The Quintessential Pain Care Provider

My dear friend, Debbie Tichenor RN, passed quietly and unexpectedly from this world on New Year’s Day 2015.

For more than twelve years, Debbie and I worked side-by-side, sometimes head-to-head, and always heart-to-heart. She was the quintessential pain care provider, possessing a unique abundance of clinical know-how, moral fiber, and you-can’t-outwork-me ethic. I trusted her with my business, my career, my family, and my life. She helped so many, loved so many, and will be missed by so many.

Today it would be my honor to participate in Debbie’s eulogy. And though I dearly wanted to serve in this role, I feared the challenge might overwhelm me, because Debbie was no longer here for me. You see Debbie was one of my vital touchstones. We shared core values, and I could always count on her for honest, intelligent, and constructive feedback. This time, however, I feared I was on my own. And my words, at best, would fall well short of the tribute due this humble angel of mercy.

Nevertheless, knowing that I owed it to my dear friend, sometime after midnight I began writing, not certain where it would lead. Hours passed, and as I fell into and out of exhaustion, the words on my computer screen gradually began to resemble verse. By 5:45 am I had composed a poem – Debbie’s poem. And when I read it aloud, alone in my room, I felt her presence, knew we had written it together, and knew I was not alone.

My sincere wish is that this poem for Debbie provides comfort to those who miss her, inspiration to those who never knew her, and encouragement to those who aspire to be like her. She was, is, and always will be the quintessential pain care provider.

 

A Poem for Debbie

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When she was born it’s right to say,
A blessing came to earth that day.

To ease our pain and bring us love,
Directly from the Lord above.

 A daughter, mother, wife, and friend,
With caring that would see no end. 

A nurse who’d go the extra mile,
Who always met you with a smile. 

If she was anywhere you were,
Then you were family to her. 

And could expect, as from God’s grace,
The blessing of her warm embrace. 

With such profound humility,
Her skill defied futility. 

And when she faced what most would fear,
With love and hope she’d persevere. 

But tending to the quiet needs,
Might count as her most noble deeds. 

And though this blessing we now miss,
God comforts us in knowing this… 

If love defines a life’s treasure,
She lived a life beyond measure.

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~Written with your help, my dear friend,

January 6, 2015

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The Voyage of the Big E

banner1

The voyage of the Aircraft Carrier USS Enterprise
January 5, 1988 – July 2, 1989

Lieutenant James Patrick Murphy (that’s me) was one of two Carrier Air Wing Eleven flight surgeons assigned to the USS Enterprise battle group. I was the “attack doc” from Naval Air Station Lemoore California, and my counterpart, Lieutenant Commander Michael Menendez was the “fighter doc” from NAS Miramar California. I was twenty-eight years old, fresh out of training at the Naval Aerospace Medical Institute in Pensacola, and preparing to leave my beautiful wife of two years to deploy with five thousand men for at least six-months.

It’s been 28 years since I made my first journal entry on July 5, 1988.  Incredibly, I managed to write in in it every day… right up until the “Big E” pulled back into homeport Alameda, California on July 2, 1989.

big e journal

Over the next six months, with the help of this recently salvaged musty green three-ring binder, I will recount my journey on board the most powerful nautical vessel mankind has ever known… and by looking back, perhaps chart a course for journeys to come.

Anchors aweigh!

uss enterprise under bridge

January 5, 1988 (0545) It is impossible to describe how I feel right now. I’ve never had to say goodbye and really mean it. It’s a damp dark Alameda morning, which in a way makes is easier… The glad handing and the “How’s it going?”s haven’t begun in earnest yet…only a matter of time.

(2040) Quickly the real world dissipates. It was surreal today. A state of mild shock. No energy on my part. Now is when I really need to understand the “one day at a time” mentality. These people will become my family. There is a sense of “This is really it,” which can be felt in the demeanor of everyone.

I went out on the flight deck and watched the preparations for departure. At 0700 the theme from “Rocky” was played on the 1-MC. We were really leaving. This is one of the few times I’ve really had to suppress my emotions. The best thing I can do, depressed as I am, is just to go to bed early.

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January 6 (1402) The latest key issue revolves around the little refrigerator I mentally beat myself up trying to decide whether or not to buy. It seems the XO (executive officer) has outlawed all stateroom refrigerators. This means that for the first time this cruise I will have to live above the law.

