Dear Patient

Aug 16 2011 Published by under Medicine

I do believe that you are in pain; I can see it in your eyes, your furrowed brow.  I can see it in your hesitant gait, the cautious way you get up and down from my exam table.
But this is the first time I've met you. I don't have your medical records.  I don't know anything about your kidney or liver function, whether or not you have heart disease or diabetes.  You don't know either, which is not unusual.  Many people come to me for the first time without a list of medical conditions or current medications.  We can work it out.

You can expect me to take a thorough history, do a complete physical exam, and request your old records.  But I am not going to give you a prescription for narcotics today.

It's not that I don't believe what you're telling me:  I believe you when you tell me that ibuprofen doesn't work or that you are allergic to it.  I believe you when you tell me that all your other doctors have given you narcotic prescriptions.  But I don't know you yet, don't know your whole medical picture.  Narcotics are potentially beneficial and potentially risky.  Dependence is a disease that is very common, and very difficult to treat.  You should not expect me to take such a risk with your health at this point.

It is possible that your disease, be it chronic pain or opiate dependence or both, does not let you understand that.  You may feel angry, depressed.  You may lose your temper, behave inappropriately.  If I suspect a narcotic use disorder I may offer you a referral to a local expert.

You may not like this, and I may be totally off base, but I have to give the best advice I have, whether you like it or not.  I hope that you will be able to see this as an act of kindness rather than another obstacle in your efforts to get what you think you need.

I will continue to try to help you treat your pain, but I will choose medications for your pain and your other conditions based on what is likely to give the most benefit for the least risk.  Sometimes this treatment may include narcotics, sometimes it will not. All I can do is advise and hope that my advice is good, and that you will follow it to the best of your abilities.

To you health,


5 responses so far

  • Kevin Nasky says:

    Well said. Brilliant.

  • IanR says:

    I have a question about this. I had a friend who a doctor pegged with having anxiety, and gave him benzodiazapenes right off the bat. Given they are addictive and abuseable, is that the best prescription? Or should the doctor have tried something else first?

  • LM Alden says:

    Dear doctor, Obviously you don't believe that Im in pain, you didn't take the time to read all my medical records I took the trouble to have faxed over to you weeks before my first appointment with you and prescribing 10 narcotic pain pills or even Ultram to tide me over until after my lab work comes back in and we can meet for the second time to discuss my chronic pain and chronic disease which has been well documented for over 3 years in those records I kindly had faxed over to you from all my previous MD visits that you couldn't be bothered to read is out of the question because you think Im med seeking. Even though you would have noted in my previous MDs notes that that I manage my autoimmune disease on 1 vicodin at night to sleep and a bottle of 90 lasts me 4 months. And that of the three refills one was never used. And that I prefer asprin and motrin to narcotics but sleep is impossible because I hurt. And that I was using 100mg of benadryl and a shot of tequila at bedtime to try for four hours of rest and that my last Rheum whom Ive seen for the past three years every three months faithfully had to convince me to try the vicodin in the first place. And that I have refused the sleeping pills she offered. Or the pain patches. Which is why Dr, I come away with mistrust and an even lower opinion of doctors in general and you in particular , thereby ruining our nwly established Dr /Patient relationship irrevocably. But Im too tired and in pain to look for yet another I might be able to establish a working relationship with. Because just as you have to try (or should) trust me I have to try to trust you. And which is why I would choose to self medicate with whatever is at hand such as alternative, homeopathic, herbal and even foreign medications to relive that pain you say you see in my eyes and on my brow but cant be bothered to treat just yet because you don't want to prescribe me a weeks worth of meds. And I wont bother to tell you about what Ive tried between our visits since I really don't think you care to hear about my pain, what works ,and what doesn't . It seems you care more about your prescribing track record. And have lumped me in with drug seekers and abusers which, if you had read my records, you would have seen continuity of care with the same doctors ,and meds year in and year out - something a good doctor would know is not the pattern with drug seekers. They doctor shop. Go somewhere 1-2 times and move on. Visit every ER in town. Have sporadic care. A good doctor would know that. Which makes me worry about your experience , diagnostic ability, and skill level. Ill stick with tequila. And asprin. And the ER when I feel like Im truly dying.

    • ZenHousecat says:

      Mr./Ms. Alden,

      No, he didn't (and won't) take two hours to go through the 200 pages of records scattered from your internist(s), ER docs, general surgeons, psychiatrist, psychologist, orthopedist, neurosurgeon, endocrinologist, neurologist, rheumatologist, physiatrist, gastroenterologist, infectious disease, and chronic pain specialists--stop me if there's anyone I missed--until you actually show up in clinic to be evaluated.

      Because if you don't show up, he's wasted time that could be better spent with his other patients, or with his family, and hasn't been compensated for it.

      *When* you appear to his clinic, you're entitled to a block of PalMD's time to get to recount your history, receive a good physical exam, and have appropriate lab tests drawn and imaging ordered. He will then review your records after clinic, likely at home, on his "off" time. He'll then, more likely than not, contact your previous physicians to get caught up to speed on any issues that may not have been included in the records. *If/when* you return for followups, the process of building a therapeutic relationship can go forward. That's. Just. The. Way. It. Is.