Several authors have described the medical-school experience as “socialization” into the medical field. Medical students often learn the scientific underpinnings simultaneously with the social processes of interviewing/dialoging, examining, and then developing a treatment plan with the patient. One “subspecialty” social process that orthopaedists learn is pain management. While we are certainly encouraged to understand the scientific basis of this important and complex topic, much of the learning comes in the form of mirroring: junior residents do what senior residents instruct them to do, while senior residents follow the direction of attendings. These passed-on habits are culturally ingrained and persistent.
As Young et al. show in the July 17, 2019 issue of The Journal, the pain-management habits learned in training vary greatly from country to country, which is not surprising. Specifically, these authors examined the prescribing of postprocedural opiates by residents in the Netherlands, Haiti, and United States. They found that US residents prescribe significantly more morphine milligram equivalents (MMEs) of opioids at patient discharge than residents from either of the other 2 countries. The authors also showed that residents from the United States were the only group prescribing a significantly greater amount of MMEs to patients younger than 40 years old than to those above the age of 70.
Many pundits pin the phenomenon of opioid overprescribing in the US on the American public’s wish to be free from discomfort, along with the aggressive marketing and advertising of these medications in the United States. While this may be true, I think Young et al. have further identified the major influence that a resident’s training environment may have on prescribing practices. As already mentioned, residents often imitate what they see from more experienced residents and attendings, but sometimes those lessons, especially in pain management, lack a scientific basis.
What is missing from this survey-based study is data on patient satisfaction with postprocedural opiate prescribing. Having been involved in clinical care in Haiti, my impression is that patients there accept the local practice of pain management, constrained as it might be by resource limitations. I suspect the same is true in the United States and the Netherlands. Regardless, these findings demand that emphasis be placed on teaching orthopaedic residents evidence-based pain-management protocols. This will require a concerted effort from teachers and mentors at all levels of our medical-education system. This investigation is an important reminder that developing solutions to the opioid overprescribing problem in the US might begin in residency, where “cultural formation” occurs.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
For all of us who have been to Haiti, the norms there are severely resource- and culturally driven. This study is a waste of paper.
Once again, anything government touches gets worse. Those mandated smiley faces force people to focus on their pain, which is the opposite of what we used to do. And now, the ability of patients to give negative feedback about their pain management encourages residents to do whatever it takes to keep the patients happy. And then we have the FDA, which takes away drugs that are useful in some cases ( Darvon comes to mind) without considering the alternatives’ risks. These are the same guys who outlaw CBD oil for pain, at the same time the patent for Cannabinol is held by the HHS and NIH, which state that there is no bad side effect. That is the epitome of government malfeasance. So the answer is to get the FDA out of our prescribing and big pharma out of our med school curricula and teach honest pharmacology and ethical medicine. What’s the chance?
I am quite perturbed by the opioid crisis. The US government via The Joint Commission in 2001 decided as medical experts that pain needed to be better managed and better treated by physicians. By encouraging the use of narcotics, the US government CREATED the overuse of narcotics and exacerbated narcotics addiction. Now, some 15 years later, suddenly the opioid crisis is the fault of doctors and the pharmaceutical companies, and now the government has made it impossible to treat postsurgical and cancer patients with adequate analgesic control without going though multiple hoops. Perhaps it would be best if the government stopped intruding into medical care, as there was never a problem before 2001.
Factors which influence the prescribing of opiates in the US which do not occur in other countries are:
1. The government’s invention of ‘Pain as the 5th Vital Sign’ and the negative consequences of any patient having any pain score above zero, and
2. The risk of a medical malpractice suit, which becomes more likely with any cause of patient dissatisfaction.