Home Forums Discussions General Discussion How do people handle their chronic opiod patients?

OK, being a pediatrician, while I still have patients with Crohn's or Dermatomyositis or other illnesses with chronic pain, I am nowhere near in the realm that FP and IM would be.

Not sure if the new guidelines are federal or state, but I know that our state just passed some significantly strict guidelines on opiates. We have what is one of the highest states for narcotic abuse in the nation. Sorry: (Maine).

Allowed to use EPCS, but it isn't mandatory yet. Will need to get almost all patients down to an MME of 100 mg of Morphine by 2017, but should be starting now. Cancer patients and other exceptions will be exempt. Patients that are already at or just over 300 MME can get that amount but must have a diagnosis, a medication is medically necessary and a statement of intent to wean on the script. I believe if you are still over 100 MMEs by 2017 or so, you have to refer out to a pain specialist. You will also have to check the PMP (the state registry for the prescription record of the patient) prior to each visit. Not sure if that will be attestation or if they will check how often you are using it.

Anyway, I wanted to get opinions on what others are doing as far as giving scripts to chronic users. We have been a bit lenient, and I want to tighten that up.

To give a little background, new users of CII such as Adderall, are seen monthly times three, then every two months times three, then every three months thereafter. They are given three months worth's of scripts.

I don't know how, but our chronic narcotic patients (which are probably 1/25th of the amount of ADHD med patients) seem to be under less strict guidelines.

Today we had an example of not only poor prescribing on a patient as far as some errors were concerned, but the amount of time spent correcting them was not reimbursed. If I am going to spend time looking up the PMP, which takes at least three to five minutes to log into, plus go over pain control and what they are on, and tapers and explaining the laws to them, I may as well get paid for it. Plus, it is just better patient care.

But, if a patient, say with Crohn's who needs 30 mg q12 hours of Oxycontin each month, how often should I see this patient? Every month? Every two months? Three?

Any input as to what others do would be appreciated.

Bert,
I'm in Florida so laws a little different.

1) have written controlled med management agreement
2) put reason for pain med on script ie "for severe chronic pain from crohns disease"
3) random urine drug screens (at least once a year)
4) check state database as much required. I always check for new patients or any aberrations (early refill requests, etc)
5) documentation of need for med
6) see every 3 months if stable, with 3 prescriptions printed, the second two will "fill after a certain date", all dated the same date as actual visit. Florida requires patients to be seen face to face at least every 3 months.

I try to have a focus of the quarter to self audit chart to make sure done. Ie agreements, drug screens, database check, documentation for need.

Hope that helps. We avoid taking new non-cancer chronic narcotic patients. As you know, the pendulum has swung and now "consensus" seems to be patients should just suck it up, take tylenol and do yoga, etc...

Very helpful. Especially the seeing them every three months. That is where I want to get to. No, just automatically come in every month and pick up your script. These were just for those who could be trusted. Yes, I know.... but, I mean kids with leukemia or severe Crohn's.

Even though, I want to do what we do with ADHD meds. Every three months with three scripts. We use a stamp. Of course, MaineCare has to make it even more difficult. They only allow 15 days on any new ADHD script. So, if you are going along every three months, but then change to 30 mg Vyvanse instead of 20 mg, they only get 15 capsules for the first month. Which means a 15 day, 45 day or 75 days f/u. But, what makes it worse, is you always have to stop and think, "Will the 15 day supply take them into the next month, hence the necessary stamp of don't fill before..... or not.

I was mainly looking for 1 month, two months or three months mandatory visit for narcotics. Looks like you do three with opiods.


So, true. In the past, it has always been treat with narcotics, they do well, then refer them to pain management (sorry any pain management doctors), and they change to alternative medicine. It either doesn't work due to unbearable pain or because they were diverting it, either way, they show back in my office. I prescribe Norco. Pain goes away or diversion restarts. Then a week later get a call from the pain doc stating I ruined the plan.

