Aug 30

Aug 30 Bite-Size: Providing Good Care with a Focus on Alleviate Distress.

Introduction

A new blog concept for my website. These blogs tend to be small and introduce a concept or talks about an experience I had. Bite-size blogs should be a little less than 2 minutes read and may be less than 600 words. Nothing too prominent with a relaxed feel to it and no insane reference list.

In this edition of Bite-Size, I wanted to talk about a topic regarding good patient care with a focus on alleviating pain and distress. Dr Rana Awdish who authored In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, inspired me and provided many insights of what it is like to be a patient. I thought this topic is interesting, relevant and have quite an impact on health.

Good patient care

Good medical practice involves (see Medical Board AHPRA):

Recognising and working within the limits of your competence and scope of practice.
Ensuring that you have adequate knowledge and skills to provide safe clinical care.
Maintaining adequate records (see Section 8.4).
Considering the balance of benefit and harm in all clinical management decisions.
Communicating effectively with patients (see Section 3.3).
Providing treatment options based on the best available information.
Taking steps to alleviate patient symptoms and distress, whether or not a cure is possible.
Supporting the patient’s right to seek a second opinion.
Consulting and taking advice from colleagues, when appropriate.
Making responsible and effective use of the resources available to you (see Section 5.2).
Encouraging patients to take interest in, and responsibility for, the management of their health, and supporting them in this.
Ensuring that your personal views do not adversely affect the care of your patient.

Introduction

In this blog, I shall be talking and focusing about 2.2.7, which is “Taking steps to alleviate patient symptoms and distress, whether or not a cure is possible”. I thoroughly and solidly believe that every patient deserves to be alleviated of pain and discomfort, regardless of what type of disease or stages they are at, so that their quality of life is improved. Pain is uncomfortable and insidious; it gnaws at the patient's will to keep going and fighting. It gnaws at their spiritual level. It becomes a challenge to breathe, eat, wake up in the morning, go to the shower or toilet, any basic activities, sleep… well… basically living.

Rana Awdish who authored In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope, talks about her situation where she was in hospital as a patient (in short, in terms of trauma and diseases she went through a lot). What is special about Rana is that she is a physician working at the intensive care unit (ICU). She recounts her story through the eyes of a patient, which was then able to compare the ways of her colleagues as well as herself on how they practice medicine. It is an incredible story, and I would recommend the book.

In an extract from the book, Rana describes her moments at the hospital. She came out of surgery; however, during the surgery, the IV that contained the medication for the pain was not properly administered. Now, she had to "catch up" to the pain since it had a head start. As expected, she soon depletes the post-op orders for the pain and the nurse, who is irritable from being demanded more pain medications (and surely also from being overworked with lack of sleep), calls the on-call team. With the on-call team that has the bearest knowledge apart from age, gender, the surgeon who operated and the type of surgery, the tired and irritable resident would ask questions such as "how much pain medication do you take at home?". Rana denies taking any pain medication at home, the resident explains that usually, patients don't ask for more pain medication and asks her to be honest about taking pain medication at home. At implying and almost accusing her of being an addict, the resident withholds the delivery of more pain medication and calls the anaesthesiologist. The anaesthesiologist figures out the problem and delivers pain medication. This situation not only talks about withholding pain medication and not alleviating distress, context surrounding the patient, poor communication between teams but most importantly it talks about bias, especially implicit bias. At first, I did not understand what implicit bias is (or even knew it existed), but its definition is “implicit bias is the bias that results from the tendency to process information based on unconscious associations and feelings, even when these are contrary to one’s conscious or declared beliefs: for example, implicit bias in cases of racial discrimination”. Rana describes in her book that the bias had to be constructed, which guides and direct their beliefs, and biases start as early as the first-year medical school.

One of my course in medicine was called Preventative Medicine and Addiction Studies (PAS). In PAS we learned and discussed a lot about why it is wrong to call someone non-adherent or "that's the difficult patient type" or for example in Rana’s case, demanding more pain medication being seen in a negative context. Why was that seen negatively? And why do patients have to earn or behave so that they can get pain medication? Why do healthcare staff quickly jump to conclusions? That is why I enjoyed In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope because I could relate it to PAS. Rana describes that having preconception about a patient influence one's behaviour (sometimes we may never even identify that we do have preconceptions). While someone may know their biases such as disliking a patient type or group and thus believes to be justifiable to act a certain way, implicit bias is unintentional and subconscious. It can be activated, without our full awareness, on specific social cues that we have been taught indirectly and become bias towards race, gender, social status, profession, “difficult” patient type and so on.

Rana further explains that during a situation, a judgement is thus triggered, and it is possible that during the resident's training he/she have been conned and manipulated to prescribe more opioid medication so that a patient can try and get high. This is exacerbated as addiction creates patients that are really good at lying and are known to persevere until they are satisfied. Healthcare staff may use associations and stereotypes to quickly find out the "addicts" and difficult patient groups. But what if one is wrong about their patient? Should they let them writhe with their pain? Rana also made a valuable point which made me think about it. She said that explicit bias would make a healthcare staff act and be defensive, to shame and/or withdraw the medication. It will make them feel better for not letting another patient get high and recouping from the time they got manipulated or make them feel they are in control. How interesting is that?

Rana also explains that implicit bias will make a healthcare staff withdraw medication without even understanding why. It is a terrible feeling to give so much as a resident, physician, medical student, attending et cetera, and being taken advantage of especially when there is so much sacrificing to get where you want to be. Medicine is a huge sacrifice. You sacrifice sleep, spending time with family and friends, you are continually feeling you are in huge debts, and you feel that you have spent your youth studying. But what is genuinely the worst outcome, a patient not feeling pain or a patient that managed to get high? It is arguably worst to be left in legitimate pain and deprived of relief. Withholding medication from a physician that is emotionally guarding themselves is damaging everyone involved. Rana makes a valuable final point that trusting a patient with the right intention will occur far more often than a patient trying to take advantage.

Published 30th August 2020. Last reviewed 1st December 2021.

Reference

Medical Board AHPRA authors. Good medical practice: a code of conduct for doctors in Australia. Medical Board AHPRA website. https://www.medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx. Reviewed July 20th, 2020. Accessed August 20th, 2020.

Rana Awdish. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. St. Martin's Press, 2017. Website: Rana Awdish, MD.

Westfall JM. Change in Medical Student Implicit Bias. J gen intern med. 2016;31:714. doi:10.1007/s11606-016-3684-4.