(2134) I was looking our over the sea, watching the flight ops. The ship began a 360-degree turn, slowly, as it does on occasion for no apparent reason (for turning’s sake). The sun was reflecting brilliantly off the ocean and the light, the warm sun, shone in my face and fell across my body. I felt the warmth and at that moment a sense of relief tempered my low-grade depression, and I felt good for the first time since I stepped on the ship. Perhaps it was God’s doing. I’m not sure, but I did feel something at that moment. I felt a sense of relief that this ominous task was finally being done. I’m really doing it. The worry is over. The doing has begun.

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mydu-a7S3IALWt6TnjlGBXQ

January 7 (1044) We go off Spuds time at 1900 today. “Spuds time” refers to the Pacific time zone. Adele and I each received “Spuds MacKenzie” watches for Christmas. We synchronized them on 4 January, and I have vowed not to change it until I return. So in about eight hours I’ll officially be on “cruise time” from a Spuds standpoint. I’ll take off the watch now, and when I ceremoniously put it back on it will be a happy day.

January 8 (2016) Sometimes I really feel like I’m in a prison. Other times I think I’m lucky to get the chance to have the experience of a lifetime. I ate dinner tonight with three daddies-to-be. When I said I had been thinking about Adele and having a baby, they all laughed and agreed: “Well if she has a baby now it won’t look like you.”

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fod

January 9 (2105) I participated in a FOD (“foreign object debris”) walk down today on the flight deck. I began to feel good about being on the ship (Feeling “good” means merely not feeling “bad”). Then just as quickly I realized how fragile my world really is – how helpless I am to change things back in Hanford (CA) – how impossible it would be for me to come to Adele’s aid.

And just now I’ve realized that I am coming to her aid, and to the aid of millions of others in some way, by being where I am. My job here keeps her free there. It keeps my (unborn) children free – just as my father’s four years in the Navy and his cruises helped keep me free and allowed me to be who I am. Let me not forget. I am always connected. My efforts always count for something.

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January 10 (1144) I was saddened as I pondered the world map that was on the wall of the makeshift chapel (the library, actually). I was saddened because I realized again that I have only been given a tiny slot of time to live in the evolution of time. When I thought about how early explorers (e.g., Christopher Columbus) must have viewed the world, how much it has changed, and how much it will continue to change, it makes me want to be there. Be somewhere. For more of it.

IndianOceanWaves3

I was standing on the bow of the ship yesterday. It was cold, damp, and windy. But there was a warm moistness in the air as well. Anyway, I observed how much the Enterprise rocks up and down, side to side, in the water. I must say it is incredulous that anyone even resembling a Viking would have tried to venture out across the sea in, of all things, a wooden boat! And the most amazing thing is that this all happened not too long ago – from a world history sense.

We haven’t even been gone a week yet.

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cvw11

January 11 (1410) I have just crawled out of my little time machine – a two and one-half hour nap. Fact: the more you sleep, the less time you are on cruise. I had been dreaming when, I guess, another “cat shot” from three feet above my head (i.e., my bunk is situated just below the flight deck) woke me up…but only slightly. I kept on dreaming. In my dream a high school friend, Dale, came to our house, and I heard him tell Adele of a “revelation” he had after reading a book that day. The revelation: “I don’t want to die alone.”

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January 12 (1130) Eat less, sleep more. That’s the slogan for the day. That’s going to be the theme to this cruise. We’re pretty close to Hawaii now. The sky is crystal clear and the sea is deep dark blue – a log flume at Six Flags sort of blue. Shimmering like sapphire.

“Distinguished visitors” are onboard and that means a number of things. That means the food will be better. It means we’ll have a break from all those general quarters drills. It means there may be one or two women on the ship, which means you can’t be a carefree man and run around in your underwear.

Yesterday I got my first letter from Adele, dated January 5th – the day we left port. It made me feel so good. Today, most importantly marks the end of the first week away. Only twenty-five more to go.

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January 13, 1988 (1242) The Beach Doc rides again! I’m taking a helo off to Barbers Point, Hawaii on the island of Oahu, in order to take in a suicidal patient. And bring back as much medical supplies as I can get my grubby little con-man flight surgeon hands on.

sun e

Only fitting that I go to the beach (i.e., any land is considered “beach”) on the very day that the parachute rigger of VA-22 gave me my new nametag sporting the call sign: “Dr. Sun E. Beach.”

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January 14, 1988 (0956) Well, the Beach Doc did NOT ride again. The helicopter did not come out to get us because we were greater than 70 miles off the coast. The “Distinguished Visitors” sure got off with ease though… and the helos that came to pick them up sure didn’t bring any mail.