Totally understand the pain doc. It's just that they come to me and sit in front of me in pain or incredibly acting mode. Anyway, at least we will be able to use the law as the
reason.

As to pendulums, look at the CT scan. When it came out and was perfected, it was the best thing since sliced bread. Now you can have massive internal injuries, and the risk of radiation will overrule it. I know, that is an exaggeration, but it has really become more and more difficult to get a CT.

Chronic pain management will likely drive me into an insane asylum.
When I started practice (1975) you could lose your license or be severely punished if you gave an elderly patient a Tylenol #3 at bedtime for arthritis.
A couple of decades later we were giving "back pain" patients 80mg of methadone per day if they were on Medicaid (that was the only drug they would pay for).
Now we are swing back to the 70's.

Pain patients are all different, all pains are different, but as far as the CDC is concerned, it's all the same thing -- except "cancer".

I have never understood why some loggers can be completely smashed to smithereens and not need chronic narcotics, while others with the same injuries become chronic users and some become addicts.

Or why some people with no discernable injury at all develop "fibromyalgia" and have to have truckloads of drugs.

I resent having to be a policeman -- how do I know what people do with their drugs -- I can't follow them around. And its even worse when the patient is elderly and can't speak for him/herself -- but you are pretty sure that some or all of their drugs wind up with family or caregivers. What am I supposed to do about that?

I certainly try hard not to get involved with any more chronic pain patients -- but they just come out of the woodwork, and they have such sad stories. The "pain specialists" aren't any help at all. They just want to do expensive procedures on people who have insurance.

Tom, you are so right. It's likely ten times worse in FP than pediatrics, but pendulum swinging is greater in medicine than just about anywhere I can think of.

I think, from reading your post, we kinda think alike as far as the drug police goes. I generally think or say, I can diagnose the pain (I hope), I can treat it, but I can't control what goes on once they leave the door. And, frankly, I don't care. Please don't take that the wrong way. I mean it's not good when a six year old isn't getting their Adderall.

Not sure how it is in every state, but Maine has been declared an epidemic as far as deaths due to overdoses. But, the statistics show that 42% of the overdoses stem from mixing Fentanyl with Heroin. I can't remember the last time I prescribed Fentanyl, and I am pretty sure that Heroin is considered CI. Couldn't send it in EPCS, I know that.

They hired nine new DEA agents. Now, we have to have everyone under 100 MMEs by January 1st unless, like you said, they have cancer. Then, they can have as much as they want. And, the patients at the methadone clinic can have as much as they want.

The numbers are staggering, but how much of it is due to doctor's prescribing habits vs. the horrible economy I don't know. I am sure I have started someone on Vicodin or Oxys who has subsequently turned into Dr. House, but I am rather sure I haven't contributed a ton to Heroin overdoses. I get an email from the Maine Medical Association every Monday, and the lead story has been about the opioid epidemic. The Maine Attorney General (I don't think she is a Surgeon General) has given out 1,000 doses of Narcan to law enforcement agencies. Which I am not sure will help a lot. And, now anyone can get Narcan from the pharmacy so they have it if one of their friends has an addiction.

Of course, before all this started Medicaid already had a seven-day rule. You could only get seven days worth of a narcotic before you had to pay for it yourself. So, now, if a patient needs pain meds, they just go on goodrx.com and get 120 5 mg oxys for $15.00.

Funny thing is, every state seems to think it is the epicenter of the opiate epidemic.
Has to do with prosecuting the "war on drugs" -- which is clearly losing steam and support in the public, so they have to gin up another "crisis".
I don't think Maine is one of the "legal marijuana" states. Oregon, Washington, and soon probably California have a pretty long experience with that substance, and I can't see much of a problem there, despite what the drug warriors say.

The "overdose epidemic" is conflating legitimate prescriptions with drug mill, diversion, and even suicide.

I am positive the whole thing is bogus.

