Caring for Patients: What still causes me to lose sleep at night

I have spent many nights not sleeping. The biggest reason was worrying about patients and medical decisions. I would call the ICU at night to make sure patients were stable. The nurses would always reassure me. I would worry about a sick patient from the office and hope my treatment plan was the right choice. It has taken years to be less worried but I still am.

I worried that the new drug I prescribed would treat the condition and not cause a serious side effect. Pharmacology was my best course in medical school. The professor was awesome. We did have to read and know every page of the textbook to pass the exam. I quickly learned that a patient can have the side effect from the list of 10% or 1% most common side effects and that can be a nightmare or a nuisance. So when I am prescribing any medication, I think first is it really necessary. I don’t give out antibiotics for colds. If I give the “Antibiotic to Hold “prescription, my patients don’t fill it, they get better with just time. I love it when they bring back a folded piece of blue paper.

I don’t prescribe sleeping agents or narcotic pain medications to my students. In the past, I reluctantly wrote those prescriptions. I always tried non-narcotic pain medications first and referrals to the appropriate specialist. They came back on narcotics. Also, I tried to get patients to exercise, turn off the TV in the bedroom and meditate to treat insomnia. Those suggestions were met with resistance and the need for an instant cure. So, I prescribed then Halcion and Restoril. They really did not work and caused other problems. In older patients, memory loss, loss of balance and depression. In younger patients, they caused dizziness and palpitations.

The narcotic pain medications were also a problem. My worst case was a nurse that stole my prescription pad and wrote her own prescription for pain medication. She was caught by the pharmacist. I had a very noticeable way of writing prescriptions for controlled substances. She did not notice that and it was her undoing. I learned that technique after a patient changed a quantity of 10 to 100. The pharmacist caught that too. I always gave small quantities. A lesson learned as a resident when one of my drug diverting patients used his prescription to overdose after being confronted by a physician for using multiple doctors to get pain medications. I had to admit him to the hospital because I was the resident physician. With the new electronic data bases, more patients are being caught. I recently had a patient with a 17-page report. The resident I was working with learned the same valuable lesson.

Generics are cheaper and are equivalent to Brand medications but the delivery systems for many drugs are patented. So when a patient complains that their pills are changing colors each month, it is due to generic medications. Brand name drugs have patented colors and company logos. Patients can get pills mixed up and take the wrong one because they can be the same color, shape and size. We all metabolize drugs differently due to genetics based on race and sex. So a patient can be doing well on one form of the drug and have problems with a new prescription due to the rate of absorption of the of the medication.  I learned that the hard way. A patient switched from a brand medication that had the patented slow release delivery system to a generic. She complained that she felt dizzy and faint one hour after taking the new form. She was getting a more rapid release of medication and I had to write “Brand Only, no generic substitution” to get it paid for by her insurance company. I had to fill out a form with a detailed description of the problem.

So, why is this important? It is pharmacology. When I read the side effect profile of most drugs I get nervous. So prescribing them has caused some sleepless nights. So, how do I treat my insomnia? Exercise, yoga and meditation work great. I do not have a TV in my bedroom and I try not to look at any electronic device after 9 pm. I go to bed and practice breath awareness. For pain, I used my chiropractor to treat an injured shoulder and augmented it with yoga therapy. I treated my leg injury with exercise, ice and time. I have learned there is no magic pill.

Narcotic pain medications can be abused. I did Hospice Care for years and I know they can relieve pain and suffering for many patients. However, now they are a problem leading to the FDA approving the Naloxone pen to treat drug overdoses. The pen will be carried by first-responders in the community and on college campuses.

So in my new role, I reiterate, I do not prescribe narcotic pain medications, sleeping agents or medications to treat Attention Deficit Disorder (ADD). The ADD medications are being abused on campuses as “Study Drugs.” In medical school, several classmates crashed due to what we called “Uppers” when they were pulling all-nighters. I always needed sleep and good food before any examination so I could never do an all-nighter. Coffee was not even an option. I did not drink it until Residency and now, I can only have my one cup in the morning. It can cause insomnia due to caffeine.

I am thankful to my Pharmacology professor for forcing me learn all those drug classifications years ago. He also taught me respect for the 10 % and 1%.

6 thoughts on “Caring for Patients: What still causes me to lose sleep at night

  1. I would love to have someone like you as my family doctor! The fact that you care about your patients and pay attention to how drugs affect people is so refreshing. When my daughter was little she got constant ear infections. Her doctor always prescribed antibiotics whether she had pain or not, fever or not. Eventually, I used my own judgment because with every run of antibiotics she literally got the runs, severe diaper rash and yeast infections and the list went on and on. I did eventually find a doctor for her who seemed to suit our needs better.

    • I must admit it is hard to resist not prescribing because many parents want the drug. Even now parents send their kids over for drugs. I spend a lot of time explaining and giving a handout. Truth be told a quicker visit would end in a prescription. I learned from a Pharmacologist the value of knowing drug interactions. I had the same problem with my son. We finally would not give him a medication because of a rash or diarrhea.

  2. You are a caring doctor– your patients are blessed to have you. Thanks for sharing this. I think too many kids are on ADHD meds, etc where other interventions might help. An md suggested that my 11 year old niece go on meds and my brother and his wife, who is a chemist, asked,
    “what are the side effects in 20 years?” The answer- We don’t know. They opted to not put her on meds and instead make time to help her focus, etc.

    • It is a difficult decision. For many children and adolescents they do help but for others, the side effects can be too much for them. I am seeing that now the problem is complicated by family dynamics and medical problems. Many of these other problems need to be addressed. Medication can be an easy out.

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