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As a physician, where do I fit in?

September 20, 2013
by Sylvester “Skip” Sviokla, MD, ABAM
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Sylvester “Skip” Sviokla, MD, ABAM

Shortly before I graduated from medical school, a well-respected physician and world-renowned scientist in medical research summoned our senior class for a discussion of our approaching “doctor” status. He reminded us of the narcissism that could get in our way, especially before we understood exactly what was happening during our transition from student to intern. Then he made a startling request, or so it seemed at the time.

He urged that we listen carefully to all of the hospital staff members with whom we would be working, and not be afraid to take suggestions. The ward clerks, the people from social work and the nurses all would be good sources of information to help us deliver better care to our new patients, he suggested. The nursing and social work notes could indeed be more informative than those of our fellow physician consulting staff.

At first I was somewhat skeptical, but by the end of a talk that was rife with examples, I believed I would be foolish not to heed his advice. In truth, I can say that encouraging discussion by inviting questions from the clinical staff in all of my subsequent hospital and emergency room treatment settings was more than valuable. Not only did my listening cause me at times to improve patient outcome vastly, but in one startling case it saved a patient’s life.

I listened to an experienced nurse tell me “her gut” said we should keep a patient even though I had decided that her vague complaints justified sending her home. I reversed course and insisted that the patient stay in the hospital, and 15 minutes later she suffered a cardiac arrest. Certain death would have resulted had she been in her car on the way home. Responding quickly in the hospital allowed us to resuscitate her and she was discharged within two weeks, alive and well, to her young family. That is only the most striking example of how that sage advice has worked for me.

The progression of my addiction, subsequent loss of my medical license, and eventual recovery (which motivated me to write the newly released From Harvard to Hell and Back) found me beginning a new career in addiction medicine in my early 50s. I had, upon renewal of my medical license, joined the American Society of Addiction Medicine (ASAM), studied the field and passed the certification exam. I had been given an opportunity to learn how outpatient addiction treatment was being delivered at Meadow’s Edge Recovery Center in Rhode Island, an enormously helpful experience for which I am grateful. I subsequently grandfathered into the American Board of Addiction Medicine (ABAM) and started a clinic devoted to the treatment of substance abuse only. But how was this going to work? I wasn’t sure.

New paradigm

Although research into the medical aspects of addiction had been carried on at a high level in many institutions of higher learning for decades, I wasn’t sure how I was to apply the knowledge I had acquired. I had no counseling experience and my temperament was much more suited to the surgical/emergency room side of healthcare delivery (“see it, fix it, move on”). This was going to be completely different.

My own recovery had been spurred either by a long-overdue flash of insight or by the power of a spiritual moment. Since I am not one of those people who are more spiritually certain, I tend to avoid that discussion with patients. What I am certain of is that my surrender began my recovery and gave me the peace of mind to cease use and then fill up my life with good things.

I was certain that surrender did not merely denote a cessation of hostilities but was an active force in helping win the war, providing an opportunity to stay vigilant in the newly found daily quest. All the while I was experiencing ever-increasing joy. How was I going to reach those patients still actively using, or perhaps in a stage of early abstinence during which they saw only the struggle? I wasn’t sure.

But as I reflected on what had worked in the past, I changed my plan. I had asked two counselors, one with an LCDP (licensed chemical dependency professional) credential and master’s in counseling and the second with an LCDP and an RCS (recognized clinical supervisor), to come to work with me. I knew that they were both accomplished in individual and group counseling. I also was fortunate to enlist the help of a PhD-level neuropsychologist with years of experience in dealing with addiction. Initially I had engaged the three or four best people in the field with whom I had worked. I saw myself as the boss sitting atop the organizational chart.

But quickly I realized that I needed continuous input from my staff that placed me more in a wheel of treatment—one spoke among many. On reflection, I suppose that being the hub of the wheel is a more realistic characterization. After all, the buck does stop with me.

My staff taught me about what they did as much as I could provide them with medical advice. I read Yalom’s work on psychotherapy but had to sit through process groups, nursing groups and intensive outpatient groups before I truly understood the power of group dynamics.

I had obtained a contract with the Rhode Island Board of Nursing that allowed me to evaluate, recommend treatment for, and monitor nurses who would return to work under strict terms of compliance. I made my application for the contract with the board based on what the Rhode Island Medical Society had required of me prior to allowing me to treat patients post-addiction. In addition to offering counseling, this meant that I needed a well-trained psychologist to evaluate the nurses at least twice: first as part of our assessment and second before we recommended that a nurse be allowed to return to work. I knew substance abuse and dependence, but I didn’t know much psychology.

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I found the comment "I never heard that from methadone patients" curious when you were talking about the sense of clarity patients report after as little as a month on buprenorphine therapy. I work with many methadone AND buprenorphine patients on a day to day basis as the Director of a statewide patient advocacy organization specifically focused on medication assisted treatment for opioid dependence. I frequently hear reports of patients experiencing a level of "clarity" and "normalcy" after as little as a month on methadone therapy as well as buprenorphine. I'm afraid such a statement - besides it not being based in the reality my years of work with multiple methadone patients through experience has provided (including myself) - only furthers the buprenorphine VERSUS methadone mentality that began with Reckitt Benckiser's "bupe over methadone" propaganda... Such propaganda has no basis in MOUNDS of research and data spanning nearly 50 years. It's very curious you never heard that from any methadone patients... It must be that your patients simply didn't truly open up to you. My experience AS a methadone patient - and in working with methadone patients every single day - is substantially different than the image you are attempting to perpetuate.

My experience is clearly different from yours. Although many of my methadone patients were content on their doses, none ever volunteered clarity. The partial agonist effect of bup makes it special in my view. I endorse methadone for patients who can't or won't use bup. It will have to be an enlightened methadone clinic which will rise above the usual harm reduction approach in order for that patient to thrive. Good counseling trumps medication choice for sure. Thanks for your comment. Skip Sviokla

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