It’s a belly-aching sort of day. The ship is rocking side to side and I can’t understand why. The sea is as smooth as glass. I went out on the catwalk with my dentist friend, Dick Koo. We marveled at the sea. I’d never seen it so placid, so blue.

The best thing I did yesterday was talk to Seaman _______. The chaplain sent him to me to “evaluate” for depression. I believe he just misses his wife. And, by the way, she laid it on him before he left to the tune of “If you go on that cruise, I won’t be here when you get back.” I managed to talk him into a good mood. I’m not sure how. But I did.

Two days ago I was up on one of my favorite places on the ship – the “Admiral’s bridge.” There’s really not much on the Admiral’s bridge but an exercise bike and a big bay of windows.

adm brige

So I’m up on the Admiral’s bridge where I can usually be alone, but this time there’s this regular looking guy on the exercise bike.  I didn’t recognize him, so I kindly asked him who he was and whether or not he was civilian or military. He kindly told me he was the ADMIRAL (i.e., RADM Glenn). Definitely military. Not a good start for me. But by the time we parted we were the best of friends. I’ve got a way with Admirals.

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Want more? The cruise continues at: http://VoyageoftheBigE.com

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va22 jt

A Year of Confluential Truth

MY YEAR

2014 was the first year that I really began to discover social media.

Looking back, I find it revealing rediscovering which of my Twitter messages and WordPress.com blog posts piqued the most interest in 2014.

As expected, most of my “retweeted tweets” (Try saying that ten times fast!) related to popular issues such as: healthcare reform, our drug abuse epidemic, sports, holidays, and the passing of iconic celebrities.

However, my heart was also warmed by your responses to my attempts at creativity and inspiration. It’s been fun.

I am continually trying to hone my communication skills. And while I don’t always get it right, I always love connecting with you.

You inspire me. And because of you I will do my best to share ideas with substance, purpose and hope.

Thanks for going there with me.

WordPress.com has prepared a 2014 annual report for Confluential Truth. Click here to see the complete report.

And in the comments to this post I have listed my “Top Twenty Retweeted Tweets” of 2014.

See you next year!

Screen Shot 2014-12-31 at 3.35.54 PM

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Or if you prefer, here are the links…

The Top Twenty Retweeted Tweets of 2014

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4/17/14, 6:10 PM (58 retweets)

It costs your doctor $58 just to process your insurance claim. OUCH! Guess who’s getting well.
https://twitter.com/jamespmurphymd/status/456917545220464640/photo/1

 

4/22/14, 4:49 PM (50 retweets)

An inconvenient truth. Even casual marijuana use causes brain damage. Sorry to be a buzzkill

https://twitter.com/jamespmurphymd/status/458709109622067201/photo/1

 

6/6/14, 12:30 AM (47 retweets)

70 years ago 6:30 am Normandy
“For he today that sheds his blood with me shall be my brother” – Shakespeare #DDay70

https://twitter.com/jamespmurphymd/status/474770232196616192/photo/1

 

5/5/14, 12:20 PM (42 retweets)

Treating pain can be painful
#doctorburnout #painphysician #ChronicPain #painmanagement

https://twitter.com/jamespmurphymd/status/463352421784121344/photo/1

 

7/20/14, 1:18 PM (38 retweets )

Can’t believe #JamesGarner ’s only Oscar nomination was Murphy’s Romance (My personal favorite).
Miss you #Maverick

https://twitter.com/jamespmurphymd/status/490908736048074754/photo/1

 

3/28/14, 1:17 PM (36 retweets)

Hey Cats! Time to go under the knife! #CardNation #BeatUK#MarchMadness #Sweet16 #CardChronicle #CCBM #BBN #L1C4

https://twitter.com/jamespmurphymd/status/449596164636033024/photo/1

 

8/12/14, 12:11 PM (35 retweets)

Good-bye Robin. We ain’t never had a friend like you. #RobinWilliams#CarpeDiem#seizetheday

https://twitter.com/jamespmurphymd/status/499226724425793536/photo/1

 

4/27/14, 11:29 AM (34 retweets)

it is impossible to think about yourself when you are locked into thinking of someone else
https://twitter.com/jamespmurphymd/status/460440531898597377/photo/1

 

11/22/14, 1:40 PM (30 retweets)

