April 2001 • Volume 7 • Number 4
Addressing 'the pain problem'
To the editor:
I read "Pain, Pain, Go Away" in the March 2001 FP Report and thought, "Here we go again! Trying to solve a problem by bureaucratizing it." I looked up the Joint Commission on Accreditation of Healthcare Organizations standards on the Web and concluded that following them to the letter would take an unreasonable amount of time away from what we really need: just plain listening to our patients.
A major obstacle to addressing "the pain problem" effectively is assuming that it is a single disorder. In fact, patients in pain should be broadly categorized and managed in three groups. The first are persons with disseminated cancer. Long-term opioid use may be an important part of their total care and should be prescribed liberally when indicated. The second are those with non-fatal objectively definable diseases that cause pain. Opioids are often indicated in acute situations like ureterolithiasis or bowel obstruction, but are less likely to be useful in chronic disorders. For example, various agents classified as anticonvulsants or antidepressants may be better for zoster and other neuropathic conditions.
The third group are those in whom pain cannot be reasonably attributed to a demonstrable physical disease. Objective evidence that opioids really help is difficult to find. Improvement in functional status is seldom demonstrated, although patients may say that they feel better. This writer is familiar with one often-cited publication that seemed to show benefit in a 10-week crossover study, but a trend line drawn on the figure in that paper would show a return to the placebo line at about 14 weeks.
Our knowledge of the etiology, pathogenesis and prevention of chronic nonspecific pain is appallingly incomplete. The present evidence supports the concept of a multifactorial disorder driven by a combination of biological, behavioral, sociopolitical and (dare we say it?) iatrogenic processes. Family medicine is the discipline best qualified to perform the intensive, comprehensive longitudinal research needed to find ways to minimize the incidence and adverse impact of this problem. When will we begin?
Robert Gillette, M.D.
Poland, OhioOf privileges and board certification
To the editor:
I read with interest the February FP Report article about Dr. Eric Runte's lawsuit seeking Caesarean section privileges. Everyone concerned seemed to agree that privileging "should be based on training, experience and current competence." Unfortunately for Dr. Runte in particular and FPs in general, the court rejected this premise.
I see this article from a different perspective.
I have been an AAFP member for 13 years. Although I am board certified, it's not in family practice -- it's in preventive medicine. I have not found the specialty of family practice to be gracious and accepting -- even in areas of privileging where training and competence were not at issue. And a broader note: Family practice's efforts to distance itself from general practice have relied as much on certification as on training and competence. It is hardly surprising that other specialties also use certification to "rise above" the humble FP.
It is nice to be detached from this imbroglio. What goes around does indeed come around to my family practice colleagues.
W.R. Eder, M.D.
Pocatello, Idaho'It's 2020' revisited
To the editor:
I read with interest the "It's 2020" articles in the January FP Report, which gave optimistic and pessimistic views on the specialty's future. I respectfully submit the following alternate views:
"If family practice has failed, why?" -- It bought into the flawed idea that whatever society's law said was ethical, became "ethical" for physicians. When it became legal to kill an unborn child, the specialty failed to take a stand against it. "Assisted suicide" no longer seemed objectionable. And powerful forces extended the "logic" of abortion to other areas of life, such as the elderly. Soon active euthanasia was legal by Supreme Court decree. The Academy drifted with the mainstream. But a breakaway group formed a new Academy of Hippocratic Physicians that respected all human life. It became the dominant force in primary care. The AAFP withered.
"If family practice is thriving, why?" -- When confronted with legalized infanticide and active euthanasia, the AAFP passed a sheaf of new ethical principles, establishing its members as the advocates for even the most powerless patients. It became medicine's most trusted institution. HMOs and government were forced to bring their regulations in line with the Academy promulgations since most patients refused to see any other providers.
Jeremy Klein, M.D.
Louisa, Ky.
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FP Report is published by the AAFP News Department.
Copyright © 2001 by American Academy of Family Physicians.
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