Eight is enough.

"She isn't happy with our plan," my resident said. "I know you spoke to her at length already, but she's asking to speak to you again. Actually, she's sort of demanding it."

I felt my shoulder starting to sag as I stood in the hallway listening to her request. Partly because of the heavy bag I was already carrying in preparation to leave for the morning, but probably more just at the idea of going back into what had already been a pretty energy-sucking encounter to begin with. Instead of speaking, I just let my head fall back as if it could no longer be supported by my neck. Then I winced and squeezed my eyes closed. Kind of like Isaiah did just yesterday when he finished his homework and I insisted he read a book after.

My coat was already on. Zipped up to the top with a satchel on my right shoulder, too. My cell phone was in my hand and buzzing in response to the messages I'd shot out in anticipation of heading over to my office. Clinic had been busy that morning and the patients less straightforward than usual and challenging. There were a lot of resident providers with us that morning, too, so our normally social atmosphere was replaced with hustle bustle, scurrying about and very little time to even print out a prescription, let alone catch your breath. And Ms. Faison--the last of our patients that session--was probably the most challenging of them all.

You see, Ms. Faison wasn't happy. Not on this day, she wasn't, or even in general. With wretched osteoarthritis in her knees, she really needed not one but two knee replacements. The problem was, though, that Ms. Faison had smoked for many years and now had developed pretty advanced chronic obstructive pulmonary disease. Putting her under general anesthesia could potentially be life-threatening. Further compounding things was her weight. She was more than just a little bit out of range. The three hundred plus pounds she bore on those rickety knees would likely not allow for the best outcome if placed upon surgically replaced ones. So none of this was good news which made Ms. Faison even unhappier than her baseline unhappy.

To make matters worse, she was in pain. Pain that wouldn't respond to our medium guns like ibuprofen or naproxen or even those arthritis-fighting salves that we cross our fingers and hope our patients will like. The doctor she had before this resident placed her on a narcotic pain medication which seemed to mostly get the edge off. And that wasn't really that inappropriate given the severity of her join destruction and the unanticipated surgical intervention to improve it.

As a part of the agreement to put Ms. Faison, or any patient in our care, on long term narcotic pain medications, the patient and doctor form a very specific contract. Right up front, it's explained that narcotic pain medications have to be taken exactly as prescribed and not mixed with alcohol or other illicit drugs. A discussion about the habit-forming nature of narcotics makes them tricky, so the doctor and the patient must both be super-judicious about how, why, and when they're given. Of course, if the medication causes issues or is in need of a potential dose adjustment, the patient and doctor agree to talk about it and reach an agreement without any unilateral increases from the patient's end. So after all of that discussion, the patient agrees to adhere to taking the medications per instructions, not to mix them with other things, or share them with other people. (Yes, that happens a lot.) The doctor agrees to avail him or herself to the patient should concerns come up. And usually, this--the "pain contract"--goes off without so much as a hitch.

Unless you're in that small percentage like Ms. Faison who gets taken off of narcotic medication due to breaking said contract.

Some folks don't have good intentions from the start with the medications. Their plan all along is either to pop them like candy or sell them for money. The Pollyanna in me refuses to believe that this is anywhere remotely close to most patients' gameplans. Regrettably, those folks make it harder for the others. Especially once a provider gets "burnt" by one.

But Ms. Faison wasn't one of those people. She was just in pain. She'd been given a certain number of pills that she started doubling and tripling up on because her knees hurt so bad. She ran out ten days before she should have and borrowed some other kind of controlled pain medication from a neighbor. And a little bit of cocaine, too.

Now. Before anyone thinks I'm judging her, please know that I wasn't. She was fully honest about all of that--including the cocaine--and said that she just "felt like shit" and was tired of it. We'd already known that she'd been a weekend recreational drug user remotely, but thought this was behind her. When a urine drug screen revealed cocaine metabolites along with detecting some other things that weren't in line with her prescription, that ended her contract. Which meant no more prescriptions for anything stronger than motrin 800mg.

Yup.

So she'd still come for her blood pressure pills and diabetes medications as scheduled. But all of that would be suffocated by the circuitous discussion about her disabling knee pain that we wouldn't help her with. On this day, she'd been in the room crying to me, begging for us to check her urine to prove that she wasn't taking any drugs and to please, please reconsider putting her back on narcotics. "It was a mistake," she pleaded, "and I learned from it. I can't live like this. Help. Please."

And you know what sucked the most? What sucked the most about it is that I believed her. And I still believe her. Like, I truly don't think Ms. Faison was out fattening her pockets with cash for loose Percocet pills nor do I think her visits were all a part of some diabolic plot to get high. I don't think she'd relapsed into a downward cocaine spiral and I honestly believe that everything she told me about her lapse in judgement was from being delirious with pain.

But.

All of that had happened less than four months before. And, frankly, she'd tied our hands. Which meant there was very little we'd be able to do to alleviate this pain that was destroying the quality of her life. And that? That sucked.

So I'd already talked to her about this. Sat there and did my best to be empathic as she wept. Trying my hardest not to feel like shit from knowing that when she left she just might feel so hopeless that she buys a five dollar rock on the way home to escape it all. I didn't rush her either. We'd spoken for more than twenty minutes that morning about all of this. So the idea of being asked to go back and talk to her some more? Just as I was preparing to get out of there? Well. Let's just say I wasn't too excited about it.

"Oh, Dr. Manning, I already told Miss Faison you left," spoke one of the nurses from down the hall. "Because I thought you had gone already." That same RN saw me as I slipped into my coat five minutes before so I nodded in her direction and then looked back at my resident.