Card March South Bend style
@CardChronicle #L1C4 #GoCards #BeatNotreDame #CardNation #UofL #Louisville #GameDay

https://twitter.com/jamespmurphymd/status/536227794330877952/photo/1

 

5/9/14, 11:51 AM (30 retweets)

artist
is not what you
do
it’s who you
are

https://twitter.com/jamespmurphymd/status/464794743009206275/photo/1

 

4/26/14, 10:37 AM (28 retweets)

Pain affects more Americans than cancer, heart disease, and diabetes combined. #paincare

https://twitter.com/jamespmurphymd/status/460065129388732416/photo/1

 

8/13/14, 12:27 AM (26 retweets)

Chronic #pain patients have 2X the risk of #suicide
Don’t overlook #depression
#RobinWilliams

https://twitter.com/jamespmurphymd/status/499411903274172416/photo/1

 

5/11/14, 6:30 PM (26 retweets)

Thou art thy mother’s glass and she in thee
– Wm Shakespeare #BringBackOurGirls #MothersDay https://twitter.com/jamespmurphymd/status/465619939022225408/photo/1

 

7/17/14, 7:50 PM (26 retweets)

I chose TODAY to #giveblood.
Please #ChooseYourDay and save a life.
(800) 448-3543
#RedCross

https://twitter.com/jamespmurphymd/status/489920225169510400/photo/1

 

6/23/14, 10:57 AM (26 retweets)

This does not have to be our default future.
But only if we have physicians willing to lead.

https://twitter.com/jamespmurphymd/status/481088764975284224/photo/1

 

4/21/14, 2:58 PM (26 retweets)

FYI: pain patients are NOT addicts
ADDICTS are ADDICTS
#addiction is a brain disease

https://twitter.com/jamespmurphymd/status/458318971851120640/photo/1

 

4/17/14, 12:25 PM (25 retweets)

Lunch thought #417: Nuts are like the methadone of dieting – By the time craving stops you’ve probably eaten too many

https://twitter.com/jamespmurphymd/status/456830854354841600/photo/1

 

11/16/14, 12:41 PM (24 retweets)

Life is only offered one semester.
You’d better take it.
~ Nov 16 1978
#premed @WestminsterMO

https://twitter.com/jamespmurphymd/status/534038458520440832/photo/1

 

7/5/14, 10:38 PM (22 retweets)

This was the scene tonight on the border between #Kentucky and #Indiana
#Bigfourbridge #L1C4

https://twitter.com/jamespmurphymd/status/485613823651352577/photo/1

 

5/7/14, 4:04 PM (22 retweets)

patients
need you
to be
this physician
and you
need
to be
this person
emerge again

https://twitter.com/jamespmurphymd/status/464133698808717312/photo/1

 

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‘Twas the Fight in Our Clinic

orange jumpsuit

It was right before clinic and all through morn,
Not a patient was hurting, nor feeling forlorn.
The stocking of meds on the shelves was with care,
In hopes that ridiculous pain would be rare.
The front desk was nestled all snug in their seats,
Collecting the copays while smiling so sweet.
And I in my lab coat, scrub top, and a glove,
Had just settled in for the job that I love.

When out in the hall there arose such a clatter,
I sprang from my chair to see what was the matter.
Away to the window I flew like a flash,
Tore open the shutters and covered the cash.
A man on a quest, who did not like a “no,”
Gave bluster and chaos to our status quo.
When what to my watering eyes did appear?
But my signature forged on a pad that was near.
The villain prescriber had written so quick,
I knew in a moment it must be some trick.
I asked him his name and just why he had come,
But all he could say was he had to be on…

On Morphine, on Codeine, on Oxy, on Contin,
On Soma, on Xanax, and lots of Neurontin!
Don’t stop for the chart. Don’t stop in the hall.

Now right away! Right away! Write for it all !!!

As dry heaves that before a wild emesis fly,
When I met this intruder I thought I could die.
So onto the restroom I coerced him to…
Pee into a cup that might give me a clue.
But then, in his tinkling, I heard through his bleating,
The faucet, the flushing and knew he was cheating.
As I pulled back my hand and was turning around,
Through the window the specimen came with a bound.

I was stressed by his sight, and I thought for a while,
That his clothes were an orangey prisoner style.
A stencil of words were in print on his back,
When I asked him about it he called me a quack.

His lies, how repugnant; how simple his tally –
Prescription pain pills to sell in the back alley !!!

