You Don’t Say

This past week has been a crash course in addiction and substance abuse with the best trained and most experienced Addiction subspecialists in the New Orleans area. Addiction is a fascinating and complicated problem that is often not well addressed by conventional medical and health care infrastructure. There are hundreds of independent programs, often in the forms of “Houses,” that follow different paths to recovery with varying levels of commitment and self-direction. It is also a field where I suspect there is often a very wide divide between the patient and the physician: the physician, often a psychiatrist or family practitioner or internist, serves as one of the leaders of a multidisciplinary treatment team consisting of a psychiatrist, a psychologist, nurses, social workers, case managers, and more. While the multidisciplinary approach is excellent in eliciting the strengths of each team member, it also dilutes the relationship formed between the patient and any one member of the team.

Today, I had the unfortunate experience of observing a lecture by a nurse-educator to a group of inpatient substance abusers. The nurse-educator was attempting to provide scientific explanations, based in neurophysiology and neuropathology, for the development of tolerance to various drugs such as alcohol and opioid drugs, the main drugs from which the patients were detoxing. However, the nurse’s approach was very detailed and (by patient report) far too complicated for most individuals. Furthermore, for someone (like a medical student with some interest in Neurology) with a medical science background, the lecture was absolutely appalling with respect to the degree of misinformation provided. Yesterday, one of my team members (another medical student) and I did our first Health Education Group lecture to our inpatients on our psych ward which was regarded as a great success: we were able to keep things simple, provide clear messages and concrete suggestions and facts, elicit meaningful questions from the patients related to our topics of discussion, and provide adequate explanations. However, this nurse not only focused on too much detail and provided wrong information: he did a disservice to the treatment team and patients by cultivating distrust and confusion. In one case, a few of the patients were confused as to why doctors might use methadone to treat heroin and opioid dependence when methadone itself can be abused and can have terrible withdrawal symptoms. Instead of answering the question with a clear explanation of the rationale for treatment (methadone has a longer duration of action than the opioid drugs patients abuse and is gradually tapered by the doctor with close observation, thus aiming to avoid the symptoms of withdrawal that might drive a patient to seek the original drug and relapse), the speaker called methadone the “1950’s treatment” (implying that it was outdated, despite its continued usefulness at this time) and diverted the discussion to the topic of buprenorphine, a newer medication used to treat opioid dependence. The patients then expressed concern about buprenorphine as being the “2008’s methadone,” a notion the speaker failed to adequately dispel. Essentially, due to his lack of complete knowledge and his failure to say “I don’t know” when appropriate, the nurse-educator fostered distrust in current medical treatment for dependence.

Saying “I don’t know” used to be a major problem for physicians… especially in the 1920’s around the time of Dr. Richard Cabot, a well-known Boston physician who wrote extensively on the subject and the need to improve the patient-physician relationship with honesty. Dr. Cabot would say and suggest other doctors to say, “I don’t know the answer to your question, but I have a colleague in that field that will know the answer. I will consult him/her and find out the answer.” Every physician I have shadowed, worked with, or encountered has done the same when asked a question by a patient that he or she does not know the answer to. The third year of medical school trains us to do so when appropriate: we have a basic level of knowledge that cannot answer all patient questions or the “pimping” questions of our attendings and residents, so we can say, “I don’t know” and then learn from them. Is this not engrained in the professional culture of other health care workers? Today’s example exemplified irresponsibility.

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