Completely agree. Again, it's like third grade, where everyone is punished until the kid who fired the spit ball stands up.

Another example of government maybe not ruining helathcare but making it more and more difficult to practice medicine.

MU, CCHIT, MACRA, MIPS and now STOP (Stop Treating Opioid Patients).

Stop helping the good, because of the bad element in society.

I guess there is little we can do. But, it feels good to vent.

Oh wait....another acronym. The AMA. They should be able to help.

AMA - "Against Medical Advice?"

American Medical Association

It was a stupid joke.

The AMA isn't much help that I can see.

I thought it was a joke but you had seemed perplexed a couple of times so just wanted to be sure.

We have one of the largest built-in advocacy groups but they seem to be working again us.

This is where we need the wit/knowledge of John Ryanjo for guidance.

Thanks for the plug, Bert.

Nothing funny to say about the AMA. I'm not a fan of any of the big professional societies, they all left small practice docs in the dust running after MACRA.

About the recent dressing down we all got from the Surgeon General about opioid prescribing: does anyone remember the "Fifth Vital Sign" campaign several years ago, and how doctors were under treating pain, blah, blah, blah. Seems to have been forgotten by the big medical muck-a-mucks. Someone even retracted the article!

Don't get me started here.... That's why I'm selling an ECG and Spirometer after all... Trust me, You don't want to know...

Have a great weekend Folks,

Paul

Thanks for the help, Bert.
At this point, I'm not so perplexed as I am outraged.
Here I am in Seattle (UofW medical school) at a "Family Medicine Review" course.
A distressing waste of time and money.

They started off with a "pain specialist" telling us we are in the mess we are in because of "poor training of primary care providers."

Then went on to detail all the wonderful advances made in interventional pain management. Didn't happen to mention that only a tiny subset of pain sufferers have access or could potentially benefit.

Then came a supposedly "motivational" segment -- yes, indeed, with proper training, the FP's and other "PCP's" can provide meaningful pain relief to their patients. -- The message here being that it is our job to sort out the people with insurance and qualifying conditions for pain management, and refer them to the "specialists." (And keep all the rest for ourselves.)

Then there was a lecture on Hepatitis C -- there are probably 15 new treatments, that vary in effectiveness. But the choice of treatment (or not) depends on your insurance carrier -- not on matching patient to treatment.

Then a segment on adolescent obesity -- in which the influence of advertising and fast food was completely ignored.

And there is more - I'm only a day into a 5-day course.

I am totally disgusted -- American medicine is no longer a profession, it is an industry, and a rank, twisted, self-serving organization at that.

I am wasting several thousand dollars for me and my wife (a CNM/FNP) to take a week out of the office, pay someone to cover the office, pay for transportation, hotel, and not to mention a week of life (increasingly short!) -- for a dumbed down mishmash of dubious truth, let alone value.

All for the demigod of MOC.

I really have an issue with pain specialists. (I apologize to those on here who are. I know there is one who used to post regularly. It is not that they are bad, it's just the system).

We understand we are not that good at treating pain. That is why there are specialists. Here in Maine, we now have to get EVERYONE under 100 mg Morphine equivalents. Except cancer. Again, not making light of cancer, but every entity thinks that cancer is the only pain.

I continue to get emails from MOC telling me I have until 12/15/16 to finish my last part, where I do this survey thing that takes weeks to months. The problem is you have to enter all this information onto the site and once you get it in, there is a one month waiting period. Every time I get one, I tell them that if they want to supply a locum tenens to me for one week, I will be happy to read through their useless Part 4 of the MOC.

There is one section of the MOC which is worth doing. The board that is doing the email weekly where you answer a clinical scenario and can research it is on top of it. That is the way to learn. Who cares if it is open book or open Internet. You still learn.

I can't stand the MOC. And, when I finally pass, I can pay them $1200. ABP. It's a joke.

