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A Piece of My Mind
April 26, 2016

The Patient You Least Want to See

Author Affiliations
  • 1Division of General Medical Disciplines, Department of Medicine, Stanford University, Stanford, California
JAMA. 2016;315(16):1701-1702. doi:10.1001/jama.2016.0221

Signing my first orders as a medical intern was distinctly disconcerting. Wait, I can just sign this order and it will happen? Are we sure this is safe? Safe or not, new physician trainees suddenly wield the power to administer medications that can be lifesaving or life-ending. Pharmacists corrected my orders for excessive doses of insulin or potassium, while senior physicians guided my selection of vasopressor infusions and antibiotics. When it came to intravenous opioids, however, those same pharmacists never hesitated to approve my orders, and I found little structured guidance from supervising physicians. With no questions asked, I included “as needed” acetaminophen, oxycodone, and IV morphine in my standard order set for every patient I admitted. I congratulated myself on a time-saving trick to anticipate patient and nursing needs that would spare me an extra page to respond to. Instead, I unexpectedly found patients skipping the acetaminophen and getting their “as needed for severe pain” intravenous opioids around the clock for days. This often culminated in a last-minute desperate discharge plan, with many demoralizing negotiations over “just one more push of IV Dilaudid and Benadryl.” I came to appreciate a more insidious problem and, even worse, worried that I was contributing to it.