Home Forums Discussions General Discussion Aggravating patient

How many of you AC friends and family have aggravating patients? Well one of mine called me 3x tonight.

The 1st call was a message from a patient visiting out of state. I'm in Maine and she was visiting in North Carolina.
On my web based answering service, she left a message claimed she had a bladder infection and needed antibiotic called in immediately. If she were a frequent customer of mine, I'd have done it in a second. But in 6 years I've seen her 4 times. So I ignored the call and continued working out at the gym.

Then she called later and I ignored it again, figuring if her bladder infection was a true "emergency," she could find an E.D. somewhere in N.C.

Then she called me a third, so I figured I couldn't refute the call. I was polite and she begged me to call in antibiotics. Keep in mind this was 10:30pm, and I ask "where do you want me to call in at this hour?" She didn't know. Then she asked if I even have reciprocity to prescribe there. I said my license is for the State of Maine. So while many of you will tell me that I can call in Rx's out of state (which I know I can), I didn't want to.

Why ? Bad medical care to treat a bladder infection over the phone especially when she had fever and flank pain (i.e. probably pyelonephritis) and she needs to go to E.D.

You know what she said to that??? "I went to the E.D. at 6pm for an hour and there were people waiting since noon. I'm not waiting there all night long."

I WANTED to reply, "So fine, get an abcess in your kidney or urosepsis because you don't want to wait a few hours to get antibiotics. Instead stay home to SPITE the E.D. and prove a point, then bug me all night long because of your emergency that I can't fix! Then end up getting admitted for 4 days to treat the infection."

I ACTUALLY said, "Please go to the E.D. so that you don't suffer complication like a life threatening infection or abcess and die." She said "I'm no doing that." I said "Then just drink lots of water, take OTC pyridium, and hope for the best. But this won't treat your infection and you could still have major complication, and you need to be seen and probably need antibiotics."

Why do we have to be nice??? If I went to the grocery store and said, "Hey can I have this bread for free?" They would politely say "NO," or "are you out of your mind?" Then I would ask again and make a fuss, so the manager would come out and I'd ask again, "I want this bread for free, can't you just give it to me?" And he would probably more sternly tell me "we are not in the business of giving out free bread, give it back."

So why am I in the business of giving out free medical advise?? That's a question I ask myself more and more when patients call, especially for stupid things. Every day I move closer and closer to the concierge practice model, fire all my staff and have 300-500 patients who want to PAY me for services.

What is a traditional FP to do??? I role with the times for now, but concierge practice is essentially what I do for 2,300 patients and I don't charge them all $1,000 for it.

Here's really thinking outside the box. These guys have a very interesting business plan and seem to be thriving. I'm not sure how the whole ObamaCare thing will affect this (and your) model, but I'm guessing it won't look good.

Check them out: www.xconomy.com/seattle/2008/12/22/...e-health-care-by-freezing-out-insurance/

OK , here's the deal.

If its that important that you need to contact me, I deserve to be compensated.

Yesterday, I had two new patients scheduled, They came in and told my staff that they were there for a "meet and greet". I don't do "meet and greets". My time and schedule are valuable. They had already had medical records forwarded to me, and it appeared that I would be their third doctor in two years. They were switching insurances and said that there was no need to bill the old insurance company.

Sorry, but go do your research in the community and internet.

Our hospital receives compensation to take care of the indigent in the community. I don't receive any of those monies, but the hospital expects me to come in and see the pt for free. I get to eat for free in the cafeteria ($100.00 per month at the full price). Then physicians get called on the carpet by a staff nurse who writes to the local newspaper how the "rich doctors with their fancy cars" eat for free.

Humana just came in and (MSO changed) changed from fee for service to capitation. I was one of the first providers to accept and see Humana patients because I a had a group of patients (longstanding , about 30 pt's) come to me and ask me to go on it. So I did. So I will not be reimbursed for January if I see a Humana Medicare pt (didn't get the contract back fast enough, I had 14 days to decide). They have shifted the pts to another provider and won't notify my patient's ( They are not your patient's doctor they are Humana's patients). It is my responsibility to contact the pt's and have them notify Humana that they want to return to my practice 2/1/2010. Humana's MSO also advised me that I should see the patients for free during January to help keep them in the practice.