I feel like I have whined enough, and that I have been heard.
Now life must go on.
There actually have been some pretty good sessions at this review session -- but virtually all of them skirt around the sociopolitical causes of most of the disease that we see.
That is discouraging, but understandable.

No Tom keep it coming, I've been waiting for a Lenny Bruce kind of tirade from you.
Get really pissed off and let 'em rip, I for one do appreciate your reflections!

Wow! Irony is sure strange. I have been slaving over a consult note for a sexual abuse case for most of the evening. I had just saved it when I had to edit it, because I had spelled Colby, "Koby."

Oh and, btw, MOC for ABP: I won't be able to get around to that Developmental module today. Funny, how things like child abuse cases seem to get in the way of board policies.

Bert--
I want to meet you some time. This is not a personal letter, but it does seem like we may have had similar professional trajectories -- or at least, have wound up in a similar place.

This is a thread about chronic pain meds, but I think it isn't too far off the mark to talk about sociopolitical aspects of medicine, since that is mainly what chronic pain is all about.

And, by extension, not too far off to complain about the hypocrisy of Northwestern Ecotopian (Portland/Seattle) behavior, which pretends to care about the adverse effects human behavior has on the planetary environment, but really just is more of the same "I got mine, now leave me alone" mentality that might sit well with supporters of Donald Trump.

The rant is that this U of W Medical School "Family Medicine Review" turns out to be dumbed down classes aimed at "PCP's" (NP's and PA's who are doing "primary care"-- and doing the work of the corporations that are destroying the medical profession, with the total acquiescence of the doctors) -- not practicing, experienced physicians who come in from the countryside to learn what the gurus in the Ivory Tower are thinking. People who are so politically correct -- yet they eat the most appalling crap at their breaks and luncheons -- box lunches and bottled water, with the residue thrown into the great garbage patch of the Pacific Ocean -- and peddle all the latest drugs, which have never been shown by "randomized controlled trials" to make any practical difference in a real person's life, but cost $200 - $2000 per month (or up to $100,000/month if you have lung cancer).

I asked the "pain specialist" why we now have at least 4 new time-release hydrocodone pain meds - when it has been conclusively established that these meds are contributing to the "epidemic" of opioid mortality. He didn't have an answer, and didn't care.

The Diabetes Specialist said she her job was to tell us about the new drugs, not to tell us what would really help people with diabetes (which wasn't under her control anyway, because it wasn't her business to deal with what people chose to eat or what corporations chose to promote).

The radiologist said it would really helpful if doctors would include some clinical history on the radiology order forms -- except that the EMR didn't allow the history to get to him, so it effectively became useless. But that is just the way it is, so don't worry about it. And for sure, don't complain -- he's well paid.

Yes, I'm pissed.
But I'm so over it.

Well, at least I am hijacking my own thread. I sometimes wish I would have started a blog and been a solo pediatrician for the past 20 years. There are so many things I could have written about. But, I likely would have pissed off 300 people instead of just the 100 without it.

Don't even get me started on radiology. You give the rule out, which is not allowed to contain the same word as the diagnosis so if the diagnosis is scoliosis, you have to rule out curvature of the spine. But, then the dictation will at times talk about the film but not even mention what you asked for. But, we are now forced to add a clinical vignette, which I think can be helpful. But, what kills me is when you give the rule out and all of the clinical information, they still say, "suggest clinical correlation."

And back to pain, I have an appointment with one of my patients who is paralyzed from T12 down, and her Dilaudid and oxycodone isn't covering it. But, she is already well over the 100 MME they are allowing, so I will either have to get a prior authorization or refer her to a pain specialist. And, the PA will require PT/OT and accupunture, something that isn't going to help someone with multiple decubitus ulcers. Actually, her story should be put on 48 hours or some documentary as it is both a heartwarming and horrible story, which has just culminated with a beautiful baby.

