Patient-centered care – you may need a buddy!

BuddiesA friend of mine was undergoing an outpatient surgery a few weeks ago. Once in a gown, and her IV started (not a power position for us as patients, by the way!) her surgeon stopped in before heading to the OR to scrub. Having already talked with the anesthesiologist, my friend also shared her concern with her surgeon that she has had really severe nausea with codeine-based pain relievers after surgery (I mean really awful – I’ve been there!) with me nodding along vigorously and asked for different post-op medication. Her young-ish (to us, anyway!) surgeon was patient and gracious in responding that all narcotic pain relievers cause stomach upset and she would provide an anti-nausea medication to take along with the codeine-based drug she preferred to prescribe. Before my friend could share that that she’d had anti-nausea medication before and it wasn’t particularly effective, the surgeon exited stage left to prep for surgery.


Now alone together, my friend asked me again if there wasn’t another medication alternative. We agreed before they took her back for surgery that I would ask again after her procedure if her surgeon couldn’t prescribe something else for pain.


When I got back to recovery and saw the hydrocodone prescription, I asked the nurse if she could contact the surgeon so we could discuss pain management again and explained why. The nurse confirmed that she, too had seen serious nausea and vomiting with hydrocodone and that some of the surgeons in this hospital prescribed a particular non-codeine-based narcotic that seemed to cause less of a problem. She would ask the surgeon if she would change the order to that medication. Now that’s the kind of nurse you want advocating for you!


Unfortunately, when the nurse returned, she apologized and told me the doctor had said no, that the other drug was contraindicated after surgery. After quickly consulting my smart phone and confirming that the drug the nurse was suggesting was not, in fact, contraindicated after surgery (at least based on the Physician’s Desk Reference online), I asked the nurse if she might contact the surgeon again and ask if she wouldn’t reconsider the options to find an alternative medication. My friend had made quite clear on waking up from her surgery already nauseated that she wasn’t going to take the codeine-based drug and post operative pain from her procedure was expected to be significant.


Let me acknowledge that I am quite certain this doctor didn’t appreciate my pushing back on this. She was already starting another case, and an insistent friend of a patient (who also happens to be a private patient advocate) asking for a third time that a doctor consider changing their post op orders was clearly more than just an interruption.


I was polite, but firm, acknowledging that I knew this wasn’t her standard procedure, but my friend wasn’t going to take what had been prescribed for her, and if an alternative wasn’t found, she could easily end up back in the ER the next day for intractable pain.


To her credit, the surgeon did step out, do some research and ultimately agreed to prescribe the alternative the nurse had suggested. And the good news is my friend did well – no nausea, no pain.


Standard processes are an important way that errors are avoided. Standard processes absolutely have a place in medicine but when processes diminish the patient’s voice, maybe not so much. This becomes doctor-centered care, not patient-centered care.


In fairness though, the optimal time for my friend to have had this conversation was in her pre-op visit in the office, when she and her surgeon could have negotiated this based on a clinical discussion of the reactions she’d had to codeine previously. And if her surgeon hadn’t been open to considering other alternatives, since this wasn’t an emergency, my friend would have had the opportunity to consider whether this surgeon was the best partner for her in her care.


Still, having a person with her who could speak for her when she didn’t feel up to it, made the difference. And by asking politely and insistently, my friend had a predictable and uneventful recovery and her doctor avoided a phone call, or maybe worse.


Some thoughts about medication management and surgery:


1) Know how medicines you’ve had previously impact you. If you’ve ever had a reaction of any kind to a medication, let your doctor know.

2) Ask what your doctor’s usual post-operative medications and instructions are when you are having your pre-op office consultation. Learn what side effects might be expected and how to manage them when you’re clear headed and in a position to ask informed questions.

3) If what works for you isn’t part of your doctor’s usual protocol, don’t be afraid to ask your doctor what other options are available.

4) Many post op medications for pain have to have a paper prescription (that is, they can’t be called in to the pharmacy on your behalf). Ask if you can have your doctor’s standard post-op medications prescribed and filled before your surgery so they’re waiting for you at home and don’t require a stop on the way home from the hospital.

5) Use the Buddy System, whether it’s a family member, a friend, or a private patient advocate when you have a procedure or a hospitalization. Make sure your buddy knows what’s important to you. You want someone to have your back if you can’t speak for yourself.



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