I was going to kick my Airdale terrier Odie, but all he ever does is wants to play and is happy to give the whole family his love.


Dr. Lauer, keep fighting the good fight. That's what we do as physicians for our patients and profession.

Great article Dave!
Obamacare will be phased in over time, from what I understand, provided it passes. And I'm only wondering if every practicing physician will be REQUIRED to accept the rules.

If the option exists to have a cash only practice, that will be the single biggest motivating factor for me to move in that direction(UNLESS Obamacare actually improves the red-tape of the insurance industry).

Wow Frank, what a bunch of bullsh*t!!
You know what's really sad? I'm 6.5 years into private practice, and what you said doesn't surprise me at all.
It should freak me out, but I'm totally not surprised.

This ridiculousness has become the NORM.
Crazy....

Ya, let's keep fighting the good fight. But when it gets to the point of bankrupsy, those of us on the AC message boards will start a concierge message board and we can all decide how to opt out of insurance games and make our own rules.

We see this type of behavior quite a bit in our clinics as well. Patients don't understand the problems that can come up from treatment without seeing the patient. We have 4 screen steps to get a patient into the clinic before its ever even brought up to our doctors. Most of the time it works and we have fewer evening calls now than we used to.

I personally would LOVE to be a cash only basis. The contracts and power of the insurance companies are ridiculous! They can now come back and do a retro denial and refund request on a paid claim 2 years AFTER the date of service, while the time frame for submitting a claim to them is dropping lower and lower for the doctors. (ok, sorry off my soap box now).

What would be great, is if the insurance companies would actually pay for the telephone service codes - they exist, they are valid - just mostly not covered. Perhaps that is something that could be implemented in your clinics. State up front that telephone calls and advice come with a charge that may not be covered by insurance. See if they still want to keep calling when they know it comes out of their pocket!

I've considered that idea many times, about charging for phone calls. What's deterred me isn't some altruist sense of helping people. It's simply that when they call me, I'm doing something and don't feel like carrying a pocket billing sheet w/ me. I should though.

Those telephone answering services that screen your calls and give triage advice will charge the subscribing office about $25/call, sometimes more! We should tell pt's that for every phone call requiring my advise, will be $25 charge. I could even say that in the message, "If you stay on the line to page Dr. Lauer, you will be charged $25."

However I would probably not charge that person if they called me for chest pain, then I later admit them to the hospital. But what if they didn't complete the call due to the charge and then died of a heart attack? It wouldn't look good. Maybe I say "you will be charged $25, but if you die don't come looking for me!" HaHa

LOL!!!

My staff had to ask what I was laughing about. That was good.

Hey that patient called me tonight (again). She stopped in an E.D. on the way home to Maine today for "full-blown case of cystitis." I never understood what was meant by a full-blown case of anything. They never taught us that term in medical school. We learned: UTI, ascending-UTI, cystitis, pyelonephritis. But my post-grad training didn't teach me what "full-blown" meant.

She has back pain, fever 101 and chills. They put her on "ciprosomething" and when I asked if it was 250 or 500mg she said "I don't know." I asked if she had the bottle and she "doesn't know where it is." Do you feel nauseated? "yes" and did you take it with food? "No" Will you please try? "I guess I can." Are you drinking lots of water? "Gallons and gallons but I'm very thirsty."

Knowing that she waited several days before seeking treatment, I advised her to treat the fever and pain w/ Tylenol 1,000mg q6h and if that isn't helping control symptoms within 24hours she needs to go to our local hospital for admission and IV antibiotics. She actually said "If that's the case can I call you and have you arrange it so I don't have to wait in the E.D.?"

What is it with E.D.-itis? I know we are a consumer society, drive thru pharmacies and express-everything. But really, can we all just take a step back and remember that life isn't about racing to the end and try to savor all of it's flavors both good and bad?

I'm taking a mini-vacation to Orlando tomorrow. Good bye snowy Maine, hello palm trees!

If only you could take Bert - he needs to put e rx on hold and go on vacation..... LOL

Steve, what are you doing up at 10:30pm Pacific.
I mean what the heck am I doing up at 2:30am Eastern???

