Home Forums Discussions General Discussion Aggravating patient

The ambien ones are tough. We usually end up losing them as patients because here they just get really obnoxious and basically say just give me my ambien as if they are ordering a hamburger and the doctor is the "flipper."

@Melanie--we haven't had a seeker in a while. We aren't urgent care, so the story is a little different. Usually about how their regular doctor or pain specialist is on vacation, cant be reached, and there is no covering doctor. They are out of meds. Yep, its some kind of controlled substance. We send them to the ER since she "doesn't prescribe that. Only a specialist does"

Then its the migrane folks. The only thing that works is fiorecet?Is that how you spell that? Oh, the doctor who always prescribes this is also out of town. Dont prescribe it. See the neurologist.

You know, even if I know that these pts. are not just limited to my practice, it's still somehow comforting to hear that i am not the only one dealing with this!!

And the Ambien pts. - ugh!!! Happens all the time out here in Silicon Valley (did you think California was full of healthy-lifestyle, thin, bike-riding/hiker type of folks? ) And those stupid Lunesta commercials - "safe up to 6 months of use" In fact I just told a pt. yesterday "Sure, and just TRY and get a pt. off of it after they've been on it for six months!!" No thanks...

Leslie, we give our pts. a fixed amount (I'm talking Ambien here) to last over say, 3 to 6 months (which amounts to about one a week). If I were you, with that pt. who then runs to the Neuro with her sob story, I'd invoke the "trust" thing that I mentioned in my Vicodin rant above. I have told pts. that if I find that they are getting these drugs elsewhere, then I will not prescribe it for them again - once they breach my trust, which is so vital for a working doctor-pt. relationship, then I will not rx. that med again. Period.

Having said all of this, lest you think that I am a cruel and inhumane doc who lets her pts. suffer, I will add that I DO use Vicodin regularly for a very select group of pts. One that comes to mind is a wonderful, very mentally intact 90 year old woman with crippling OA, who has a GFR of like, 18. I wouldn't let an NSAID past her lips. She has gotten an rx of one Vicodin (reg. strength) BID from me for about 3 years now. She never asks for more, and the rx request comes in like clockwork. I rx it every three months, and she is forever grateful, because that allows her to go about her ADLs with SO much less pain...

It's just a shame that it's been so abused. I heard that it was the second most common cause of liver transplants (behind chronic liver disease from hepatitis and cirrhosis) - don't know if that's true, but I wouldn't be surprised...

Melanie,
When I see a "new" patient on my schedule that looks sketchy, I check his ER visit record, make a "Narc-check" call to one of the chain pharmacies and if he's a seeker, walk in and spill the facts right up front. I give him an exit strategy: leave now, no charge, don't come back. No income, but little wasted time. Harsh pruning up front has given me an enjoyable patient population. You'd be surprised how fast Mr. Loser will spread the word to not waste time on my office.
Dave

Melanie,

I basically handle things similarly to you and use the same trust discussions. Just when you think you have made some headway then "Bam" you are defeated by a colleague. I also am liberal with pain meds for those that need them and, like you, prescribe a lot of plain codeine or hydrocodone for people with questionable liver or renal functions.

Dave,

I do also the narc check up front- but perhaps your method is better, 'cause it saves time. May I ask- what so you say to them when you walk in? Is it that you've checked their record, etc.?

Here's the thing. I used to try something like that, but then one pt said "Well, you didn't even know that I was going to ask for it, you didn't give me a chance to tell you anything" etc. and started threatening to report me to the Board. Ugh! So then, I changed my strategy to the present one, where I hear all their complaints, examine them, catch them in a lie(s), and then tell them that I'll be happy to rx alternatives, but not what I know that they want. That way, though, I have to charge for an OV and that's where (sometimes) the yelling starts. Most pts. will meekly pay and walk out. A few, here and there, make a scene. The other day, one called the police because we were going to charge her CC for the visit that she didn't think she should have to pay for.

It's an ugly business we're in, sometimes...

But today, whatever happens, I have some respite afterward. I'm going to see Cirque du Soleil's "Ovo" show in San Jose. Ahhhhhhhhhh....

