PAIN MANAGEMENT
Facts and Misconceptions
Pain management is a public health issue in the United States because of decisions made about the use of resources in treating cancer patients, insisted Kathleen M. Foley, MD, chief of Pain Service, Memorial Sloan-Kettering Cancer Center, New York City. Speaking at a meeting sponsored by the Center for Health Care Ethics, Saint Louis University Medical Center, Foley said that aggressive anticancer treatments are often used when they are known to be ineffective, while proven palliative care methods are neglected.
In spite of the "explosion of information on pain syndromes" in cancer patients in the past 20 years and the availability of sophisticated methods for assessing pain and for modeling drug therapies, many patients do not receive adequate pain treatment, according to Foley. One-third of children in active cancer therapy and two-thirds with advanced disease have significant pain, she said.
A wide disparity between patients' own ratings of pain levels and the ratings of their care givers was revealed in a Johns Hopkins study of perceptions of cancer pain, Foley added. Failure to believe patients' complaints, she said, is the greatest barrier to adequate pain management.
Other barriers Foley listed included physicians' ignorance of current approaches to therapy and pain assessment, inadequate patient-physician communication, patients' limited expectations, the unavailability of narcotics in many states, and fear of addiction.
According to a national survey, many physicians incorrectly define addiction as physical dependence when the correct definition is psychological dependence, Foley said. Cancer patients do become physically dependent on drugs, but Foley said there are ways to easily reduce dependence. She explained that the fear of psychological dependence stems from confusion with the behavior patterns of compulsive drug abusers, who are physically dependent and tend to relapse after withdrawal.
Pain management is also impeded by state regulations such as New York's requirement that patients using narcotics for more than three months be registered as habitual drug users and Texas's law that makes any physician prescribing opioids subject to prosecution, she said.
Foley called for much more attention to the facts and the misconceptions about pain relief therapies before society considers physician-assisted suicide as an option to relieve cancer patients' suffering.
INFORMATION SYSTEMS
Data Bank Off to Disappointing Start
The U.S. Department of Health and Human Services (HHS) has some hard work ahead to help its National Practitioner Data Bank live up to expectations, according to a U.S. General Accounting Office (GAO) report. After hospitals and physicians expressed concern, the GAO investigated why it takes several weeks for the data bank to respond to requests for information, why some institutions have received sensitive data to which they are not entitled, why HHS has not adequately monitored the data bank contractor, and how HHS will oversee its redesign of the data bank.
The National Practitioner Data Bank, which began operation September 1, 1990, "was created to help prevent unethical or incompetent health care practitioners from moving from state to state without disclosure or discovery of their previous damaging or incompetent performance," according to the GAO report. The Health Care Quality Improvement Act of 1986, which authorized the data bank, requires hospitals to query the data bank whenever they are hiring, granting clinical privileges to, or reviewing a healthcare practitioner.
To accelerate the response time to requests for information, GAO recommended the data bank use telecommunications and urge those requesting information to use physicians' Social Security numbers on all documents. HHS responded that its current controls for handling queries is sufficient; however, HHS is waiting for Congress's response to a proposal to provide for mandatory reporting of Social Security numbers.
The GAO identified six cases in which organizations received sensitive information to which they were not entitled. In some cases the address was incorrect. HHS plans to reduce such errors by using electronic transmission.
Because HHS has not adequately monitored the data bank contractor, "system processing deficiencies continue, system documentation is inaccurate, and proposed changes have not been thoroughly reviewed," according to the report. The GAO recommends on-site monitoring to ensure the contractor is correcting system problems. HHS has agreed to this and "plans to focus its increased monitoring at key points in the design, testing, and implementation of revisions to the automated system."
To avoid perpetuating existing problems when the data bank is redesigned, GAO recommends HHS ensure user needs are adequately identified, requirements fully defined, and alternatives assessed. HHS concurs.
FAMILY LEAVE
Much Ado about Nothing
With the recent passage of a family leave law, companies may fear it will have a disruptive and costly impact on their businesses. However, even though many American workers are now entitled to 12 weeks of unpaid family leave a year, evidence from states and companies with family leave provisions shows most workers will not take full advantage of it. Many need the pay; others are unaware the leave is available; and many employees "just don't dare put their private lives ahead of their careers," reports Fran Hawthorne in Institutional Investor.
Although the family leave law orders employers to continue employees' health insurance coverage while they are on leave, few companies offer much practical assistance to workers taking time off. "A paycheck, even a partial one, would be nice," writes Hawthorne. She points out that one company, Ben & Jerry's Homemade, provides a two-week fully paid paternity leave and a six-week maternity leave at 60 percent of salary (beyond the six weeks of disability).
One subtle way companies discourage family leave is by not publicizing the option, notes Hawthorne. Sometimes managers will acknowledge that employees are allowed a specified amount of leave, but urge them to return to work as soon as possible, says Carol Sladek, a consultant at Hewitt Associates.
Employees who can forgo their paychecks for awhile often do not take the unpaid leave to which they are entitled because they fear such a move may hurt their careers, especially if they are being considered for a promotion. Some family-friendly corporations are trying to quell these fears.
To assure employees that the company supports those who take family leave, Stride Rite Corporation's vice president for human resources took paternity leave early this year, notes Hawthorne. Johnson & Johnson has added to its official credo, "We must be mindful of ways to help our employees fulfill their family responsibilities."
Managers sensitive to a company's family leave policy are an important aspect of making the policy work, explains Hawthorne. Johnson & Johnson held a half-day managers training session before its family leave policy went into effect. Its bimonthly in-house newsletter always includes an article about work and family issues. Each year Time Warner holds 40 educational programs on work and family issues.
Whatever tactics companies use, "the idea is to put the subject in the limelight so that employees as well as their supervisors are aware of the leave option and come to accept that there's nothing shameful—or career-threatening—about taking time off for family reasons," asserts Hawthorne.
PHYSICIANS
Pollution Breeds Poor Health
Pollutants are believed to cause a host of diseases that affect the world's population. To help physicians become aware of pollution's impact on our health, the National Association of Physicians for the Environment (NAPE) has been formed, writes Wayne Hearn in American Medical News. The group, which recently convened in Washington, DC, will be "a mechanism for the exchange of views and information on environmental issues."
NAPE will give specialty medical groups an opportunity to "discuss the impact of environmental pollution within their respective areas of medicine," Hearn reports. Physician leaders believe the time has come for such an organization. "It's important for us to have a forum for specialty societies to exchange ideas on environmental concerns," says Peyton Weary, the American Academy of Dermatology's president-elect. Those concerns include the extent to which air pollution affects asthma and the connection between the increase in skin cancers and cataracts and the depletion of the ozone layer.
Physicians are increasingly linking the planet's poor health with the poor health of the persons who inhabit it. "Every environmental problem . . . is or will become a medical or public health problem, and thus, pollution prevention can become disease prevention," asserts John Grupenhoff, a public policy consultant to the academies of otolaryngology and dermatology who will serve as NAPE's executive vice president.
But physicians say they need more facts from scientific research to warn patients of the threats pollution can pose to their health, according to Hearn. There are "far more questions than answers regarding pollution's impact on humans," he adds.
To help answer some of these questions, the U.S. Environmental Protection Agency (EPA), which employs about a dozen physicians among its work force of 17,000, is looking to physicians to help assess the risks of toxic pollutants. "We really need the physician community with us," notes Hugh W. McKinnon, senior EPA physician. Until the formation of NAPE, "the environmental public health agencies and the government really haven't had a physician coalition to draw from" McKinnon adds.
Copyright © 1993 by the Catholic Health Association of the United States
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