I'm going to invite Bert to Boston w/ me soon, but he doesn't know it yet. A man-date weekend, if I can get him to leave his computer!

It is actually 10 minutes to midnight and I am in the ER with an elderly male with chest pain, a baby "not acting right" and another chest pain arriving....

Ewww, I am so sorry you have to deal with all of that tonight.
You are a good man.
I pray the New Year brings rest.

But, Adam, what did you answer the patient who asked for direct admission?

And please tell me what the guy is holding in your avatar. A saxaphone? A baguette?

Looks to me like a femur.

ah, good call GP!

Most likely is either or is supposed to be A.T. Still who is the founder of osteopathy.

Only another D.O. would catch it....

Good job Steven.

A.T.Still it is and that is a femur.

I am embarrassed.

OK, the whole time I thought it was a sax and wondered why it was his avatar.

And, the irony is that Paul figured it out. I guess it makes sense since if he knows what his own avatar is....

Bert,

We will have to have Adam sit you down over beer and pretzels and give you a history lesson on A.T. Still and osteopathy. Really is an interesting history review, although now it mostly only affects philosophy.....

Horray Steven and Frank.
You guys win the prize!!! (My applause)

It only took 2 years of my being on the User Board for anyone to ask what my avatar was, and then on the same day the question was posed, it was answered by my D.O. counterparts. Good job.

You are correct, that is Andrew Taylor Still, M.D., D.O. who founded Osteopathy. He is holding a human femur. It is one of the classic pictures of Dr. Still that is commonly seen in D.O. schools or books.

And it is only something that would hold significance to a D.O.
But I'm glad one of our M.D. colleagues posted the question. THANK YOU PETER!

Peter to answer your question about what I did for her about seeking direct admission. I told her I'm leaving to go to Florida the next day visiting family and she would have to talk to my coverage (who might agree or might ask her to go to the E.D.)

My general policy is that I will direct admit patients only from my office anytime during regular hours, 6a-4p (unless I need further workup or stabilization in the E.D. in which case I send them there).

If a patient is home, I will only direct admit them if it's a problem I've seen them for very recently (like that same day or the day prior) and is something that is relatively stable. Example is the out patient pneumonia patient who has seen me, been on Levaquin for 3 days and still coughing up blood and has fever, and is vomiting and can't keep down fluids. I'm comfortable direct admitting them to the floor and seeing them a few hours later.

Our hospital requires that we see them within 4 hours of a direct admit from home, or 24 hours from orders called into the E.D., or 24 hours from direct admit from the office. I won't admit unstable patients from home to the floor.

And in the case of this patient, I haven't seen her at all, she has received the only advice from me after 8pm.

That's what I found most annoying is that she was having all of her problems during the day, but only found the time to call me well after office hours and well after the pharmacies were closed.

Well, it had been preplexing me for awhile LOL

I was partly guessing by context, assuming that the guy looks to me like a frum yid--though I guess in 19th century that look was more common.

MDs hold stapes

I still need to know what Paul's avatar is.

Okay I couldn't stand it - after over 5 years I had to put in an avatar.......

It is a phoenix. This is from Wikipedia and is pretty close to what I learned studying mythology in my teenage years -

"A phoenix is a mythical bird with a colorful plumage and a tail of gold and scarlet (or purple, blue, and green according to some legends). It has a 500 to 1,000 year life-cycle, near the end of which it builds itself a nest of twigs that then ignites; both nest and bird burn fiercely and are reduced to ashes, from which a new, young phoenix or phoenix egg arises, reborn anew to live again. The new phoenix is destined to live as long as its old self. In some stories, the new phoenix embalms the ashes of its old self in an egg made of myrrh and deposits it in the Egyptian city of Heliopolis (sun city in Greek). It is said that the bird's cry is that of a beautiful song. They can also turn into humans."

Adam, we had a patient call from Florida with a UTI over the holidays. Now, we have Online consultation capability but she didnt' want to do that ($30 charge). 'Course, Dr. C isnt licensed to write Rxs in Florida anyway. We told her to go to an Urgent Care Clinic instead of the ER. We told her to check the local yellow pages or Google to find one, but if she couldn't she'd need to see a local doctor or go to the ER.

