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All is Lost -- Or is It?

Monday, February 11, 2019

Detail of John Constable painting of a lonely beach

Two more.

Two more patients of mine died this past weekend. Two more on top of two more on top of two more. I have lost more patients in the last three years from opioid deaths than I have lost patients from all causes during my entire career. I can’t keep up. It is been a combination of deaths unknown, suicides, and clear overdoses. With the latter leading the pack.

What am I doing wrong? When patients come in I have taken the approach from tough love to completely understanding the issue as an inherent disease like any other disease or illness. I try to look people in the eye and find out how they’re doing, who they are, what drives them and beats them down. We have a team approach with nurses, a behavioral therapist, a primary care option for all patients in OBAT, weekly staff reviews of patients, etc, etc. Until recently we have had a health coach who worked with OBAT patients on personal health goals.  We have group therapy for those with severe psychological problems, group visits for those with chronic pain, and weekly mandatory group visits for those on Suboxone and Vivitrol. We are working on getting acupuncture.  

And yet one by one they slip through the cracks.
The last patient to die I had seen four days earlier with a smile on his face.
He was ready to re-commit. He was determined. He seemed like everything was coming together. And all it takes is one slip up. 

So we sit in our team meeting and wonder if all is lost. Is the glass half empty? One wise team member looks at the list of patients and says look how long the list is. Look at all the people who are alive. Look at all the people that are thriving. For everyone we have lost 20, 30, 40, even 50 are still alive. And many are in a much better place than they used to be. They are getting primary care now and are up-to-date on screens and vaccines; they are attending groups and even using our discounted membership to go to the YMCA. Nothing ventured nothing gained. These are the highest risk patients in the community and perhaps in the Commonwealth. Did you think you could save them all? A fool’s errand. 

I recall the allegory of the old man walking along the beach after the ocean has withdrawn.
He is picking up shellfish and throwing them back into the ocean. There are tens of thousands of them scattered along the beach. A child says, "What is the use? Look at all the ones that are still on the beach." And as the old man throws a shellfish back into the ocean he says "There’s one. There’s another." 

We do what we can. And we do what we can, well. Not perfect, but well.


This piece originally appeared in the UMass Department of Family Medicine weekly "Thursday Morning Memo".  The author is Hugh Silk, MD MPH, Professor, Dept. of Family Medicine & Community Health.  Hugh is the Medical Director of the Primary Care Wellness Center/Community Healthlink in Worcester, Mass and also serves as a mentor in the UMass Chan Medical School's Learning Communities.