When we arrived at the local emergency room in an affluent neighborhood, my mother was placed in a wheelchair and taken to the waiting room. She curled up on the cold barren hospital floor, the only position she could find comfortable. Although my mother usually puts on lipstick and high heels to go to the grocery store, this time, her hair was unkempt and her pajamas worn out. Her knees were tucked into her chest and her belly was distended.
It should have been clear to onlookers that she was in agonizing pain, but people were hesitant, skeptical even.
“Ma’am,” someone yelled. “Ma’am, we can’t have you lying on the floor. Get up.”
My mother lay still.
“Get up, ma’am,” she was told again, again more forcibly.
They helped her back into the wheelchair.
“Help me,” she said. “The pain is unbearable.”
Reluctantly, they put her in a stretcher and prepared to place an IV in her arm. To convince them the pain was real, we asked them to call my father, who could fill in all of the medical details: her multiple prior hospitalizations, surgeries and diagnoses.
We knew what they had not yet discovered: She had another blockage in her intestines.
My soft-spoken mother has suffered from Crohn’s disease, a form of inflammatory bowel disease, for nearly four decades. To her, hospitals conjure images of nasogastric tubes and surgical scars. So understandably, she avoids these places until she cannot any longer.
But here she was, vulnerable and asking for help.
Now, nearly a decade later, I have completed medical school and my residency in internal medicine. The opioid epidemic has taken over our country, and I think back often to that day with my mother.
We are cautious about prescriptions, as the number of fatal opioid overdoses has increased dramatically. We have state registries to see what prescriptions people have received before granting a new one. We also have increasing treatment options and programs.
In response to some of these regulations as well as manufacturing problems, some hospitals are facing shortages of intravenous opioids. This limits the patients who can receive intravenous pain medications, which are notably faster to work and more effective.
Therefore, it sometimes seems as if doctors must determine who “deserves” opioids for their pain. Layered on top of this is an informal curriculum about the “drug-seeking patient.” Certain patient behaviors are considered suspicious, and often it is perceived as a weakness on the physician’s part to “give in.” But it is not always easy to tell drug-seeking behavior from a legitimate desire for pain relief. As physicians, we have a duty to heal and to treat pain.
Not surprisingly, our rationing of opioids may play out along lines of implicit bias. Racial-ethnic disparities in prescriptions of opioids in emergency rooms have been demonstrated at national levels. I can only imagine how the situation may have been worse if my mother were not white.
Furthermore, pain experienced by women is often treated differently than that of men. Studies have shown that in men and women reporting similar levels of pain, women were less likely to receive any pain medication and less likely to receive opiate medications. In addition, women waited longer to receive such medications. Similarly, women are nearly twice as likely as men to receive an “emotional or mental diagnosis” compared with one for a physical ailment when showing the same symptoms.
Yet pain does not discriminate. Pain makes you vulnerable. Pain is the great equalizer.
My mother was subsequently admitted to the hospital for a few days. A tube was placed through her nose into her stomach to remove air and gastric contents. We waited for her bowel obstruction to resolve. Fortunately, this time it did — without surgery.
At that point, I had little insight into the larger health-care system. But I knew my mother. And she knew the system’s flaws better than I did.
“They must have thought I was drug-seeking,” my mother said to me a couple of days into her hospitalization.
I think she was right.
During all of my mother’s suffering, she had perceived the attitudes of those caring for her. She realized that her initial story had been discounted and her pain dismissed. She began to doubt herself and doubt the system. She still blames her disheveled appearance for her mistreatment.
This is not meant to be a narrative of opioid abuse or addiction; this is merely a narrative of suffering. It is a reminder to challenge our implicit assumptions and biases and think critically about each patient. As Sir William Osler, considered by many to be the founder of modern medicine, said, “Listen to your patient, [she] is telling you the diagnosis.”
DeFilippis is a fellow in cardiovascular medicine in New York.