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An Opioid Crisis Or A Crisis in Medicine?

By Morhaf Al Achkar, MD, PhD

A little over a year ago, I published a paper on the lived experiences of patients with pain as the laws around prescribing opioids changed.1 Yet there was something else I needed to say, like what I realized when I became a patient with stage IV lung cancer, and I set out to reflect on the obligations of our discipline to patients who are suffering. I stepped out of my role as doctor when I interviewed nine patients as research participants. I wanted to understand their lived experience, and it was not my intention to alter their suffering. Suspending my role of problem solver helped me better understand, from afar, what we do as doctors. And putting aside the role of doctor to be a researcher—and then a patient—was liberating.

Until then, I thought that I went to medical school to learn technical skills so I could “help people.” Thus, my training was focused on the skills necessary to diagnose, treat, and communicate. Everything I did as a doctor was toward ends assumed to be known and agreed upon by all—to get the patient better. My research on opioid prescribing challenged my perceptions. If what we do is help solve problems, then for someone with pain, prescribing opioids that helped was right. And if our discipline failed to regulate over-prescribing doctors, then regulating them by enacting effective laws was also right. Yet both arguments are faulty, but not because these interventions fail. They are faulty because their goals—lowering pain scores and decreasing opioid use—are not the only ones that matter.

No one argues that pain and over-prescribing are not problems. But, living in pain is not just a problem; it is a multi-faceted experience for a person, the patient.2-4 Likewise, over-prescribing is not just a problem; it is an action of another person, the doctor.5 While both matters are in crisis, the root of the crisis is the way we conceptualize these matters! Viewing the patient’s pain and opioid over-prescribing as technical problems to solve instrumentally, with opioids and laws, respectively, are two sides of the same reductionistic framework. I argue, like others, that this reductionistic framework is the problem.6

No one argues that pain and over-prescribing are not problems. But, living in pain is not just a problem; it is a multi-faceted experience for a person, the patient.

Missing from this instrumental characterization is the recognition of the subjects: the patient and the doctor. The patient is not an object with pain, and the doctor is not an object with prescribing capacity. Also missing is the normative aspect. The patient and the doctor interact with one another in a social context where they are entitled to assent to what is right and denounce what is wrong. These abstract notions can be clarified by listening with empathy to the following story of a patient. In my published study, one patient story stood out. Elliot (pseudonym) had the language to name his struggle and call out what was not right. In my reflections on our conversations, he helped me question what we do as researchers, educators, and doctors. He was in pain “24 hours a day, 7 days a week, 365 days a year.” A 43-year-old man struggled with debilitating arthritis that he “wouldn’t wish on my enemy.” The way he described pain challenged the doctor in me who was familiar with pain scales going from 0 to 10 but never to the unbearable. He also challenged the researcher in me who took health for granted and could not understand. Back then, if I dropped my wallet, I bent down to get it without any problem. So to understand his experience and reflect on it, I drew upon my own position as a patient.

I related to Elliot’s frustration when people were not empathetic to his struggle. His suffering was not because of anything he did, nor did he choose his illness. Humans live contingent and fragile existences, and his was unlucky. I had a similar experience when I developed cancer. We were both dealt bad hands. I understood the frustration with individuals who lack empathy saying things that demean your suffering. Medicine had failed Elliot. And as a medical educator, I personally failed him whenever a learner mastered self-assurance before empathy.

Photo by Wesley Tingey on Unsplash

Pain medicines helped Elliot, but his experience changed “when they changed the laws.” The law provided shortcuts for doctors, who now had no need to convince a patient that a treatment was right or wrong. Instead, we could simply say “It’s the law.” To Elliot, however, “doctors should have the patient’s best welfare in mind and not be thinking about what politicians tell them to do.” As a rational citizen, Elliot did not accept the law merely because it is a law; he criticized its legitimacy. For him, interactions with doctors were regulated by the norms of the doctor–patient relationship. Turning treatment decisions into a solely administrative task was a categorical mistake, he argued.

Elliot was angered to learn that the law, although leveraged by doctors to halt certain conversations, did not prohibit prescribing, as he was told. The law only stated specific procedures to be followed if pain medicine was prescribed. Elliot’s frustration no longer focused on the politicians or the law but, rather, at doctors, whom he felt had betrayed the essential duty of caring for the patient. He reminisced about doctors from his past: “They cared about what you felt, listened to you, and they tried to help you. And they weren’t worrying about that law, or if they were, they weren’t telling me about it.”

Before our conversation ended, Elliot had a request. “Would you tell doctors to stop letting elected officials, politicians, some board, or anyone else affect how they treat their patients? When it was just the doctor–patient relationship, hey, I was doing a whole lot better.” I promised.

In primary care, we are better positioned to lead conversations rethinking medicine.

