Ethical Case Discussion Case10
(Chronic Pain Management)



1999. Case 5 (Choronic Pain Management)

The patient was 45 year old truck driver.

The patient suffered the rear-end collision accident and after that had
numbness and pain in the left leg.
The patient consulted many clinics and hospitals and was checked by
MRI and Nerve Conduction Test, but all the results were all right.
So he got a medical certificate for one month absent from the company
for a muscular ache.
But the pain persisted for three months and he could not work.
His company and the insurance company
told him to go to the big general hospital and get a medical certificate.

The patient went to A General Hospital.
The doctor who examined the patient in the A hospital thought, from his
interviewing and physical examination and many test results done for
the patient before, that the pain was due to psychological problems
or malingering, and tried to refer the patient to the psychiatric department.
But the patient said the pain is not owing to psychological problem
and refused to go to psychiatric department.

This patient has tended to be absent from the company from the first, and it
is said that the money he is paid from the disability insurance is much better
than the salary he was paid when he was working.

What the doctor in charge to do for such a patient ?



Comments on this Case



Howard Brody
Department of Family Practice and Center for Ethics and Humanities in the Life Sciences,
Michigan State University, East Lansing, MI USA.

Topic: Japanese case: Chronic pain management
Conf: Social Aspects of Care
Date: Thursday, September 02, 1999 10:15 AM

This case raises a number of complicated issues. Many physicians in the US very much
dislike seeing patients who are receiving worker's compensation payments. The stereotype
persists that these patients, either due to conscious malingering or subconscious secondary
gain, will simply not respond to any treatment that is offered, as they have too much
financial incentive to remain sick. In some cases this is no doubt true but in other cases this
is probably a great barrier to the patient receiving proper and humane care.

Even if compensation is not an issue, many doctors strongly dislike dealing with patients with
chronic pain. There are many "legitimate" causes of chronic pain that cannot be detected by
MRI, NCT and other standard tests. Ultimately pain is an subjective symptom and only the
patient knows whether or not he has pain. But physicians like what they can see and
measure, and many physicians persist in thinking, when there is pain but they cannot see
any objective findings, that the patient is manipulating them or taking advantage of them.
Physicians naturally dislike being in this position.

So there seem to be at least four possibilities in this truck driver:

1. He has no pain, or much less pain than he claims, and is malingering.
2. He has real pain, and the most effective treatment for that pain would be some sort of
psychological intervention.
3. He has real pain, and the most effective treatment for the pain would be some form of
organic medical intervention such as drugs, nerve blocks, etc.
4. He has real pain, and the most effective treatment would be a multidisciplinary approach
with both psychological and organic components.

There is a great advantage to a multidisciplinary pain center which has both psychological
and "organic" services on site. This means that the patient does not have to be sent away
from the pain clinic to get psychological services somewhere else, so there is much less
chance of sending the very negative message, "you do not have real pain, you are just
imagining it." As a US family physician, if I have a patient with chronic pain that I cannot
manage myself in my own office, this is the sort of center to which I prefer to refer my
patient if possible.

I am assuming that this sort of integrated pain center does not exist in A General Hospital.
If so, it is important to remember that of the 3 possibilities for this patient which involve
"real pain," two require psychological services. So you can explain to the patient that
sending him for a psychiatric referral does not mean that he does not have real pain. I often
tell my patients that anyone with chronic pain for many months is bound to be depressed
and anxious, and so receiving help for those needs is part and parcel of receiving chronic
pain treatment.

If counseling and persuasion do not work, one could, I imagine, simply tell the patient that
most chronic pain requires a combination of psychiatric and regular medical services for its
proper management; and so if he refuses to go see the psychiatrist, he is actually refusing
medical treatment for his pain, and you will write that on the certificate. But to engage in this
sort of adversarial posture is to risk losing any real therapeutic relationship with the patient.
Sadly, the adversarial posture is largely forced on the physician by the insurance
arrangement; the physician is partly the patient's agent but is partly the agent of the
insurance company. This will make it hard for the patient to trust the physician enough to be
fully frank in describing his pain and the response to various treatments.

Incidentally, there are some maneuvers on physical examination which, if positive, make it
very likely that the patient is malingering. Or the patient may have been secretly observed
doing activities easily which he claims, on medical history, to be unable to do because of
pain. If such evidence of malingering exists then the situation is different. But I did not
understand the case description to indicate that this was happening here.