Oh, we had another one today. Already. She starts off by showing up 30 minutes late, but signing in only 10 minutes late, for her preventive and claiming she'd been out there waiting (I had been out checking, so I know she wasnt there). so, took her in. She wanted a preventive and a doctors note. I bail and let
Alice ask about the note. Turns out she states at work they are having her carry 2 laptops, and she wants a note to say she cant. No, have to send you to a physical medicine specialist to evaluate you for taht. "What you arent going to do anything? Its just a note!" Alice eventually got rid of her. I was prepping her next patient.

I had a lady come in with low back pain. She had been seen in the ED and was given Nubain. She was new to my area and was referred to me from the ED. When she presenedt to the office, she was dragging her right leg and wouldn't sit in the reception area because of pain. In the exam room, she mentioned how helpful the nubain was at least 5 times. Her exam was entirely normal. There were no radicular symptoms whatsoever! She also screamed when I asked her to point to the area that she had the most pain! SLR's were normal, normal neuro. I explained that I would not administer nubain to her, but that nsaids plus acetominophen, along with Physical therapy and stretching exercises and deep water walking should work wonders. She followed me out of the exam room and loudly insisted on an injection. My nurse came around the corner asking what was wrong and I said,"this woman wants nubain but I don't feel it's indicated." She then marched out of the office, without dragging her leg, accusing me of a hippa violation because I told my staff what she wanted! She reported me to the state board of medical examiners and they did a full review. Fortunately the documentation was excellent and they found in my favor. I did submit her bill immediately and was reimbursed for the visit! I wrote her a letter dismissing her from the practice. I also spoke informaly to the ED and other Doc's in the community about a new patient who might be looking for nubain. The report to the state boardwas a first for me after 22 years of practice.

Unfortunately I have had reports to the states board and they have uniformly been people who have been dismissed due to pain med issues (diversion, abuse, etc), or who have psychiatric issues and have threatened either me, my staff or others.

Unfortunately all you can do is practice good care, document well and hope for the best.

In my state (VA) they now have a database of narcotic abusers which one can query and immediately get a list of all narcotics filled by a patient. It's a great idea, as many of these patients have visited other docs for pain medication refills and the list can be used to immediately kick them out of the office.

I'm sorry to hear about the rough time this patient gave you, Steven!

Al

Don't you just love it when you have a patient waiting in an exam room to be seen for a cough and they are quiet for minutes. As soon as you knock on the door and enter they begin this gut-wrenching, near syncopal, about to throw up coughing fit which continues throughout your exam? Drives me bonkers.

You know, it seems like physicians should be able to file suit against someone that makes malicious false charges. Has that ever been done?

Leslie, we had a girl do this the other day. New patient, and we were a little backed up (it was later in the day). Complained of coughing and green phlem. and a sore throat. Did not cough once while I checked her insurance, scanned in all her paperwork, scanned in her ids, added info to her demographics page and took and recorded her vitals. about 30min. Alice said she didnt her anything in her chest. Did not cough "spontaneously" the entire exam and discussion (a good 15 min at least). But when she apparently didnt get what she had decided she needed before she came in (whateve it was) she then has this cough she is obviously forcing out.

We have similiar problems to those listed. We have fought it by using a couple of tools. First anyone who calls as a new patient for "back pain, neck pain, etc." is informed that our physician does not prescribe narcotics for this type of ailment and before you come in we will routinely pull a Pharmacy Board report telling us other doctors you have seen and medications prescribed. If they still want to see the doctor, then we charge $75.00 up front for all new patients without insurance and we collect that before they see the physician.

Once a doctor is known as a "wall" around our parts then we get very few calls. It is nice how well this community communicates!

