occasion, planting yet another seed of doubt to infect my interactions with other patients.

Yes, our jobs are difficult all around, and ER physicians have reason to be frustrated by certain aspects of their jobs . But we need to learn to deal with the fact that about every 7th patient encounter (15% estimate quoted in the Med Ec article) will raise our blood pressure with some kind of manipulation, lack of insight or just plain dysfunction on the part of a patient.

No, we don't have to prescribe narcotics in inappropriate settings. Indeed we should prescribe narcotics as little as possible.

No, we don't have to argue with patients who are in need of deeper emotional care than their insight allows them to recognize.

No, we don't have to treat these people as GOMER's ("Get Out Of My Emergency Room") even as we show them the door.

But we can upgrade our skills. I for one, need better strategies to remain calm, especially when I know I'm being manipulated.

And if you're a patient who is tempted to flame me, read this:

There is a reason you need a prescription. There is a reason you need to see us. Don't forget, many of us have pain too . We don't let it stop us. We do want to treat it well . There are alternatives to medications. But the expectation of a painless existence is no longer a credible or reasonable expectation for you. Work with us and do not put yourself in the position of being lumped in with the malingerers.
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