He had a clear package tied up with a bow,
And the powder inside was as white as the snow.
A piece of lead pipe he held tight in his hand,
And he swung it at me as he started to stand.
He had a gaunt face and not much of a belly,
And I shook when he laughed ‘cause his breath was so smelly.
He was stealing prescriptions, I thought to myself,
And I cringed when I saw him reach into the shelf.

A wink of his eye and a poke to my head,
Soon gave me to know I had something to dread.
He said he had come to us straight from his “work,”
And turned ’round to face me and called me a jerk.
He gave me the finger, then fingered my nose,
‘Til both of my nurses, they stomped on his toes.
He sprang to his car when we asked about jail,
And away he did run with the cops on his tail.
But he heard me exclaim, ‘ere he drove out of sight,

No prescriptions for you, because we do it right!

022812 police-chase

 

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While drug diversion is certainly no laughing matter, I couldn’t resist poking a little fun at some of the bumblers who have chosen this “career” path.

Here’s hoping that you have a joyous and pain-free holiday season!

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Treating pain patients like addicts?

Treating pain can be simple or complex.

simple_complex

The simple approach focuses on cause and effect.

Knee_Jerk_large

Remove the cause of pain and the effect is…relief.

This often works when the cause is clear, i.e. acute pain. Just ask the lion with the thorn in his paw.

lion

But chronic pain is often more complex.

Nature tries to smooth out rough spots; this is called “adaptation.” So when the brain is exposed to prolonged painful stimuli, or to foreign chemicals, such as opioid pain pills, the brain adapts.

Two examples of these neuroadaptations are:

(a) tolerance – the need for increasing doses to maintain the same effect; and
(b) physical dependence – the need to keep taking a drug to ward off withdrawal symptoms

The presence of drug tolerance and physical dependence does not mean the individual is addicted to the drug.

pain not addiction

Addiction is a life-threatening disease of the brain’s reward circuitry, typified by a persistent destructive preoccupation with satisfying an unhealthy craving for a substance or behavior.

Brain

Addicts will often develop tolerance to drugs of abuse and develop physical dependence. And they experience withdrawal symptoms when these drugs are leaving their bodies. But tolerance and physical dependence (and withdrawal symptoms) are normal expected physiologic adaptations that can also occur in non-addicted people who take their medications as prescribed.

Furthermore, in the American Psychiatric Association’s authoritative Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, tolerance and withdrawal symptoms are no longer counted as criteria for diagnosis of substance use disorders when occurring in the context of appropriate medical treatment with prescribed medications.

Screen Shot 2014-11-21 at 11.06.01 AM

In pain sufferers exposed to opioids for an extended period of time, drug tolerance and physical dependence can extend to brain structures that control stress, anxiety, pain, memory, emotions, judgment, critical thinking, and even the ability to experience joy. These patients may not be addicts, but if and when they are in withdrawal they sure feel like addicts. They may need the opioid for more than just pain relief; they may need the opioid just to feel “normal.”

depressed patient

If not addiction, then what is this complex neuroadaptation to long-term exposure to opioids? In a 2012 commentary article from JAMA Internal Medicine, Doctors Ballantyne, Sullivan, and Kolodny referred to it as “complex persistent opioid dependence” (JAMA Internal Medicine September 24, 2012, Vol 172, No. 17):

Dependence on opioid pain treatment is not, as we once believed, easily reversible; it is a complex physical and psychological state that may require therapy similar to addiction treatment, consisting of structure, monitoring, and counseling, and possibly continued prescription of opioid agonists.

I concur.

mpc

For years in my practice, my colleagues and I have treated chronic pain patients, many of whom are stable and functioning well on opioids. Interestingly, many will describe their pain as severe (i.e. “ten out of ten”) but in the same breath say they are doing “OK.” We have had a measure of success at tapering some patients to lower opioid doses, but a significant number simply will not function well at lower doses.

How can this be?

I believe the answer is in their neuroadaptation. To my understanding, long-term pain coupled with long-term opioid use appears to alter the way one’s brain experiences pain. It is almost as if the pain level is “locked in” and will not fluctuate significantly regardless of interventions (e.g. physical therapy, biofeedback, injections, adjunctive medications, or even more opioids). In this sense it is similar to how a patient with phantom limb pain can have real pain where the limb once was. In both situations the pain experience is determined by complex interactions between multiple nerve pathways – far from simple cause and effect.

Therefore, when treating complex persistent opioid dependent patients (“CPOD”) the most beneficial course might be to shift focus from the conventional drumbeats of: (a) trying a steady progression of new treatments; and/or (b) tapering off the opioids “at all costs.”

