Home Forums Discussions General Discussion Discharge for Non-Compliance

Wow! I didn't even notice that! Yes, Bert, I did watch them, thought the last one was hysterical. Here in Oregon we are just much more laid back. I had to wait until I saw an opening and then I had to rev up my crochetiness again.

Could the board administrator please insist that members accurately report their locations.
If someone is living in Oregon they should not be allowed to claim residence in Southern Indiana.

oops

And, this from a former mod, no less.

Let's get this thread back on track!

Should doctors dismiss patients because they disagree with doctors' orders?
I say, absolutely not.
In our office, we dismiss patients who threaten the staff, and that is it.

You can be rude, you can disagree, you can sometimes even cheat on urine screens or forge a prescription (once).

But you can not threaten to harm a staff member.

Just because the CDC or some insurance company says something is good (or bad) doesn't mean that their recommendation is a law that I need to enforce. More people die of tobacco abuse than ever died of pertussis.
Are we to "fire" people for smoking?

But I have said enough.

You lost me on that one. I wouldn't fire for non-compliance -- not sure the comparison between tobacco abuse and Pertussis came from.

You can fail a drug test, but you can't cheat on one. And, you definitely can't forget prescriptions. And, being rude, while not 100% is rather close. I think mainly because being rude is as close as my patients have ever gotten to harming or threatening a staff member.

Well, let me explain.
1. I strongly advise my patients not to smoke. They do anyway, and they harm not only themselves but their family. Many of them die.
Of course, there is no comparison (it's "apples and oranges") with pertussis, but the only reason I can fathom for applying police state rules to immunization mandates is that non-compliance leads to social harm. My point was that tobacco smoking kills far more people than pertussis, so the social harm is worse -- and so we should logically exclude smokers from our practices.

2.You certainly can cheat on a drug test, and forge prescriptions --and many people do. I use drug tests as part of a conversation with patients -- they really aren't reliable, so I don't think they should be used to exclude people from the practice -- even if I catch them red-handed in full cheat mode. Not the first time, anyway -- and even then, it would only to be to tell them I can't prescribe any more schedule II drugs. Same with forgery. It's not an absolute "out" -- people try increasing the allowed refills, etc. If they were actually to forge prescriptions to obtain drugs to sell, that would likely be the end.

3. I don't suppose that pediatric patients normally would be considered threatening, so maybe you haven't experienced the difference between "rude" and "violent." ("Sticks and stones can break my bones, but calling names won't hurt me.") We have very rarely experienced truly violent people -- they are the only ones we actually exclude and forbid to return.

We have parents.

In our practice, if a patient has repeatedly (more than 3 times) ignored our office policies (i.e. not keeping necessary follow ups if we're prescribing meds that need to be monitored), then we write them a letter indicating that the doctor feels they have a medical condition that needs to be followed by a physician for their health & safety. We let them know that they've been either unable or unwilling to follow the doctors advice and that they need to find another physician to take care of them. We give them 90 days (RI Law) of continuous care (refill meds, see them if needed) but they need to find another doctor or have their PCP or another neurologist take over their treatment plan. Records accumulated by this office will be sent to a physician of their choice.

There is a massive shortage of neurologists in our area that aren't booking out 3-5 months. What we have no shortage of are people looking to feel better and be seen in a timely fashion. We don't want to waste our time, or the patient's for that matter, if they're not going to follow the advice given or the policies that are put in place for their protection.
Hope this answers your question.

Thanks Bert.
I sense that this subject has been beaten to death.

I agree. I think everyone has given good advice. It's now up to Chris to choose the way he wants to go.

I just want to say I was speaking in generalities. We tend to stop the medication and not dismiss the patient.

It's sad, but I am hesitant to dismiss the patient even when they attack me. I have had that happened once. This is because of the board complaints.

We only called the police on three patients. A nine-year-old girl with ADHD that was out of control. A very large patient with autism where I should have deescalated the situation instead of escalating it, and a drug rep.

The first two I understand. But I would really LOVE to hear the story on why it was necessary to call the police on a drug rep.

JamesNT

Sure. We noticed shortly after starting the use of Focalin XR and/or Focalin that patients became labile (becoming tearful or upset) far out of proportion to the provocation, i.e. being asked to put a book away or do you want a sandwich.

In medicine, when you bring up a side effect (whether reported by other practices or not), they may ask for clarification, but the drug rep is simply required to share this with their company and manufacture. It is rather obvious why this is done.

But, she would argue and complain to me and my staff that this has never been reported, and we must be wrong.

This got worse and worse every time she came until one day, she started screaming at me down the hall and coming towards me. As she was adjacent to the examining room, she was scaring some of the children. I asked her to leave and she wouldn't. Finally, I asked my staff to dial 911. The police department had a field day and came back multiple times to try to arrest her. She had left telling me she would never be back.

Sounds like she was helping herself to her own drug samples

I think she may have been. I wish I had it on tape.

"You have never liked me!" "You have never liked Focalin!" "You are the only one ever who reported lability with my drug!!!"

Wow.

JamesNT

Wandering further off topic...

We don't see drug reps in our practice. But not because of this kind of incident. I think that the whole system of promoting pharmaceuticals in our country makes me ethically uncomfortable.

I do understand that a lot of my colleagues see reps to get meds for less fortunate patients, very admirable. But the whole system of drug promotion disguised as education of prescribers is laughable.

"Side effects may include nausea, vomiting, problems with balance, and death."

JamesNT

I don't know. I like drug reps. They never sway my opinion. I think the cost is cheaper to deal directly with the doctor than Claritin and Viagra ads on television. We used to have a little of nearly every medication. You could try it and see which works best.

One of the best uses was after a urine test, especially a cathed specimen, we would give two doses of Cefzil (there is a 2% chance of inoculating the bladder with bacteria) plus simply coverage while waiting on the culture. No ten-day script. Giving ten bottles of Vantin for a plane trip when questioning an OM. So many good reasons.

I remember a good friend who would come in with Strattera. Every time, are you using Strattera? No. Why? Because it sucks. Thanks for the coffee. And, I don't need to go to Belize. But, an iced coffee was nice and talking football. Adderall XR? Yes, it's a good drug. Just not covered by MaineCare. Will you think about it in your private pay patients? No. (Unless it turns out to be the best option).

Like John, I agree with those on the other side and those in the middle. As long as you have a "we call the police on Focalin reps," you are fine.

"Find another doctor who will practice poor medidine"

Wendell: Do you discharge them for non-compliance if they will not vaccinate?

Depends on the rationale.

For the most part, yes, I will tell them that I practice evidence based medicine and that includes vaccines. If you refuse the XYZ vaccine because you heard it causes the child to grow a 3rd ear, go find a doctor who will agree with that.

If they or a close relative had a significant side effect or a (semi)legitimate religious reason (don't ask, I won't go into them) I will consider.

I honestly think more patients should be discharged from practices. We have a low threshold for doing so. It is a two way relationship, and there are plenty of other doctors they can see. One of my best teachers once told me, 5% of your patients will cause you 95% of your headaches. He wasn't referring to their medical complexity, but their mental issues complicating their treatment. If you can weed through those patients, your life will be much easier. Sometimes personalities just don't match. My two cents.

David Lee, MD
IM
Dallas, TX

That's true no matter what you do for a living. Just ask any mechanic, electrician, anyone.

JamesNT

I agree 100% with Dr John, Internist. I also do not accept free lunches or meals or seminars.

Sandy

I guess the Soup Nazi was right after all.