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.
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.
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.
- 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.
- 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.
- Kroenke K, Cheville A. Management of chronic pain in the aftermath of the opioid backlash. Jama. 2017 Jun 20;317(23):2365-6.
- 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.
- 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.
- Beresford MJ. Medical reductionism: lessons from the great philosophers. QJM: An International Journal of Medicine. 2010 Apr 15;103(9):721-4.