A physician's assistant that I worked with for 4 years and liked very much retired last year.

A patient showed up that said that the PA had sent him to me.

The patient was a mess. Diabetes, weight, and on a very high dose of chronic opiates and difficult.

He was not argumentative. He talked but he usually did not answer my questions. It was a bit like twittering. It was talking that conveyed very little actual information and made my brain turn off.... almost a super power.

I asked him to keep a pain diary on the first visit. He forgot. He was late to the first visit. Then he no showed. He talked about how he really didn't do that well in school and it was hard to remember things and especially when he was in so much pain.

On the third visit I got angry. "Why aren't you doing the pain diary?"

"I forgot."

"I give you the instructions and the whole note in writing every visit. Are you reading them?"

"Uh. I haven't read them yet."

I refilled his pain medicine. But, "You need to read my instructions within 24 hours of the visit. And now you need to decide whether you are going to the pain specialist for a visit or whether I ask telemedicine about your pain medicine or whether I just wean it. I am working harder on your health than you are, and I won't keep doing that. If you are not going to work with me, you should switch doctors. Call me with your decision."

He didn't.

At the next visit I said, "Ok. We are weaning your pain medicine." He was on 120 morphine dose equivalents, the maximum dose that a primary care doctor can prescribe in the state of Washington. I dropped his dose by 15mg. I explained that he might feel some mild withdrawal symptoms for the first week and a mild temporary increase in his pain.

No show the next visit. I thought he switched.

About two weeks later he called, said he had pneumonia and came in.

He still has opiates left. He has dropped himself another 15mg. And he was sick but not pneumonia. And he asked how he could make contact with some other people to help get himself motivated to deal with his diabetes better.

I have a very very chronically ill patient who volunteers in the nursing home when he is discharged from it. He has been in and out twice in the last year. The specialist expected him to die over a year ago. That patient is alive because he's stubborn and engaged. I said I would talk to the nursing home about another volunteer.

So the virtues of anger.... I was frustrated and I let my patient know. I CAN'T make his health better if he won't do anything that I suggest or prescribe. Only HE can improve his health. And I was not willing to let him stay static: work with me or go to someone else...

...that's not how they describe motivational interviewing in family practice. But ... that is why the physician's assistant sent me this patient. He could not get him to budge and he thought maybe just possibly I could....

motivational interviewing: http://www.aafp.org/fpm/2011/0500/p21.html
for obeisity: http://www.aafp.org/cme/cme-topic/all/motivational-interviewing-obesity.html

written to this: Roland the Headless Thompson Gunner

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