Kiyoshi Sano, MD, FAAFP
University of Michigan
Department of Family Medicine

   I had many cases very similar to this in my practice back in Minnesota.
Mostly worker's compensation(Rousai).The way I handled was to
set up the treatment schedule such as physical therapy regularly for
reasonable period, for example 3-5 times per week for 2 weeks and
tell them he needs to check with the designated primary Dr(you in this case)
like his family physician as a care coordinator regularly(every 2weeks).
Most of the time the insurance company sets a primary Dr for this purpose.
He/She is the one to orthorize any referrals. Pt can not see any other Dr for
the problem without this referral.
I also try to send pt to work unless pt is totally disabled(bedridden) with
restriction of even desk work only or limited hrs of work a day or any
other.Employer usually prefers this to being off work and they are
co-operative most of the time.
Tell pt that he has to comply with these treatment plan. If he is really sick
he will go to the treatment and come back to you for follow up. If he fails
to follow up with you or physical therapy, document it well even report it
to the insurance company. You can also use a physical therapist for
functional disability evaluation which will determine how much and what he
can do or can't do at work. Based on this result, you set the restrictions.
Try not to give permanent disability too soon, you might limit his future
employability by this.
When you send the pt to so-called "Pain clinic" they always use the MMPI to
assess Pt decency. If normal, then they teach pt biofeedback, relaxation
technique,electric muscle stimulator(Tens Unit) and counseling. Minimize the
use of medications.
The important thing is to keep patient busy in treatment, if you keep pt off
work. Recheck frequently. I would sign disability certificate for only 2
weeks each time then recheck pt to update. Use consultant if not better
after 1 month of conservative treatment.
Make sure tell the pt that the insurance company will cover as long as pt is
compliant to the treatment and the primary physician's advice.
I always trust pt. If he has pain , treat it. Continue treatment until it
is gone. If pain is real he will keep coming to you without fail. When he
starts to fail, then you can send the letter saying pt fails to follow up
and send the notice of termination of disability certificate.

I hope this helps to manage this kind of pt.



Philip Hebert MD PhD CCFP
Assistant Professor, Family Medicine
Sunnybrook Health Science Centre
Clinic Office: A102, SHSC, 2075 Bayview Avenue
Clinical Ethics Centre: Room 228b, SHSC
Toronto

Thanks for the latest case -- it's a common one in primary care:
patients with chronic, non-physiologic pain whose disability may have
"secondary gain" for them. the question is, is this man's pain &
disability genuine or not? This can be very difficult to sort out. The
patient's primary care physician has an obligation to serve the
patient's wishes & interests. He should try to help this patient with
his problem, try to appreciate his disability & work with the patient in
an agreed upon rehabiliation program.I'm not sure psychiatry would be
very helpful here but a multidisciplinary rehab programme might be (do
you have these clinics in Japan?). A confrontational approach that
assumes the patient is lying would be less likely to succeed & would
undermine the trust between patient & phsyician. A global rehab
programme looks at the patient's experience of his problem & treis to
help him function better. That being said the monetary gain this pateint
may have with the insurance money may undermine efforts at developing a
cooperative plan. If the patient refused ALL efforts at rehabilitation
(& not just psychiatry), ethically it would be justified to limit his
benefits.



Yoo-Seock
Department of Family Medicine
Dankook University, College of Medicine, Korea
Family Medicine in Korea

I'm really pleased receiving your new case. I have communicated about your case to
my new friend, John McGuire(Ph.D. Canadian ethicist) who is working at Hoseo
University in Korea.  We discussed about your case, recently. so, I'm sending our
opinions to you.

Regarding your case, physician only could tell known(confirmed) facts as a medical expert
such as patient's symptom is not related to physical illness but possibility of psychological
basis.  Maybe patient's behaviors are caused by secondary economic gain from insurance
company.  But, the physician has any responsibility to confirm what the real situation is.
I don't think it is the doctor's responsibility to decide whether or not the patient is lying.
Nor does the doctor have any responsibility to assist the patient in collecting money from the
insurance company. The doctor does, of course, have a responsibility to be honest, which
means telling the insurance company and the patient that he can find no physical basis for the
pain.



Discussion Summary of the medical students of Saga Meical School
by Masashi Shirahama

The Main points the students told were as follows;

1) It is difficult to make the diagnosis of malingering. If the doctor has
such a kind of prejudice, it is very difficult to make good patient-doctor
relationship.
2) In Japan, Pain Management Center is not so popular, and a doctor in
charge needs to discuss with many specialist, such as psychiatrist or
anesthesiologist.
3) How do the family members of the patient think? How does the patient do
in his house? What kind of support does the patient's family can do?
4) What kind of medical certificate can be written in such a difficult case?
To this question, I commented to the students. First we Doctors cannot
write the false certification. But in some cases we cannot know the true
diagnosis. So we can write the possible diagnosis as far as possible.
If possible show the certificate to the patient, it will make less
misunderstanding between doctor and patient.
5) In Japan, Business is still in depression, so companies cannot pay much
for the patient for a long time. What is the situation in the prosperous
USA.



Respond from Howard Brody to the Comments Above

Please congratulate your students on some excellent and insightful comments.
I also enjoyed reading the practical suggestions from Dr. Sano.  I think his
approach offers a nice compromise -- it does not label the patient as lying
or malingering, or as having less than an earnest desire to go back to work;
but it deals equally well with those possibilities in case they should be
present.

What about the "prosperous" US, you ask.  In my experience very few worker's
compensation plans or disability plans pay nearly as well as one's regular
job.  I think it is not uncommon for a disability plan to pay only about 1/3
to 1/2 as much as the wages one was used to receiving at work.  So there is
little financial incentive to become disabled if one thinks one could go
back to work.  The financial incentive comes when one has been off work
because of pain or illness for a long time, and one is making no money at
all; and the 1/3 or 1/2 then looks like a very good bargain.  The entire
system in the US seems to me to be very adversarial, assuming that the
person is lying about their disability until proven otherwise.  Most primary
care physicians hate to become part of that system as it seems to seriously
compromise or distort the relationship with the patient, as Dr. Hebert
mentioned.



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Masashi Shirahama M.D.
Director, MItsuse National health Insurance Clinic
Lecturer, Department of General Medicine, Saga Medical School
2615 Mitsuse, Kanzaki Gun, Saga Ken
842-0301 Japan

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E-mail:HQC00330@nifty.ne.jp
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