I am pleased to be near the completion of my studies, and this module was a great way to amalgamate all that I have learned through the previous modules.
Managing pain in the community is a vast subject, and to me, highlights the need for MDT collaboration, as pain is certainly not simple, rather multi-faceted, and no one discipline holds all the answers in treating it.
I was impressed with our first tutorial especially, where the speaker discussed frequent service users, multi-morbidity and chronic pain. As with many things through my studies, I was unaware of many of the problems encountered by many patients. I was impressed by the dedication of the team who analysed why there were so many frequent attenders to A&E, and their setting up of a service to support these patients. I've long said that many people need a ‘professional best friend’ to aid them through life, and it was good to see an example of this being used in the real world. I looked to see what my area has to offer along similar lines, but although we do have pain services, they appear to be fragmented, with little obvious collaboration between them.
In my clinical role, especially since the COVID-19 pandemic, it was obvious to most that NHS services were overstrained. As I work in private practice, I have the opportunity to spend time with my patients, to really get to know them. I knew GPs didn’t have much time to spend with patients in their 10-minute appointment slots, but not that their overall examination time was around 2 minutes. How can any medical professional be expected to perform at their best with that time constraint? So, I have enhanced my clinical skills so I am able to examine a patient in more detail than before and to report my findings in an email to their GP summarising them. At least if the GP still wishes to see that patient for themselves, I have done a lot of the groundwork for them. I was initially concerned that I would appear to be ‘stepping out of my lane’ but as I have a few local GPs as patients, I have been told first-hand that they appreciate me doing this.
The course material on ‘Prescribing in the Community’ and ‘Managing Particular Patient Groups’ were particularly useful to me as they gave me a little more background knowledge/information to consider when writing to GPs.
I personally found the tutorial on patients who experience suicidal ideation interesting, as I had a chronic pain patient who I was treating take their own life a few years ago. This came as a huge shock. I had only seen him two days before. I have wrestled with this, as initially, I felt that I had perhaps missed some clue, some sign of what they were planning, and maybe I could have prevented them from committing suicide. I have concluded that as they planned it carefully, nothing was going to deter them, they were experiencing a horrible run of painful weeks and decided that death was their only way out. As a solo practitioner, I had no support at all in processing this, but I have ultimately made my peace with it. I think the tutorial was good at explaining how to spot the difference between a person who intends to take their own lie, or whether it's just an idea based on their current state of mind.
Pain management in the community has been very much on my family's mind of late. We have a relative who is in stage 4 prostate cancer, which has spread into many of his bones, resulting in two fragility fractures and of course, much pain. This person is not an easy patient. He will only take medication as and when he wants to, due to the side effects of being sleepy, feeling nauseous and becoming constipated. He wants to drive, be mobile and active in the community as he was before. Polypharmacy and an elderly patient such as him are not good bedfellows. He gets confused by what he can take, as he has many packets of the same drug name, but all at different dosages, and will only follow the instructions literally as they say on the box, ignoring what the palliative nurse has told him to do!
He won't entertain the pharmacist putting some of his medications into a dosette box, as he will have to pay for that. It's exhausting for us, and terrible for him. He has been deemed of sound mind, so how do you manage a patient like that?
His GP doesn’t seem to know what’s going on, but palliative care does seem in control of his pain management, however, this patient deems his carers, who have no medical training, as being his go-to advisors for advice about his medication. They even ask him if he wants to take his medication, implying he has a choice (which of course he does) but the reality is that he has no choice if he wants effective pain management!
My personal example, plus hearing similar stories from other patients, highlights how communication or lack thereof can be a barrier to effective care. I for one would appreciate more guidance on dealing with non-compliant patients.
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