I have a third-year medical student under my tutelage this month. After completing his first two didactic years, he now starts his clinical rotations and actually starts seeing patients. It’s my job to not only teach him about medicine and disease states but also to teach him about people.

One of the patients he encountered his first week while working with one of my medical partners, was a patient who is dependent upon narcotic pain medications. The student was sickened somewhat by the “show” that occured when he went to examine this patient who was there to get another prescription. Even the slightest touch elicited extreme pain and started the academy award winning performance witnessed by the student. It was “pathetic” as he put it.

But what is a physician to do? We all handle this type of patient differently because we all handle pain differently too. I crushed off the last two inches of my left thumb and only used two Aleve for pain. Apparently not everyone can do that. But from years of experience in dealing with these patients, I was able to give some practical advice.

First of all, I don’t tolerate this behavior. So subsequently, I don’t have many of these types of patients. No audience, therefore, no performance. When I do have a chronic pain patient, I know they want or need pain medications so at low levels of use, I will help them. I explain to them what I expect and I treat them like adults. I don’t use the “If you eat three peas then you can have dessert” approach. I didn’t play that game with my children at the dinner table and I won’t play it with adults seeking pain medications in the office.

Secondly, I fire them from my practice if they don’t play by the established rules. I can’t be everybody’s physician, nor do I want to be.  I know that this may seem harsh and uncaring but it isn’t. What’s better, lying to them and playing the game or showing genuine care for those who have real pain and sending the rest down the road?