American Society of Regional Anesthesia and Pain Medicine May 2018 - 24

listening carefully to patients, sitting down rather than standing
at the bedside, not interrupting patients, maintaining eye contact,
asking patients how you can specifically help them today, and
dealing with patients' emotions-all to establish a resilient doctor-
patient relationship that can withstand the future need to deliver
controversial or disappointing news.
The psychologist A. J. Mariano4 provided advice in 2017 for dealing
with difficult patients. His primary focus was answering whether
pain physicians should reinstate opioid prescriptions in patients
who had been successfully weaned off the medications, but the
principles have broader application. Mariano noted that learning
self-management strategies is difficult for patients and most
patients have an opinion about what physician-active treatment
is needed next. Yet, treatment must always be safe, logical, and
sustainable.4
In making treatment decisions, patients must be advised to
consider their other life problems even while we are trying to
treat their pain-all that's wrong in their life isn't only their
pain.4 Our responsibility is to get patients the help they need as
opposed to what they think they want (eg, getting more tests,
seeing other specialists,
having their medication
dose increased). Mariano4
recommended not responding
to their accusations; the
reality is, we are making
recommendations, but it is a
patient's responsibility to make choices. If a patient starts making
threats, the best course is to document and explain our rationale
for seeking advice from other colleagues or services. If you are
very truly uncertain what action to take, then seek consultation for
yourself at the time when you believe it is the right action, even
if the patient disagrees. The bottom line is to err on the side of
safety, patient education, and support, despite the patient's ardent
passion.4

do harm to anyone."6 The goal of health care is to keep healthy
people healthy and take care of those who are not. Adapting his
ideas to pain management, we should empower patients with a
single source of information (grounded in our pain practices from
which consistent information is generously provided to patients
and families), expand access to care (recommending necessary
consultations to expand the database upon which treatment
decisions will be made and referring patients to centers for
specialized procedures), centralize care in centers of excellence
(using pain specialists, even if across state lines), and optimize
technology (in the evaluation and the treatment phases of care).
Finally, Mandelbaum adds that "politics should not determine how
we care for people in need."5 We are well aware of how unsettled
the current health care climate is, where patients worry about
insurance coverage for needed therapy and access to necessary
care mandates. Mandelbaum is correct in saying that "patients
need to be served" and pondering whether the Affordable Care Act
is patient or even physician centered.
In the end, we truly need to manage neuropathic pain, as we
do for diseases such as diabetes and asthma, because curing
chronic pain is exceedingly difficult. Neuropathic pain exists at the
intersection of physical and
psychological pathology,
which compounds the task
of management. We need
patients who are active
in the evaluation process,
management planning,
prescription phases of care, and provision of physician feedback.
Engaged, insightful patients can be helped more than those who
demonstrate learned helplessness or passively wait for the doctor
to fix all of their problems. Placing the burden for improvement
entirely on the physician is naïve and nonproductive, but this
demeanor can be induced by pain-related anxiety and depression.
Thus, ongoing patient education and re-evaluation are major,
ever-present responsibilities of the pain management practice.
Establishing a clear and correct diagnosis is uniformly paramount,
because it is essential to treat the underlying cause of the pain
rather than addressing only the symptoms.

"The bottom line is to err on the side of
safety, patient education, and support,
despite the patient's ardent passion."

Beware of patients who perceive that you promised medications,
particularly an opioid, only if they will try other modalities first.
Those patients may attempt to "wait you out" and often offer
(plausible, at least to them) reasons why they could not comply with
the alternate options. We must appreciate, too, that patients will
interpret clinical responses differently. A patient whose pain has not
improved after three opioid dose escalations will continue to voice
that the "right" dose simply has not been reached yet, whereas we
see that as a pain that is not opioid responsive.
Looking toward the future of health care, Mandelbaum5 emphasized
that it would behoove us to remember five important principles.
Per the Hippocratic oath, "I will prescribe a regimen for the good
of my patients according to my ability and my judgment and never

24

Factors that lay a solid foundation for success in the doctor-
patient relationship include taking time to understand and address
concerns from the patient's perspective.7 With this mind-set, the
goals of chronic pain treatment plans should include ensuring
that patients perceive that their needs are taken seriously,
feel educated about their pain syndrome and about available
treatments, understand their diagnosis and the rationale for the
treatment or action plan, endorse that treatment is lessening their
pain symptoms over time, and establish that they are able to live
with residual pain. Ultimately, patients should feel that the negative
impact of pain on their ability to function in life is lessening. Early in

American Society of Regional Anesthesia and Pain Medicine
2018



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