"I don't know what else to say to her," I said.

"Me either. Maybe it's a gift that Ms. Caldwell thought you were gone. Let's just leave it be." My resident was obviously frustrated. Before I could respond, she'd already headed back over to the computer bank to finish her charting.

I decided not to overthink it. I knew it was a bit disingenuous but my reluctance to reenter another twenty minute discussion with the same endpoint won over the sword of honesty. I secured my bag on my shoulder, checked my phone once more, and headed out toward the stairwell.

My head was down looking at my text messages as I leaned against the exit door in preparation to go. I was startled when I heard Ms. Faison's voice. "They told me you was gone."

I could feel my face warming up from being caught in what originally wasn't a lie but had become one. "Um, yes. I'm sorry about that. Ms. Caldwell thought I had left already, Ms. Faison."

"I had asked to talk to you again. They didn't tell you?"

I looked down at my feet and felt my shoulders melting down like ice cream on a hot day. I lifted my eye to hers and spoke. "Let's talk, Ms. Faison. How can I help you?" There. That was all I could do at this point.

"What I'm 'posed to do, Miss Manning? Just be hurting all the time? Just miserable?" She wasn't mad. No venom shot from her lips and no angry scowl was wrapped around her face either. She wasn't mad. She was sad.

I sighed hard and dropped my bag to the floor. Pressing my lips together, I thought before speaking for a moment. "Ms. Faison? This whole thing is making me feel so sad, too. Because at this very moment, I don't know what to do. I really don't. Like, I think that eventually, some day, we might be able to work out getting you back on something stronger. And last time we injected your knees with steroids but really, you need knee replacements. But right now you can't have that surgery so . . . I just. . . yeah."

That's when she started crying again. This hopeless cry that broke my heart into a million pieces. I reached out and put my arms around her and hugged her. I didn't know what else to do.

"I wish I didn't have to deal with this," she sobbed.

"Me, too," I whispered back. And I just let her cry and rubbed her back and hoped that somehow, some way when all of this was over, that she'd feel cared for enough to keep coming back and to not make any desperate choices.

"What can we do, Miss Manning?"

"I was just thinking. It's been more than a year since we spoke to the orthopedic surgeons and the anesthesia people about you and knee replacements. And actually, I wasn't the one who spoke to them personally. Why don't we try that again and see if there is any chance you can get something done."

She seemed to like that. I wasn't sure if it would work, but in that moment I did realize that this idea of her never getting surgery was mostly something I'd gleaned from other doctor's notes.

"I know a lady bigger than me that got her hips done. And she used to smoke."

"I can't promise anything, Ms. Faison. But I agree that maybe there is something that they can do that I'm no aware of. I'll call them myself, okay?"

She nodded while patting her cheeks with the sleeve of her shirt. "Okay."

"In the meantime, though. . . . we'll have to keep working with the alternating tylenol and ibuprofen and the capsaicin knee cream. What do those get your pain down to?" I was referring to the one to ten pain scale that she knew quite well.

"Most days? Like a eight. Some times, though, it can get to a five or six."

I sighed and twisted my mouth. Because I really didn't have anything else I could do at the moment. "Okay." That's all I could say.

"I guess for now, eight gon' have to be enough." I hated that thought but it was true. But surprisingly she didn't look as sad as she had before. "Miss Manning?"

I raised my eyebrows. "Ma'am?"

"Something about you jest dropping that bag and stopping what you was doing, though? Something about that give me a little hope. And it's funny but it kind of took my mind off this pain."

My eyes started prickling when she said that. I was still feeling a bit ashamed for trying to scoot out under the radar earlier. But mostly it was because, like her, I felt better after that exchange, too. And a lot more hopeful.

"Oh, Ms. Faison. I so want you to feel better. I do. I hate knowing you're in so much pain." And I told her that because I meant it. "But fight with me, okay? Fight all the stuff that will make it harder for us to take good care of you, okay? I know it's not as simple as me saying it. I know that. But you're strong, Ms. Faison. Stronger than me, that's for sure. Let's fight, okay?"

"Okay. Plus, I been through worse." And since I've known her for a while now, I knew that this was true. Her life wasn't an easy one and this, comparatively speaking, wasn't the worst thing she'd faced. And you know what else? Now she was smiling. Smiling in my direction in that same back hallway when she said that.

Which made me want to cry even more.

I gave her one more hug and watched her disappear down the hall. Just before I could get out of the clinic, nurse Caldwell caught my eye from the other end of the corridor. "Oh no. You still aren't gone?"

"No, ma'am. Ms. Faison caught me so I was speaking to her."

Ms. Caldwell widened her eyes and then looked at her watch. "Oh. . . .I'm sorry about that Dr. Manning. It's almost 1:15."

"That's okay, Ms. Caldwell. It was meant to be."

She chuckled and went back to what she was doing and, finally, I left.


No. I don't have all the answers. I don't. And I'm pretty certain that Ms. Faison is still somewhere wrestling with her pain in her knees that is probably an eight on a scale of one to ten. But this idea of raging against my own impatience and increasing the dose of empathy as the yet untapped therapy in all of this gave me hope. Real, true hope.

For her and for me.

Nope. I don't have the panacea to allay those gigantic physical, systemic and psychosocial maladies that many of my patients like Ms. Faison must face in their quest for wellness. But maybe, just maybe, I have more than I realize. And perhaps, if I think of it that way, eight will never have to be enough. Maybe.

Yeah.

***
Happy Wednesday.