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Sympathy vs Empathy With The Devil

What’s the difference between sympathy and empathy?

Example in action*: I was on call. I got that page, that very typical page: Patient running out of pain meds needs immediate refill please call.

Ugh. More often than not, the phone call that follows this page is full of excuses, explanations, promises, and demands. This one was no exception.

My doctor prescribes me Oxycodone for my back pain, it’s worse than bad, I’m on disability for this, but my niece and nephew were visiting this past weekend and I lifted one of them up- shouldn’t have done that, I know!- But I wrenched it out again, and I need an early refill. My doctor knows I don’t abuse this stuff, I swear I don’t even like to take this stuff unless I really have to, and I know he would fill this for me no problem, so sorry to bother you, I know you’re only covering…Any way I can get a few more than the usual number, since I threw my back out? It REALLY hurts. 

The whole time my stomach was twisting, my gut instinct practically screaming out FRAUD LIES SCAM RUN AWAY but there I am, on the other end of the phone, on the hook to deal with this.

In the past few years, laws and guidelines around opioid prescribing have changed, for the better. For any of these calls, I now need to look first for the signed controlled substance contract on file in the electronic record, and then, check the recent drug and toxicology screens. All patients on chronic narcotics are required to have a contract on file, and minimum yearly drug screening: Drug screening that better show the prescribed drugs, and no illicit ones.

In this case, the data was on my gut’s side. Yes, there was a signed contract that clearly stated that the patient would not ask for early refills, would only get refills from their usual provider, and would not use any illicit substances while taking the prescribed medications.

And there was recent drug screening that did not show any Oxycodone, and did show THC (marijuana). The absence of the opiate reveals that the patient is not taking it regularly, and diversion should be considered.

There it was. There was enough data: the decision on whether or not to prescribe was taken out of my hands.

Still, this is not a pleasant conversation to have. I calmly explained these things to the patient, adding, I’m sorry, but your drug testing results are not compatible with our mandated prescribing guidelines. Therefore, I cannot prescribe this for you. And I kept repeating that, over and over.

Needless to say, this was not well-received. The patient expressed outrage and defamation. She was going to complain to the hospital administration about me.

She described all the reasons why the testing may be incorrect. And then insisted that all of this had already been cleared with their doctor.

Then came blame, guilt-tripping, drama: I’m in so much pain. What kind of a doctor are you, that you can leave someone like me totally stranded here, in pain? I’m suffering. You don’t know what it feels like to have this pain. If you had this pain, you would be begging for medication, you know it. 

I stuck to my line, quietly, firmly. It went on and on. I did not budge.

Then, very suddenly, there was a change in the patient’s tone. There was a higher pitch, a desperate crack in her voice: Okay. You don’t understand. I have two kids, I’m on my own, and I’m having money troubles. I need all the income I can get right now, just to put food on the table, to put lunches in the lunch boxes. I don’t need this from you right now. Okay? Can you just fill my prescription? 

I knew right away, I understood, that this patient was almost admitting that they were, indeed, selling their drugs on the street, and probably for quite a profit. They had likely come to depend on this income. And I was shutting it off.

When I repeated again why I could not fill this prescription, the lady exploded with rage. She called me several choice expletives and hung up.

While I did not feel sorry or sad or bad about not filling the prescription- it would have been illegal for me to do so, with proof of likely diversion- I did, for the first time in one of these cases, have a glimpse of understanding of where the patient was coming from.

I could almost see the squalid apartment, the almost-empty refrigerator, the kids in Goodwill clothes, the landlord demanding the rent. I could hear her frustration with everything: fighting with the ex for alimony, waiting in line at the food pantry, relatives turning their backs. I was touched that she had come THAT close to a full confession, to revealing a painful, shameful truth, to me.

And that is the difference between sympathy and empathy: sympathy would have been to feel sorry or bad or sad; empathy was to have a better understanding of where she was coming from, and from that, to feel… a sort of kindness. I was able to come away from the encounter without judgment, and forgive.

There but for the grace of God go I.

It didn’t make what she was doing alright, and it didn’t change my management. I was more than happy to get a few Oxycodone off the street. Heck, I couldn’t even wait to get off the phone and be done with the whole unpleasant experience.

But, I had been given a snapshot explanation of why she was who she was, and what would make someone do what she was doing. With that understanding comes kindness. And that, when you’re trying to take care of another person, makes all the difference.

That’s what I would like to always be, regardless of what I need to say or do as a doctor who tries to do the right thing by her patients:

Kind.

*a composite of cases, with any identifying characteristics omitted or changed, as per usual

9 replies »

  1. I love this post. … Many of the things that are irritating (and also, yes, unsafe) in medicine are really symptoms of societal problems, human problems, that are unaddressed in other venues and become health care system problems. … Thank you for sharing. It is actually a lot easier to have empathy when this woman essentially confessed. She is desperate. And that is so hard. But obviously illegal drug prescriptions are not a solution. It’d be nice if you happened to work in a large enough environment to be able send her to a social worker? Maybe there are some welfare benefits she is not receiving she could be? Or info on a food bank, vocational training, etc. … Ugh. Tough one.

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    • You’re right, it would be ideal were I able to connect people like this with services to help (this case was a composite of several). If a patient is abusing meds/ addicted, then we are obligated to write a medication taper and provide a referral or at least information on drug treatment resources. Diversion is a different issue… In most of these encounters, the patient has eventually turned hostile and threatening, or become so personally abusive, that it kind of makes it impossible to help.

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  2. This is how I safely prescribed opioids for years in primary care. I never ever ever ever (not ever, not once) gave early refills. Not.Ever. I was explicitly clear about that when I gave the first scrip and documented it every time (I had an info sheet I gave out – I didn’t use contracts and didn’t do drug screening). The “nos” are hard to say, and the anger is hard to listen to, and it is utterly the right thing. And yes, this is empathy. And the answer is still “no”.

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    • Thanks! Always good to have really clear rules. It has been such a relief to have our institution lay down the ground rules. Now if I have to say no, I can deflect some of the anger by citing “the rules”.

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  3. what a great, eye-opening post. Thanks for the reminder to always be kind. Even when it may not be appreciated or make a difference. I wonder: if your policy is to not refill opioids early, is there any way to screen out those calls before they make there way to you? I’m sure its a huge time burden not to mention the emotional toll.

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    • You still need to assess each one. Some of the requests (actually, most of them) are for undertreated pain. So you may need to make a dose adjustment – not the same thing as an early refill. I usually needed an office visit to sort that out. I also counseled patients that if they realized the pain wasn’t well-managed, they were to call me immediately, not increase the dose on their own. If they increased the dose without calling more than once, I stopped the opioid.

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