It amazez me, the attitude that a lot of people have "Anything to save a buck when it comes to my healthcare." But they will spend ridiculous amounts of money on the car, home entertainment system, or cigarettes.

Yeah, we get that sometimes. We don't feel the need to coddle those people. We tell them essentially what you did. ERs and urgent care exists just for this type of emergency and if I the doctor say you urgently need to go there and you refuse what the hell are you doing in my practice?!? That's how I feel anyway.

Ok, here is a new one. Yesterday a 63 year old unemployed patient asks my MA to ask me if I will complete a form to get her off jury duty. When I ask her on what grounds, she says because she takes Lasix every day for non-cardiac edema and mild HTN. She also says she has "religious reasons". I tell her I cannot speak to her religious objections and that I do not feel her taking a diuretic would be grounds for dismissal. I advised she take the medicine in the afternoon or get up earlier in the morning and take it. I explain that many, many people are on diuretics. She got ticked, hung up then called back to cancel an upcoming appointment and to say she would be finding another doctor.
Now I get a lot of requests for jury dismissal from frail, elderly, debilitated patients and I gladly write them an excuse. But this is a "young" generally healthy adult. Why should I be put in the middle of this judicial affair?
Anyway, good riddance (I say that but in truth it bothers me).

Amen Dr.Strouse

Leslie, if she uses willingness to commit fraud, as her measure of worth for selecting a physician then she would never be able to appreciate the skills you have to offer your patients. Accordingly she could never offer you a thank you that would be sincere or meaningful enough to begin to repay you for that percentage of your effort that is unfunded. You desire a better class of patient and you needed to get rid of her to make room for one. Good riddance.

Thanks, Martin. You always make me feel better.

Oh, we had another one the other day. I recall my phone discussion with her for her appointment seemed strange. She was unusally high-strung and all "uppity." When she came in I ask her why is she here to see Dr. C. She says her specialist told her to have her pcp give her a referral for a ct scan. It should say "this" and hands me a prescription. Well, you need a pre-auth for that. And why didnt the specialist orget it--he's the one with the data. She's mad, wants to know why I didnt go through all this explanation on the phone. I told her I dont have time to do that. You come in for a visit, we tell you whats needed. And besides, this specialist should have told her. He's the ENT! He should have just called for the pre-auth. OH, then she mentioned that he might be out-of-network. So, we still need a consult letter stating his Dx and why he wants the CT. So I get her copay and let her talk to Alice about it.

Turns out she's a lying u-know-what and its a scam. She wants nose job and she and the plastic surgeon are trying to have it covered under her insurane as surgery for a deviated septum.

I think I would have just punched her in the nose right then and there and given her a really good reason to get her nose job!

Man, sometimes I just hate people. These stories solidify the people that irritate me.

I came in this afternoon from morning surgery and my office staff tells me one of the patients I'm seeing tomorrow has already been ridiculously hateful to them on the phone. Why? Because she's a no-pay (oops, I mean, self-pay) patient who my office staff informed would need $100 to see me. She went ballistic and said I was a rich surgeon and she shouldn't have to pay because I make "plenty of money" and she needs medical care, blah, blah, blah. They also informed her that if she needed surgery that a portion of the surgery would need to be paid up front to the hospital as well as myself. Needless to say she wasn't happy with that. We'll see if she shows up. I'm sure she will be more than pleasant.

I've had a lot of these folks too. I ask them if that argument will get them a loaf of bread at the grocery store, a gallon of gas at Exxon, or a bag of cash at Bank of America, since all those companies have much more money than I do.

Well, I am not even an official AC user (yet) but I had to add my $0.02 after reading these posts...

As I said, we take "walk-in" pts. - and here's a scenario that not infrequently pops up (it's usually on a Saturday or Sunday, at about 2:30 to 3 PM - note that we close at 3 PM those days)...

Two days ago, a "cash only/no insurance" pt comes in complaining of a "sprained neck". She actually tells me "If I could get some Vicoprofen for it, I'll be just fine..." (as if by couching the word Vicodin in Vicoprofen I won't notice it as much. Bwahahahah!)

So, I check the chart. 4 other visits total, spread out over about 3 years, and the last was 2008. All for "sprained neck/back" - and she got (big surprise) Vicodin and Soma every time.