I would never suggest these pain patients abandon efforts to achieve more relief and improved function. But I am suggesting, as do Doctors Ballantyne, Sullivan, and Kolodny, that the better therapeutic approach may be to view their care through the lens of Addiction Medicine in addition to that of Pain Medicine.

asam book pic

CPOD patients might be well served by care plans influenced by principles outlined in The ASAM Criteria from the American Society of Addiction Medicine.

asam crit screen

In this paradigm a patient is assessed in six categories or “domains.” Care plans are determined by severity in each domain. With CPOD patients the six domains would look like this (i.e.,“ABC & RRR”):

  1. Acute issues
  2. Biomedical issues
  3. Cognitive and behavioral issues
  4. Readiness to comply with the program
  5. Relapse potential to aberrant behaviors
  6. Recovery environment for ongoing safe use of opioids

Consideration of these six domains assists the clinician in formulating a treatment plan with the most appropriate structure, monitoring, counseling, and use of opioid medications.

For example, imagine a patient with chronic pain who presents for continued use of opioids and is assessed to be stable in five domains but has not adequately addressed his or her diabetes. The diabetes is a biomedical issue that left untreated could jeopardize safe use of opioids. In order to move forward with the plan of care, optimizing this “biomedical” domain becomes a priority.

Treating pain can be simple or complex. When the cause of pain is known and removing the cause is expected to result in pain relief, the decision whether or not to include opioids in the plan of care is straightforward. However, when long-term suffering and opioid use lead to significant neuroadaptations and the development of complex persistent opioid dependency, the best course of action may be to offer these non-addicted pain patients a plan of care modeled after that which has been shown to be effective in treating addiction.

Those afflicted with the disease of addiction suffer biological, psychological, and social harm. Respect, dignity, and science are the pillars of treatment. Success requires ongoing partnership between the patient, caregiver, and support group.

This plan of care can also work well for complex persistent opioid dependent pain patients. They may not be addicts…But you can treat them that way.

Simple.

 

joyful

 

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Purified Prose

I think of poetry as prose that has been purified.

And with brevity the soul of it’s wit, Twitter can be thought of as a “language distillery.”

Now please allow me to offer you a taste of my higher proof poetweets…

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purified prose
produces poetry

*November 10, 2014

 

every scratch
a fallen petal
on father’s watch
is precious mettle

*November 8, 2014

 

give pain meds the blame
for drug abuse shame
and outlaw their use
to combat abuse

but when drugs are craved
lives will not be saved
and no addiction
is only fiction

so passing the laws
that ignore the cause
may rid us of pills
but won’t solve our ills

*October 31, 2014

 

fascination
from
finding
fall’s
finest
foliage
foreshadows
finally
feeling
fate’s
farthest
fall

*October 26, 2014

 

if
why
when shared
shows us where

then
where
will now
show us how

*October 10, 2014

 

I hid but my failure discovered me.
I ran but my failure recovered me.
I forgot by my failure reminded me.
I blinked but my failure it blinded me.

I talked and my failure it studied me.
I bathed and my failure it muddied me.
I fought and my failure it pounded me.
I fell and my failure it grounded me.

I hoped that my failure would end for me.
I found that my failure was friend to me.
I learned that my failure was me to me.
I then let my failure be free from me.

*October 2, 2014

 

To fight poor health discreetly
You gave yourself completely
You might have loved your medical career
But will you love this tomorrow?

Is care a hope to treasure
Or something you must measure?
Can you believe the tragic change in sight?
Will you still love this tomorrow?

Faced with healthcare that’s broken
You say that you are only “one”
But you won’t feel like jokin’
When your right to a choice is gone

You’d like to show that you love
To give what we’re in need of
So tell yourself to face that task again
And you’ll still love this tomorrow

September 16, 2014
Hint: Try singing it to the tune of Carole King’s Will You Still Love Me Tomorrow?

 

though my ideas
are in my post
it’s your ideas
that matter most

*August 27, 2014

 

my body age
not so illogical
is easy to
discern

but true mind age
not chronological
is really my
concern

*August 23, 2014

 

first day of spring
say thank you please
to those who ease
our suffering

*August 5, 2014

 

artist
is not what you
do
it’s who you
are

*May 9, 2014

 

And finally…

since brevity is the soul of twitter
longevity as a goal is bitter

*November 13, 2014

 

 

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Words that matter…to me

journal

September 24 was a mentally fertile day…on at least three occasions in my life.