Elliot is one of many calling out medicine’s inconsistencies. I argue here that our old framework has failed them, so we need a new framework in medicine and medical education. We ought to restore the normative and let patients speak. It is time to stop viewing medicine only as a technical discipline. Medicine and its education are social endeavors that must, unlike the actions of an engineer upon objects, take into account other people as subjects. Even better, we doctors ought to take patients as people with the competency to act authentically and to express their own values.

In primary care, we are better positioned to lead conversations rethinking medicine. We deal with the end of life. We know how to engage people in conversations about what is and is not effective for a given goal and what is or is not the right goal for patients. We can engage in a conversation that restores humanity to patients and shun what objectifies and dehumanizes them.

Medical education needs to support students finding the competency for critical dialogue and reflection, so they can empathetically engage with patients as subjects. This happens only if the patient can join the conversation and is given the opportunity to enlighten others.

Photo by Matheus Ferrero on Unsplash

Medicine makes space for a conversation between two subjects: one who is suffering and one who has cultivated the knowledge and authenticity to deserve the privilege of that conversation. Practicing medicine is a normatively authorized social action of those who do right and seek more effective ways of attaining what is good and meaningful for patients.

This is not just an opioid crisis. It is a crisis of medicine. Or is it an opportunity for a New Medicine? That is the practical question I aspire to answer as a doctor, researcher, educator—and patient.

References

  1. Al Achkar M, Revere D, Dennis B, MacKie P, Gupta S, Grannis S. Exploring perceptions and experiences of patients who have chronic pain as state prescription opioid policies change: a qualitative study in Indiana. BMJ open. 2017 Nov 1;7(11):e015083.
  2. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. Jama. 2016 Apr 19;315(15):1624-45.
  3. Kroenke K, Cheville A. Management of chronic pain in the aftermath of the opioid backlash. Jama. 2017 Jun 20;317(23):2365-6.
  4. Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. Journal of pain research. 2016;9:457.
  5. Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT. A brief history of the opioid epidemic and strategies for pain medicine. Pain and therapy. 2018 Jun 1;7(1):13-21.
  6. Beresford MJ. Medical reductionism: lessons from the great philosophers. QJM: An International Journal of Medicine. 2010 Apr 15;103(9):721-4.
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Dear Fellow Americans, Trump Is Cancer. But We Can Have A Cure If He Is Removed

By Morhaf Al Achkar, MD, PhD

It was November 2016 when I developed stage 4 lung cancer, and my life had not been the same since the diagnosis. That same month, Trump became president. His election was more shocking to me than my cancer. When I received the news of my cancer, my first thought was, “I am not an exception. People get cancer, and I am one of the people.” But when Trump was elected, I said, “This is impossible!” And starting that sad month, the two events became intertwined. Three months later, I wrote an article, published at the Huffington Post, and said, “Mr. Trump, you are cancer, and I only live if you shrink.” I drafted that piece not knowing if I would last much longer. I wanted to speak the truth — all the truth — at once.

I shared about living with what I perceived then as a terminal illness. I reflected on being a doctor and a teacher, then a cancer patient. The disease awakened my sense of self as a vulnerable human. It also brought out my authentic self. As a Syrian immigrant affected by the ban on Muslims, I had fears that I might not be able to say goodbye to family. I wanted people to put a human face on the suffering because of Trump’s inhumane politics. The ban on refugees had affected countless people. Often, their stories were left unheard. I shared my story to tell theirs.

When I came out, I was overwhelmed with support. Still, some people commented, “Why doesn’t he leave the country to see his family?” “What is he doing here, anyway? He should go and die in Syria!” These odd voices were few and far between, so I treated them with sympathy, the sympathy someone has toward those diseased with callousness in their soul.

Photo by Toa Heftiba on Unsplash

I reflect on these comments now as the attack on immigrants has reached unprecedented levels. Over the past 2 1/2 years, we have seen immigrant children in cages, immigrant children dying in the water or deserts, immigrant women being told to drink from the toilets, ICE terrorizing immigrant communities with threats of deportation, and worst of all, “If you are complaining all the time, if you are not happy here, you can leave!” This message from Trump is so dangerous because speaking truth to power is our only protection from all his atrocities. He wants to silence his critics and alienate them as if they do not have the same rights or do not belong to this place.

What Trump does to immigrants and people of color has crossed the line. This attack on the marginalized and vulnerable is personal to me. I had left Syria because I heard that same “advice” from the tyrannical regime there. Several of my friends stayed, and many died to free our country from tyranny and to bring dignity to humans. As I continue to live now, a life I do not take for granted, I am an immigrant and citizen of the United States — this is my home. I will make this a better place for myself and, more importantly, for those coming after, and I will never leave. It is time to tell Trump that this is enough.

What Trump does to immigrants and people of color has crossed the line.