OK, got to vent on another one. I guess I am just getting too old for this.
Had a patient with over two years of right rib, right thoracic spine pain which I had previously done some level one evaluation on, turned up all negative. Now, this patient is not a "frequent flyer", in fact had not been in for 2 years. We had sent/called her several times telling her she was due for office follow up and then finally got her in. She continued with these complaints, worse when walking, worse with movement blah, blah. Exam was totally negative except for minimal tenderness over the right infrascapular area and a little bit in the right CVA. I tell her I believe it is musculoskeletal and conservative treatment is indicated. I also tell her one could never rule out a thoracic disc or facet problem which might benefit from steroid injections but that, from experience, I know the Pain guys in my area will not do anything without first having an MRI. I also note she has 1+ blood in her urine which is asymptomatic. She had a few RBC's 2 years ago. So, my "worst case scenario" brain kicks in and I decide perhaps it would be wise to get a CT of the abdomen/kidneys. She says she wants to find out what is going on and that, with the direction health care is going she wants it "DONE NOW!!!"
So, I order an MRI of the T-spine and a CT abdomen, send the UA for C&S..blah, blah.
Her insurance company refuses to approve either test unless I call their doctor to discuss it. My staff has already been on the phone for over 30 minutes (much of it on hold) answering questions and they have faxed my notes to them but still no go. I am busier than heck seeing patients and tell them I cannot call their doctor.
The patient calls back irate that I will not make this "simple call which will only take 2 minutes" for her. I try to explain that this is just another tactic for her insurance to deny services to her and that I cannot spend what is invariably way more than 2 minutes talking on the phone to try to justify my clinical decisions to some hasbeen for every test I order. I tell her there is nothing else I can tell them that has not already been transmitted to them via my staff. So the insurance company does not actually deny the tests, they simply won't approve until I call them. Makes me the scapegoat.
She says she and her husband have always appreciated the care they have received from me, have always been grateful that they can usually call my office in the morning and be seen that day but that perhaps it is time for me to retire. She then proceeds to say things like this must be the reason my waiting room is never very full!!!! OK, now she has really lit the fuse! I reply (I know I should have just let it go, but, well, you know me) my waiting room is never crowded because I do not double and triple book, I spend quality time with my patients and I am not always running late BECAUSE I AM NOT ON THE DAMNED PHONE WITH INSURANCE COMPANIES LIKE HERS!!
Well, you know the rest. She said she and her husband would be finding a new doctor and I said I thought that was a good idea and that I hope she is happy sitting in a waiting room with 40 other people (Please forgive Medical Protective)

Amen Sister.

By the way, what's the deal with horses, donkeys and mules??

They are my salvation!! When I have had all I can take of stupid people I go out to the pasture and discuss politics, health care reform and the price of hay with them. They always understand and agree with me, especially if I am carrying peppermints or chewing tobacco (Hubby's vice). The donkeys seem to understand the most as they are used to carrying around heavy burdens.
My sister and I raise them...have mares, studs, jacks, jennies and the hybrids thereof.

Yeah, they always want to take the extras that you perform and say its something negative. Had a patient write an negative online review starting off with "I should have know something was wrong when they let me schedule an appointment the same day " or something like that.

I have seriously considered implementing a general rule of no same-day appointments for new patients" because so many of them seem to be people with some type of hidden agenda or self-diagnosis with a pre-demand for a medication. Recently had one insisting she had a sinus infection and demanded a z-pac. Alice wrote her a script for zithromax. She calls back a couple of days later and literally yells "If you had written me a Rx for a zpac like I TOLD you to." Luckily, Alice doesnt have my out-of-control temper. Its frightening to think of my automatic response to her. I guarentee it would have be very nasty and before my conscious mind could have stopped my mouth.

I know this is an old thread yet couldn't resist putting my 1 cent in (was 2 cents yet with deflation ...)

I sometimes have patients sit with my assistant while she is on the phone trying to get the prior auth (I especially do this with medication prior auths). This gives them a clear sense of what we have to go through to get their test approved and usually they understand better our world and frustrations in trying to provide quality care. Also, if you wanted you could bill a level 1 or level 2 visit for this and recoup some income (I generally have not done this however). I hope this helps someone.

Even Peds gets seekers. They are visiting relatives coming in with their nephews etc.

I believe there is a central problem insofar as we all go in to medicine to help people and are by nature 1) going to believe what a patient tells us (I am shocked to find a patient has lied to me); and 2) going to feel terribly guilty if we don't make a patient happy. Unfortunately, the result is pretty much the same as believing everything your 10 year old tells you or giving in to chocolate before dinner. Training patients what to expect from our practice was a lot like training our kid or our pets. Try not to get angry, be firm, be consistent, get comfortable saying "no" (which took me a long time.) It took quite a while, but eventually we ended up with a patient population who rarely abuses us. I had to keep telling myself it is as Ann Landers said: "No one can take advantage of you without your permission." And oh yes, we fire people who are not trainable (see previous postings for heated discussions on this issue.)