I've been in Urgent Care for 21 years now- 10 in New Jersey, 11 in CA. I do think I've heard about every trick in the book, and know all the red flags. And she had them all:
"Allergy to Codiene"
"Can't take Tylenol because I had Hepatitis B and it hurts my liver"
"Can't take Advil because it hurts my stomach" (and just what did she think Vicoprofen was?)

I had noticed some of the red flags before I even went in to see her, and had already asked one of the MA's to call up Rite Aid and Walgreens and see when she last had Controlled Substances rxs (their pharmacies are all linked country-wide, so I always try them first)
Sure enough...#60 of Tramadol last month, 2 rxs. on the same day (another month) from different docs - one for #20 Percocet and another for #20 of Vicodin.

Well, I've developed my own little method over the years of how I handle drug seekers. After I have verified their recent use (always from different docs at different pharmacies, I go in (they are invariably over-the-top nice "Oh Doctor, I am just so grateful that you were working on this Saturday and could see me..." And, I go through the usual stuff. Take a history, examine them just as I would anyone else...

Then I lay the trap for them to walk into:
Me: "So, when was your last prescription for narcotics, SOMA, etc."
Them: "Oh, gee - that was a LONG time ago - maybe six months or more - I think maybe even the last time I was in here (in 2006)
Me: "I mean for any narcotics, like for dental procedures, surgeries, you know - anything."
Them: "Yes, it was months ago."

Now the bomb drops.
Me: "Well, gee. I'm confused...You see, I checked with a couple of pharmacies and they have a record of your picking up a prescription for this on such-and-such a date, and over here on this date, etc."

{The pt's deer-in-headlights look appears about here.}

Now the litany of excuses begin:
"Well, that wasn't ME, and I have NO idea what you are talking about"
"You know, doctor, my purse was stolen about a month ago. I think someone else has stolen my identity."
"You know, my niece is staying with us, and I suspected that maybe she was using my prescription csrd and getting medications."

And so on.

So now, it's time for the Grand Finale.
Me: "You know, my relationship with my pts. is based on trust, and I have some serious doubts about that with you right now. I don't think I can trust you - you lied to me about when you last obtained these meds, and so now I don't trust you. I cannot help you, I'm sorry. I can offer you alternatives" (which they usually refuse).

I always throw in, "You know, if you really do have issues with these meds, I really recommend that you go to the ER for an intake assessment by one of the counsellors there. They can help refer you to places where you can deal with it."

They are usually so p****ed off at this pount, they can't wait to get out of the room. They know the jig is up.

What really gets me steamed is when they refuse to pay the $75 for the office visit. That happened two days ago, after the woman refused to sign her CC receipt, because she didn't get what she wanted from me.

Arrggghh!!! Now I am out all that time I could have devoted to paying pts., and this idiot has completely wasted my time.

I hate the seekers, I really do...

Same stories all the time with the drug seekers.
I caught one patient actually pricking his finger to put blood in his urine specimen to make his Percocet-requiring-kidney-stone story all the more believable.
I give them a information sheet with contact numbers for the local substance abuse help centers during the visit.
I also reinforce to my staff the need to collect at least a partial payment up front for cash paying patients, especially those with the red-flag chief complaints.

I am trying so hard not to explode here. I am equally aggravated by colleagues, including those in the ER, who refuse to take the time to either read a note I have sent them, call me and talk about a patient or to check a patient's pharmacy history. I have a patient that I have spent untold amounts of time with trying to keep her off nightly Ambien and increasing doses of Alprazolam. She really is not your typical drug seeker but she just seems to always be needing more and more. "Oh doctor if I don't take an Ambien every night I wake up at 5 AM and cannot go back to sleep (goes to bed at 9)". I have consented to give her only 10 Ambien a month and a fixed number of alprazolam with explicit instructions that that is all she gets. She will have to use these prn rather than routinely. She then goes to her neurologist, gives him her sob story and he writes for 30 Ambien with 6 refills!!! The week before I had sent him my office note describing how I had spent 30 minutes with this patient explaining my concerns over her increasing use of these medications and explaining the "deal" I made with her. It is like having a child play one parent against the other.