Politics is interesting. Everyone rips our governor who is a mini-Trump but without all the biases. He is Republican but came in to cut all the money wasting. I probably should be in the anti-Lepage group, but sometimes, you just go with what someone does for you. He basically told both of the hospital conglomerates they can fend for themselves when it comes to Medicaid as well as the FQHC. Then, he turned around and DOUBLED the Medicaid reimbursement for all non-hospital and FQHC practitioners, which percentage-wise makes me the highest-paid Medicaid doctor in the state. Medicaid now pays me better than every other private insurance.

I will most likely be at the next ACUC if I can afford to get away. Still going on 10 years without a day off. and no vacation for 14 years.

Now, I don't agree with what the NFL football are players are doing when it comes to not standing for the flag, and I start a lot of sentences with "The problem with America is...." just as we start sentences with "The problem with healthcare is..." but what happened to me two weeks ago, makes me simply want to hate the U.S. government. I have debated talking about it. My attorney will probably kill me, but you know, I really don't give a f..k anymore. But, I will put it in a separate post, so I can delete it. One of the benefits of being an admin. I can delete my post after eternity where others only get four hours or so. The story is so sick and so pathetic, that if I could I would just quit medicine today. And, remember, I see more Medicaid patients per provider than any other provider in the state. The U.S. needs providers to see Medicaid patients and yet...

Post deleted by me.

It's nice to have a thread to vent.

As far as the opiods go there seems to be a mass amnesia among the "experts" re the pain initiative era 10-15 years ago. We were openly instructed to give patients the benefit of the doubt and prescribe narcotics. I was working ED's at the time and we were instructed to get the patient's pain score down by half, ie if they came in at an 8 they should be a 4 or less on discharge. The only way to do that was narcotics and the approach was of course heavily abused by some patients.

Most pain specialists around here just want to do injections, put people on gabapentin and send them to therapy. There will be many patients where that will not work and they are told to just live with the pain. And I agree there is nothing magical about cancer pain that somehow differentiates it from other pain. The current approach is a mess and good patients will suffer.

Well, the State of Washington is leading the charge to reverse the opioid epidemic. I am right now at ground zero -- seems like about 1/3 of this "family medicine review" is about how we FP's have been inappropriately prescribing.

So now, 50 MED is the current magic number, down from 120 MED. (And down from no practical limit a few years ago.) Benzos are absolutely forbidden. And don't even mention Soma.

All long acting opioids are anathema now, and especially methadone is beyond the pale. The concept of continuous saturation of the opioid receptors with long-acting drugs and using short acting for "breakthrough" has been deemed bogus -- leaving us all with an overhang of many people addicted to long acting drugs.

Absolutely topsy-turvy from what we were taught 15 years ago -- and MADE TO PRESCRIBE!

But the drug companies, pain specialists, medical schools and in general, all the "experts" have denied responsibility for this - it now falls to the lowest on the totem pole (the "PCP") to get everyone off their drugs. Because we prescribe them, of course, and are therefore responsible. The "pain specialists" don't prescribe drugs -- it's beneath their pay grade. They just do procedures.

I'm just about ready to quit medicine, but first I'm just going to stop all opiates and let people suck it up. Of course, I will hear them out, and empathize -- "I do so feel your pain, but you must understand that the pain is not really in your body, but actually in your nervous system, and a product of inappropriate expectations and hyperalgesia caused by inappropriate prescribing".

Cognitive behavioral therapy is what you need.

Tom, have you ever thought of being a writer. Stephen King had a great book called, "On Writing." Probably a good source for our blogging.

@Randy great post

I will comment more tomorrow.

Bert -- I don't know about writing.
But it's a thought -- I think I have been doing medicine for too long. Maybe time for a change.

I wish you luck with your legal ordeal. I don't suppose you have anything to fear -- other than a monumental waste of time. But don't take it personally -- the lawyers don't. It's just business.

It would be nice to change. I just couldn't afford it at the moment. As an FYI, I did delete the post just because, lol. But, thanks for the comment.

@bert etal.

