When I was in practice, we sometimes ran into this situation: our patient needed to be seen by an orthopedic surgeon, and the team at Children's Hospital in Oakland was in great demand. So here was how they triaged who they would see. They assayed the chances that the patient would need surgery – the remunerative part of their practice (although truth to tell, they make so much from their office visits – a couple hundred bucks for five minutes is not unusual – that one wonders.) Anyway, we could always beg as a tactic and sometimes that worked. But then UCSF provided some some competition with a nice female peds orthopod who would see everyone and who tried to err on the side of not operating, we started referring more to her, and magically the Children's Hospital orthopods were more willing to see all of our patients.
Last night I saw my friend Jeff, from our book club, at our friend Norm's birthday party. Jeff had been suffering from a foot condition and had put off surgery for fear that it wouldn't be successful. His pain became unbearable so he had the operation, and happily, it was successful. He even danced at the party, or at least that was what he claimed he was doing; objective observers were split on their interpretations. But the foot looked fine, and he said he is now pain free. It is so great that modern medicine can successfully treat conditions big and small.
“So it went well?” I observed.
“Yup,” he said. “No problems at all. I didn't realize how how big a procedure it would be. I had general anesthesia and I was out for a while. But it's fine.”
“But get this,” he continued. “So I go home and Mary drives me and we pick up the pain meds I was prescribed. They prescribed Percocet, oxycodone plus Tylenol. That's pretty strong stuff. Do you know how many pills they prescribed? 50!
“So the first night I cut one in half and took it. I didn't like it; it made me feel bad, kind of weird. And I was on the phone talking to a friend and Mary said, 'You shouldn't be talking on the phone while you're taking those pills.'
“'Why not? I said. 'Did I sound weird?'
“'Yes, you certainly did,' she said. 'Stay off the phone.'
“So I only took one or two half-pills more, and you know what, just Tylenol seemed to do just as well for me. Why did he prescribe so many pills? I've got 48 and a half pills left, I don't know what to do with them because you're not supposed to flush them. What should I do, sell them? They're very salable. And somebody paid for me to get those pills, even if it wasn't me directly since I'm insured. Why did he do that? Isn't this what's behind the whole opioid epidemic? Isn't this the path to heroin?”
Well, yes; indeed, why did he prescribe 50 heavy duty opioids? It doesn't seem reasonable or prudent.
Well, think about our peds ortho friends looking for operations and avoiding office visits. In addition, think about how surgeons are paid for operations; they get a flat fee that includes payment for any office visits for the next 30 days. Clearly, it makes economic sense for them to avoid office visits after the operation is over, or even to avoid troublesome unpaid phone calls to the office. “Up and out, my man!”
From the surgeons' point of view, it obviously makes all the sense in the world to prescribe an ample supply of pain pills. It makes narrow sense, and so many surgeons are themselves so narrow. It's not for nothing that we know their motto to be, “When in doubt, cut it out!” Be decisive, and let's not overthink it, or some would say, let's not just think it through, period.
As I say, goddamn surgeons. Not all of them, but Jeff's, and so many. Where does the opioid epidemic come from? We know it's multipronged, we know that the pharma companies and the Sackler family convinced the medical profession that opioids were more effective than they actually are, and that if taken for pain they are not addictive, which is not true. But everyone knows by this time that this isn't true, and we know that prescribing them in quantity is not only unwise, it is dangerous and IMHO it should be unlawful.
By this time, no surgeons should be doing this. Talk about problems getting information out? Hell, you could read Time magazine and figure this one out. Jeff is not a medical person and he saw the problem immediately, as would any well-informed lay person. It's not so hard to adjust - after my oral surgery last year my periodontist gave me, what, 5 Percocets or Vicodins in a little packet?
So I say, goddamn surgeons. You can set up new systems, you can pay doctors to do the right thing, you can do lots of things, but in the end you really shouldn't have to. In my disgust, I simply say, “Goddamn surgeons!”
Not that that helps anyone but me.