Editor’s Note: This story about family practice physicians and their opioid prescribing statistics that ran on the National Pain Report prompted this response from Terri Lewis, PhD.
Every time I read an article about opioid prescribing practices it raises a number of issues for me:
(1) What is the role of medical education in teaching physicians how to practice their craft?
(2) What is the role of patient characteristics in the physician’s response to development of plans of care?
I wonder if we don’t have a number of things we should be looking closely into.
There have been conversations raised about the limitations of training physicians in a hospital based environment, with little or no reality testing for the operations associated with practicing in the primary care or specialist community setting. As the hospital population is understandably sicker, treatment is focused on throwing the necessary resources into levels of patient care designed to get them dismissed from the hospital environment. This provokes an intense, acute response with a new focus on reduction of readmissions.
The patient who is living in the community however, presents somewhat differently. Their needs are different, and perhaps the treatment response should be more broadly distributed across the integration of medical practices and community resources. How do physicians learn to do this when they are not trained in community settings? Would it be reasonable to assume that hospital trained behaviors may be transferred into the community practice setting?
Could this affect prescribing and treatment patterns? Is defensive medicine the result of hospital acquired training or the absence of decision skills necessary to practice in the community setting?
Patient complexity in the community setting is wholly different and requires a different response to care than that required in the hospital setting. Chronicity and complexity are real issues that persist over time and require different decisions and models of care. Maintenance of function has different outcomes than those associated with cure. Should improvement of the illness be the standard by which treatment is measured when dealing with chronicity? Isn’t the real issue that of maintaining function and quality of life in the face of complex conditions that are likely to be present for many years and even until the end of life? If the physician has not learned how to coordinate and hand off within and between community healthcare and social services, how are they prepared to address the complex patients who enter their practice stream except through over prescribing, over treating, or in frustration, refusing to treat at all?
Finally, can physicians who transfer hospital based decision skills for community focused practice operate with the necessary frame of reference to manage the long term complex care needs of consumers, the expertise of other specialists, or make judgments about the appropriateness of care provided by others?
Are these conditions the result of our current practices in medical education?
Increasingly the evidence indicates that we might have a latent problem that is influencing our interpretation of these matters.
Seems worth taking a close look at to me.