Please don't be too discouraged or quit medicine. Our society needs us--we are all highly trained with irreplaceable experience.

Yes lawsuits are terrible and could make one want to quit. Yes narcotics are a pain. Yes we complain about specialists and insurance companies, but don't let it get you too down.

Take a vacation please. Rest/recharge - I'd say 3 weeks a year minimum. Patients are generally understanding even for a solo practice when shut down for vacation.

What I've decided to do is tell everyone on the phone that asks that we do not do chronic pain management. They can go to a pain center for that. Of course you will have your own patients moving into this realm with legitimate pain problems. From discussion with the Ivory Tower pain specialist at UW, I have been told that for the most part, all the pain clinic expensive procedures are useless. They are only intersted in procedures, however, because they pay big bucks. Further, the long-term treatment of pain with opioids is useless. Most patients at 10 years, now on 10 times the dose, will say their pain is just as high on the 1-10 scale as it was previously: tolerance complicated by dependence. A significant percentage end up on street heroine when the pain pills no long work. I tell patients about this FROM THE START, about the road they may be starting down. I do treat some of them, but when they want to move on to MS Contin, Roxy, etc, they won't be getting it here. I refuse to be an accessory to the problem. What to do about the back pain then? You need to get to the core of the problem. For many people it is boils down to Poor Physical Fitness. If they really want to get better, they need to become fit. Other pain problems have no solution, and you just have to live with it. Yes, that sucks, but that's life and better than being a heroine addict.

For my light weight pain patients, they are taking 3 hydrocodone per day, some taking just half a pill at night before bed and not accelerating, I have a careful program constructed similar to the UW pain programs. Any requests for increasing doses (remember, increasing the dose just builds more tolerance) that is too accelerated, means a red flag and perhaps going to a specialist. They all sign a pain agreement. When you doctor shop after signing this, it becomes a crime. The agreement says all records can be shared with law enforcement. There are is a "three legged stool" of safety: pharmacy database search, random urine drug tests, and pill counts. I do all these with the patients and document when the last stool leg was done in the chart. There is a lot of other language the DEA likes in the chart which I can post too. Overall, my chronic pain load just about stopped when I quit taking adult medicaid. When someone new calls and says they have back pain, my receptionist tells them this is not a pain clinic.

At least we can see notification of the retraction. One of these days it is going to be like George Orwell's Animal Farm, where the changes will just occur without acknowledgement: "All animals are equal" was the original and then it became "All animals are equal, yet some are more equal then others."

I haven't had a vacation in 12 years, 4 months, and 17 days. The only quasi one I had was at the last (and only one) ACUC that Jon Bertman was at in Rhode Island, and that was Thursday through Sunday, and I had to give two awful talks, and the room was literally 64 degrees. And, my pager went off only six times over the weekend, which is pretty good.

I just read an interesting article about codeine and not to give it to "kids" under 18. They say user "safer alternatives" like oxycodone or hydrocodone. But, I think it is because it is metabolized to morphine. They said to use older methods like Tylenol and ibuprofen. Don't use for cough.

Hi Bert,
Haven't been on the board for a few years. Sorry to see your pain. In my view, one of the major mistakes physicians make is not practicing what they preach (or from my military days, leading by example.) You need time off, or as a colleague of mine would say, you need time out of harness. While you may not realize it, the absence of time off could be impacting your decision making and definitely could lead to burnout.

As an internist I tell my patients all the time about the need for work/life balance, yet up until a few years ago I wasn't practicing it myself. Then I started cross covering with an extremely well respected older colleague of mine and he told me his secret of managing a very busy and successful practice: he has been taking his retirement for the last 30 years. He works long hours yet he also takes several vacations of 1-3 weeks in length which seem to totally recharge him. His patients love him and while he phones his office each day while away he still relaxes. Please make sure you are taking care of your health (both emotional and physical). My apologies for sounding preachy and especially for being off topic yet this did start as a thread about pain management.