Two and a half years ago, I wrote the letter to Trump, and if I had it to do over again, I would say the same things. He is a cancer, and he needs to shrink. I meant what I said because he is a narcissist, and the cure for those like him is to deflate the massive ego that is inflicted with inferiorities. I also said it because, like cancer, his values threaten to kill everything moral and humane in our country and beyond. Cancer is nasty, and when it spreads, it becomes an existential threat. Those parasitic cells of ours going rogue drain our energy and suck our life. Cancer sucks. And so does Trump. He sucks badly. I take my cancer chemotherapy treatment every day, and it has worked to keep the disease in check. But we have failed to hold Trump’s power in check, and that is dangerous.

I have lived with my cancer. I learned to find meaning in empowering others to build resilience while living with theirs. I have dedicated my life since the diagnosis to listening to cancer patients and telling their stories to help them find meaning with cancer. I also wanted to help distill strategies they can use to cope. I wrote a book, “Roads to Meaning and Resilience with Cancer,” and by helping others, I helped myself. That is also how I have dealt with Trump’s presidency. For weeks at a time, I would close myself off from the startling news so I could avoid hearing his creepy messages. I tried to find solidarity with communities injured by his hate. I maintained hope that this nightmare would end. I wrote the article hoping that things would change, but I braced for living with his presidency, knowing that things might get worse. Actually, if I were to write that piece again, I would probably correct a few errors.

My biggest mistake is that I treated Trump like a person with the capacity for empathy and understanding. I attempted to tell my story as if he could take the position of the other and feel what others feel. But Trump lacks both understanding and empathy, and I should have known that. I also used the word “authentic” to describe his representation. That was another big mistake. Trump knows what the base wants to hear and keeps regurgitating the vomit of other deviants in society. And that has nothing to do with authenticity. To be authentic is to be truthful to oneself, first and foremost, and Trump was never truthful to anyone. My third and most significant mistake was using dialogue as the framework. We know in medicine and sociology that when someone is so far gone in their pathology, the first step is to protect others by removing the harm. This rule is especially true if the disease is counter to the essence of what is social and human in us. An ideal society would put those individuals away, often in prison, before they receive correction and rehabilitation.

I did a few things well in that piece, though. I was authentic throughout, and that helped me regain my voice as a person. Yes, I was tired of battling cancer, but writing had given me the empowerment I needed. I claimed a new identity, and that was healing. I also asserted my position, which I still hold to this moment to be right: Trump is not a legitimate president, and he never will be. Because the Electoral College chose him, I believed he could legally be president. But because Trump lacks moral character and never represented the voice of the majority, I argued that he is not a legitimate president.

Another thing I did right is that, while I spoke to him as if he is a person who understands, I was prepared to make the shift in framework. I asserted that people should reclaim their voice if he does not correct his behavior.

Now, it is time for people to do just that before it is too late.

Dear fellow Americans, Trump is cancer. But we can have a cure if he is removed.

When we deal with a narcissist or sociopath, whether in society, the medical field, or behind bars, we ought to hold to our preset boundaries. Boundaries are what Trump systematically attacks when he undermines the law and our legal institutions. As an immigrant and a person of color, I have experienced prejudice countless times. In the past, people have said things that, to my ears, were racist and xenophobic. At times, the comments were blunt, and at other times, the prejudice was subtle in appearance and yet profound in impact. I no longer tolerate such aggression. I learned to call out what is unjust, and I learned to push back to maintain my boundaries. We all need to do that. We can do it as a society by putting in place more regulations to criminalize behaviors that are not acceptable. There need to be consequences to peoples’ actions.

Photo by Alexander Milo on Unsplash

I have survived 2 1/2 years with stage 4 cancer, and the journey was anything but easy. Our country’s journey with Trump has also been very painful. Can we say we survived? I am not sure. His damaging effects are deeply profound, and they are only getting more serious. There is still daunting uncertainty about what will come next. I know this uncertainty, and it scares me. My cancer can progress at any time. So can the atrocities that come from Trump. Things are bad now, and yes, they can be much worse. In fact, they will get much worse if we do not resist. I live an urgency, and I sense that I am running out of time. I need to say these words before it is too late. We cannot take another four years with Trump. I live with cancer because I have no choice. But we have the option of not living with Trump. I wrote a letter two years ago, but I addressed it to the wrong recipient. I am rewriting my article. Instead of declaring, “Dear Mr. Trump,” I now say, “Dear fellow Americans, Trump is cancer. But we can have a cure if he is removed.” Indeed, by electing someone who is positioned to heal the country, we can cure the disease plaguing our country.

Why did I write, “Roads to Meaning and Resilience with Cancer?”

By Morhaf Al Achkar, MD, PhD

I was driving back home from the lung doctor’s office. He had tapped a couple of liters of fluids from around my lungs. Yes, it was painful. It felt as if someone was stabbing my back with a knife. It is as if you know that a sharp object is penetrating through the layers of your skin and muscles, but you also know you need to stay still and not resist it. When your lung expands is when it hurts the most.