From time to time I have managed to keep a journal.
Here are three of my 9/24 entries.

September, 24 1978 (College sophomore, 18 years old)

I cannot afford to lose a day;
my life is only as short as it is.

9 24 78

September 24, 1983 (Third year medical student, 23 years old)

Life and alarm clocks
go hand in hand
unnaturally.

9 24 83

September 24, 1995 (Anesthesiologist, 35 years old)

Unless it makes any difference why the sun comes up everyday,
don’t waste time arguing about it.

9 24 95

If you’d like to see more of this kind of thing, they pop up from time to time on my Twitter feed.

Or check out the listing in this post’s comments section.

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Screen Shot 2014-09-25 at 1.11.42 PM

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I need some advice…

Screen Shot 2014-09-15 at 2.52.49 PM

Tomorrow (Tuesday – September 16, 2014) I will have the honor of speaking to a gathering of mostly retired physicians at the Kentucky Medical Association’s annual meeting in Louisville, KY.

Given this opportunity, what would you say to them?

What would you encourage them to do?

How would you instill hope that our nation’s healthcare delivery system will survive?

I only have a few hours to hone my message. I need your help.

Please leave your remarks in this blog’s comments section…

Or send me a message on Twitter @jamespmurphymd

Or email me at: basicpaincare@gmail.com

Thanks!

Dr M

Dawn of the planet of the value based

sunrise clark

It is the dawn of a new era.

Many cogs are now required to turn the wheels of our nation’s juggernaut health care industry. Physicians, historically the driving force in medicine, are not generally the “cog” type. This juxtaposition can have unhealthy consequences for all of us.

In his August Wall Street Journal article “Why Doctors Are Sick of Their Profession,” Dr. Sandeep Jauhar documented the pathology in our nation’s medical history. And while I agree with the good doctor’s diagnosis, I am not as comfortable with his treatment plan, which includes:

  1. “giving rewards for patient satisfaction”
  2. “replace the current fee-for-service system with payment methods such as bundled payment, in which doctors on a case are paid a lump sum to divide among themselves”
  3. “pay for performance, which offers incentives for good health outcomes.”

At first glance, Dr. Jauhar’s suggestions would appear to be reasonable measures. But employing such metrics may not sit well with our current physician workforce for a number of valid reasons.

In days past, the medical profession attracted highly intelligent practical dreamers in search of a career that allowed and rewarded unfettered blending of art and science; answering a “calling” that revered the heartfelt patient-physician relationship. If you were a “Renaissance man” or woman, crossing medicine’s threshold felt like coming home. Now in this modern medical renaissance, home is not necessarily where the heart is. Home is now inhabited by impostors masquerading as quality and value.

In days past, creativity and problem solving were vital to success in health care. Now strict adherence to guidelines, meeting quotas, and saving money for third party payers are paramount. Now the “rough spots” in the delivery line -physicians who view patients as individuals as opposed to populations – are being made smooth or else discarded.

Given a metric that determines their “bonus,” worker bees will instinctively aim for that mark. So if earning money to send their kids to college depends on getting a “five star” customer satisfaction rating, then expect health care professionals to make flashing a salesman’s smile the priority. Running a clinic on time will become more important than taking time to comfort that patient who’s problem unexpectedly deserves more attention than the automated schedule allowed…can’t risk upsetting twenty people for the sake of one, you know.

The story goes that Albert Einstein once wrote on his blackboard: Not everything that counts can be counted, and not everything that can be counted counts.

Regardless of the origin, this statement rings with truth. More than an observation, it is a challenge.

hand

I held a hand the other day. There was no procedure code for it. It did not satisfy any quality metric. Truth be told, it was probably more beneficial and more appreciated than the epidural injection that preceded it.

We are living in the dawn of the planet of the value based. Students now embarking upon their medical school journey will emerge light years away from where they began. When they graduate and step into the blinding sunlight of the real world, will they even recognize it?

Or, as in the climactic scene from Planet of the Apes – when Charlton Heston’s character realized man’s demise was his own doing – will they cry out…

You finally really did it!

You maniacs!

You blew it up!

 planet-of-the-apes-1968-movies-14704094-1920-811-which-was-the-best-planet-of-the-apes-a-look-across-time

 

I hope not.

I will do what I can.

But, then again, I am a rough spot.