You are completely right. I remember when I was working in a practice where we shared call with a total of five, we all got four one-week vacations per year. So roughly every three months. I recall sitting in the sushi restaurant and realizing that my vacation was going to be in 15 weeks and not 12. And, I would freak out. My god, if somehow, they said so and so is sick, you will have to get only three weeks, I would have quit.

Then the guy I worked for changed my income from salary to 50% of my gross or net, can't recall, which ironically turned out to be almost the same. But, given I only made money if I worked, I couldn't afford to take time off. Looking back, I should have, because my boss was a pediatrician and could easily have covered my patients. I remember he said, "Hey, take the week off. You can just work 16 hour days when you come back." OK.

Now, given I am solo, and there are two evil empires and no one to cross cover with, it is hard. If I were a FP, there would be at least 10 to choose from. But, I can't do adult medicine, so it has to be a pediatrician. Keep waiting for that doctor to take a full-time job at the hospital and the spouse be a pediatrician but only want to do part time, but needs coverage.

I started the thread so I can allow hijacking.

With regards to cross coverage, is there urgent care? I realize you may not trust them yet it is amazing how much can be handled over the phone and by staff. I'm solo concierge like my colleague yet he can't always work in one of my patients when I'm away and vice versa (we actually have a call group of 3). It's tough to have a tether, yet wouldn't it be nicer to be tethered in AZ or FL or Hawaii for a week or two in January instead of Maine? (no disrespect to Maine).

Hey, you can't beat rampant Lyme disease and one of the highest opioid rates in the country. But, you have a call group of three. I have thought of one way. Gotta get home after I figure out a way to get the water cooler and the refrigerator electricity.

Bert My Old Friend,
I have to say I FEEL your pain and I totally agree that you need some serious time off now and again. How far away is the Next Ped in the Next Town or Two away? There has to be some wiggle room in the rules and laws for a doc who is the ONLY doc in his immediate area to not give Perfect 24/7 coverage.

Personally here's my suggestion. Let's assume that there is at least another ped within less than an hour 50 miles away or so. Hook up as long as they're not a complete Loon and take your own call nearly all the time over the phone via your service that last I knew you still used to handle the initial screen and reach you.

If you can't half handle it at least for the night over the phone then it's probably close to being a Better Safe Than Sorry, I'm Sending You to the ER JIC, Just in Case... Right? And they can always attempt to get in with your new "Call Partner, take phone care with you or for those few exceptions that the patient might be "that sick" it's Sorry But Uncle Bert needs a few days rest too, you're going to the ER. It's one of the few downsides to being in your kind of one of kind solo practice.

But when I talk to you and read about how many years it's been since you've been off, honestly I've been more than just a little concerned for you for a good long time now.

Lastly, the wonderful sharp and such a good egg Lady Ped here in my area that has taught Peds to nearly ever doc who trained here in the past 20 plus years, she finally went solo too about a dozen years ago and couldn't or wouldn't create a cross coverage with the less than personal, less than perfect larger groups in our area. BUT, Dr. P has a good, floating Nurse Practitioner who covers her practice in person when she needs to go overseas to visit family or take a little bit of needed and WELL DESERVED RnR, Rest and Relaxation.

Please Buddy take good care of Bert. You can't properly care for those in your care if nobody cares about Bert and gives him some of this needed time off. Please try to work something like this out... Hang in there and we're pulling for ya....

Paul

Thanks Paul,

I am actually looking for some ways. It's tough. This is an early night for me, lol. But, I do have the morning off.

Talk more later. Not ignoring your PM. Just too busy to get to it.

Bert:
If your practice is "tuned-up", I would be so bold as to contact one of the family practitioners to see if they would cover you for a week (for a nominal fee). I am a solo family practitioner and would not hesitate to do this for a pediatric colleague that is as hard-working as you. He might be able to return the favor in some fashion with difficult pediatric patients in the future. Just a thought. Marlon