Those airways had collapsed for so long under the pressure of the fluids around the lung that when they opened up again, I felt a pain like I never had before. I thought I couldn’t take another breath. The pain and inability to breath lasted for only a few minutes, but it felt like hours.

After finishing the procedure, I headed home. That was the second time I’d had this fluid tap; the first was at the emergency room a few days before. As I was driving, I asked myself when this was going to end. I thought of the x-ray image of my shrunken lung and all the fluids around it and wondered when I would be back to my old self.

It turned out that would never happen.

Two days after I’d had those thoughts, I sat down with the same lung doctor in his office. He appeared concerned, and his face was dark. He still maintained a kind but faint smile of genuine care as he suggested that we go over the images of my chest that had been taken a few days prior. He explained what we were seeing.

I am not an exception. People get cancer, and I am one of the people.

Since I had looked at them myself, multiple times, and read the report, there was no news. But afterward, he went on to explain the results of the pathology report. He promised that he had called the pathologist himself to confirm them and that he had been shocked to find that there were “malignant cells in the fluid around the lungs.”

It was cancer!

I knew that finding malignant cells in the fluids around the lung means a Stage 4 cancer of some sort. That is not good.

I have cancer, and it’s Stage 4.

Photo by Shawn Lee on Unsplash

That was my first thought. But what I said first with my eyes starting to water was, “I am not an exception.”

People get cancer, and I am one of the people.

I am also a family doctor, and throughout my career, I have taken care of people with cancer. I have ordered the workup for patients who presented with troubling symptoms and then given them the diagnosis of a malignancy. I had shared the news of difficult diagnoses with patients.

To think that I would have been immune from that same fate was not something to occur to me; anyone can develop cancer.

Still, when you are the one who has developed cancer, you are alone.

Your cancer is your disease, and while it can spread in your body, it fortunately does not spread to other people; the disease is isolating.

All of a sudden, your life path, which was once in parallel with the paths of others, takes a different turn. But you are still a person. You want to connect with others, and you want to share because what you experience is meaningful, at least to you. It is significant to you, and you wonder if others would see it the same way.

I grappled for a long, long time with why to write about my experiences. I started writing a book at least four times.

But I have never finished the work.

When you write about yourself, some tensions and conflicts arise. Whenever I start writing, I struggle with the tension between writing about myself for me, as an authentic person, and writing for others in a way that is meaningful to them. There is also the guilt that arises because, as I tell my story, I become self-indulgent, and that is shameful.

Cancer patients, aware of their mortality, are sensitive to the vanity of self-indulgence.

It was not until November 2017, when a year had passed since my diagnosis, that the feelings became more mixed. There was the joy of still being alive after having thought I would be dying in a few months.

There was also the hope that comes with surviving one year: if I had survived 365 days, I could survive many more.

As I attempted to begin writing something about my experience, I found an article in a medical journal that led me to a whole body of work about the experience of lung cancer patients.

At first, I was scared to dive deeper into the struggle of others. A lot of the lung cancer patients described in the literature had died quickly. Many, with advanced diseases, did not have the opportunity to make sense of their story, let alone share it with others.

What troubled me the most, however, was that much of what had been written about the experiences of these patients had been written about the patients and not by them.

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What was written about lung cancer patients was in a language I would not use to describe my own experience, as a subject with agency. There were words about the experiences of shame, blame, and guilt. There were also words about living in constant fear or in denial. They were words that one would use only when describing the experience of another that they, themselves, had never understood.

Because I struggled to understand my experience and make it understood to others, I thought I could do something here, and it became my commitment to lend my voice to the people who struggle with this illness.

I know how to have a conversation with people. I have learned as a doctor, and as a researcher, how to invite others into spaces of reflection and authentic dialogue. Should I not use my talent where I could make an impact?

That is why I decided to write this book.

I interviewed thirty-nine people with lung cancer, and in this book, I share aspects of our stories. They are individuals, like me, who are fortunate to be alive at a time when science has made it possible to survive with advanced lung cancer for more than a few months.

Our experiences resemble nothing that many of us have lived or witnessed before

 They are also like you, before their illness, men and women with busy lives, families, and friends. Some worked as doctors, teachers, writers, builders, and managers. Others stayed home to take care of their loved ones. Their ages ranged between thirty and seventy-five.

We are living longer than we initially expected, and this has made our experiences resemble nothing that many of us have lived or witnessed before.

These are authentic people who have had time to reflect and think about themselves and their lives in the face of the absolute dread: death. Many of them have captured with their words some of the essences of our struggles as humans. Some are examples to those who are curious about the meaning of our existence.

“Roads to Meaning and Resilience now” is available now on Amazon.