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Sent to the pain clinic this am, after the conference yesterday.

Dear Swedish Pain Clinic Faculty:

I attended Swedish's 20th Annual Pain Management Symposium yesterday. Thank you very much for holding it.

I am a rural family practice physician, for over 25 years, and I opened my own clinic in 2010. Later that year I took the buprenorphine class at UW with Dr. Merrill and then over the next year and a half presented 30+ patient to their telemedicine. My patients are primarily family medicine, with 2/3 female and 2/3 over age 50. 1/3 are over 65 and I have many frail elderly, the current oldest 99.

I wanted to take this course in part to see how Swedish approaches chronic pain differently than UW.

I think it is interesting that the conference barely mentioned addiction or opiate overuse, as if that is rare. It is not rare in my county of 27,000, with opiates, meth, heroin, benzodiazepines, alcohol and tobacco addiction all being major problems.

When the case presentations were done, one faculty member teaching joked about a patient with fibromyalgia. He joked that he would do pressure points so that when the patient returned, he would press them lightly if the patient was following the protocol and he would press very hard if the patient was not doing physical therapy. I find this horribly disrespectful of our patients. Two of the women at my table were physical therapists there in part because they have family members with chronic pain. I was embarrassed for MDs and DOs when the physician teaching spoke that way. I would have trouble referring a patient to him, particularly a women and particularly with fibromyalgia or chronic fatigue.

Also in the case studies, the facilitator at our table talked about drugs first. Gabapentin for the fibromyalgia patient. I work differently. I am practicing slow medicine. I set up a super low budget clinic to have time with patients. At the first visit I spend an hour. I do the GAD 7 and the PHQ9 but I also do the PCLC*, because a huge proportion of my patients have sleep difficulties which are often a marker for PTSD. I choose different medicines for my PTSD insomnia patients. I also talk about ACE scores. I have a veteran who ran away to live on the streets at age 8. The highest ACE score I have seen is in a woman in her 80s who disappeared from her family 40+ years ago. I do not know what they were doing. My imagination worries about it.

I don't always do the psych panel on the first visit. I do tell patients that we don't prescribe controlled substances on the first visit. I phone screen the chronic pain ones so that they have an idea of the rules. I use the WA PMP**. I do a urine drug screen on the first visit and send it out: no prescription until I get it back. My goal is to be able to treat any person who comes to me, including chronic pain patients. Including addiction patients. Meth addiction, alcohol, opiates, heroin, cocaine.

So much of the pain I see is psychiatric: high ACE scores, childhood abuse, addiction families and ongoing family dysfunction. I think that many physicians feel helpless in primary care. I think we are making a huge mistake in having patients fill out four pages of history in the waiting room. I don't. I have a form with address and insurance. I fill out the entire history in the room in my EMR in that first one hour visit. Because then I know the patient and I print the entire note for them to take home. "Please read it and tell me if I got anything wrong." Patients don't like the laptop: but when I had them a 3 page note about them, they are shy. Three pages? About me? And you got all of it? This builds huge trust. Even if I say I don't know, I need old records, I need to check the urine, I need to think....

The biggest problem with the four pages in the waiting room is that the physician doesn't read it until the patient leaves. I saw a patient in follow up from a specialist last week. "What did she tell you?" I asked. "Lower lisinopril from 20 to 10 and come back in 3 months." "She wrote in the note to lower lisinopril from 20 to 5 and to come back in 2 months." I gave the patient the specialist's note. I see this frighteningly often: and I conclude that the specialist changes their mind and changes their plan after the patient leaves and they read the intake, writing the note then. This is a set up for "non-compliance" when the patient doesn't "follow the instructions". In our county patients cannot see their provider note on EPIC, they only have access to lab and xray results. The hospital has set it up this way.

I thought that the information about marijuana at the conference was excellent and very helpful. I do not feel comfortable recommending it at this time. The most helpful piece was the information about how to test patients to see if their use is minimal or higher than they are reporting. For buprenorphine patients I discourage thc but tolerate it. I will not accept alcohol metabolites or benzos.

Thank you for listening.


*PCLC: http://www.mirecc.va.gov/docs/visn6/3_PTSD_CheckList_and_Scoring.pdf
**WA PMP: Washington Prescription Monitoring Program http://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/PrescriptionMonitoringProgramPMP