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White is the new look for fall

sep me cover

On July 28, 2013, the University of Louisville welcomed the Class of 2017 medical students. As an annual contribution to each new generation of emerging physicians, the Greater Louisville Medical Society purchases the students’ first white coat. As President, it was my honor to congratulate the students on behalf of the Greater Louisville Medical Society. Here are my remarks from the podium.

share in an adventure gandolf

“I’m looking for someone to share in an adventure.”

Fans of the author J.R.R. Tolkein, will recognize this as the challenge Gandalf the wizard made to the hobbit, Bilbo Baggins. This is, among other things, an adventure.

I am honored to be here on behalf your medical society – The Greater Louisville Medical Society – to congratulate you on this milestone. At close to 4000 members, we are one of the largest in country. Our mission is to: promote medicine as art and science, advocate for the wellness of our community, and protect the patient – physician relationship.

Today is a big day for you and for us. Today is a milestone along the road that will lead to a your joining our ranks. Today you are not only putting on your white coats, but you are also becoming members of the Greater Louisville Medical Society. To help you stay connected you will have access to our mobile app, where you can get alerts, educational materials, and access information about your new GLMS colleagues. As sponsors of the White Coat Ceremony, your medical society colleagues are honored to provide: your first white coat, provide, your medical society pin, membership in the Greater Louisville Medical Society, professional photographic portrait of you in your new white coat. We are your colleagues, here to support you, and we welcome you.

The Greater Louisville Medical Society has strong ties to the University of Louisville. Most of our members either graduated from the University or did post-graduate training there. I am proud to call myself a graduate of the University of Louisville Medical School Class of 1985.

Back when I was in your shoes, we did not have a white coat ceremony. Back then they wouldn’t let us wear a white coat until third year, much less actually touch a living patient. I wish we could have had a ceremony like this. That is why I invited my own family to come today. This is a special day for you and for your family and friends who have supported you. To these special people in your life, I also offer my congratulations and my gratitude.

Gratitude, yes, because you have chosen a path that is not easy and does not compensate you materially for the years spent, the sacrifices, the risks – financial, physical, emotional. But it is indeed an adventure.

As I look out upon you I see a discovery. I see a cure. I see lives saved from disaster. I see longer, better, meaningful lives. I see a suicide prevented. I see a critically ill baby saved. I see an aneurysm removed. I see a heart murmur discovered. I see a cancer detected because you followed up on the red blood cells you saw in the urinalysis report.

I also see heartache, depression, fractured lives, and failures. It is all part of the path you have chosen to follow. You may not know all the reasons why you are sitting here today. I don’t think I knew. But every day, from this day forward you will be finding answers.

The white coat itself is significant. I remember the day I finally got mine. We walked around the medical complex and even went to eat lunch in one of the hospital cafeterias. In my 3rd year of medical school Dean Ganzel was my attending on rotation through Otolaryngology. On the last day she, so graciously, took her four medical students to lunch. We ate lunch at the Kentucky Center for the Arts in our white coats. The coat meant something. It said something to the world.

9403531070_63bc08e2e1_o

I have worn many white coats since them – short, long, in between – but whenever I put on the coat it still has meaning. It speaks. So I wondered what the message would be if instead of me, my white coat could says a few words. Well, my white coat and I discussed it and now, on behalf of my white coat, I offer this:

a white coat
I symbolize
the goals you hope
to realize

a white coat
my color’s pure
to show your values
will endure

a white coat
I will glisten
if you can try
to mostly listen

a white coat
in my presence
comfort, care and
convalescence

a white coat
wear this fashion
only if
you share my passion

a white coat
for my profession
put patients first
make no concession

a white coat
answer alarm
with answers that
first do no harm

a white coat
hear the calling
wear me when
you lift the falling

a white coat
my fabric must
be nothing but
a weave of trust

a white coat
ability
tailored with
humility

a white coat
a solemn oath
a way of life
or maybe both

a white coat
I’m going to
forever be
a part of you

Dean Ganzel, colleagues, friends and families, Mom, I thank you for this day. And to the class of 2017, I congratulate you and welcome you. For those who hear this calling there is no greater professional honor than to wear that white coat and hear the words, “That’s my doctor.”

Looking out at you, it is clear that I have found someone to share in an adventure.

Gandalf_the_White_returns

… and the white look is very becoming, I must say.

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This year’s White Coat Ceremony was held on July 27, 2014 and is the subject of current GLMS President, Dr. Bruce Scott’s September eVoice.

bruce evoice

 

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