Guest guest Posted August 3, 2007 Report Share Posted August 3, 2007 > > Seriously, should the state board of health be involved? > The local hospital ER is going to get crushed. > If you have professional or legal advice, send it... Tom, a similar thing happened to a friend on mine who bought a practice : 800 charts, many with monthly visits, ultra-brief office notes per encounter, most patients on vicoden and xanax. I do prescribe short-term narcotics to a few patients, xanax maybe four times a year, ativan never. I have a patient on oxycodone from previous MD (for legitimate reasons) and one on dilaudid at night (also for very good resons). There are cases when you can't avoid narcotics, there is no other option. After working in places like and Hammond Indiana, I can smell an addict on the phone, so I have a few rules : -I refuse to see new patients who call for acute migraine or back pain on friday evening, saturday or sunday and need to be seen " ASAP " . 9 out of 10, these are addicts. -I do not see people with fibromyalgia or chronic migraines who give me on the phone a long and elaborate story about all the crap they have ingested and how they are allergic to everything minus vicodin. -I ask for old records on all patients who come on pain killers and if they refuse to sign for release, I tell them to go someplace else. -there is a controlled substances contract that all patients on opiates have to sign, the contract states that if the cat eats the pills ahead of time, they are out of my practice... and many other things like that. Make sure you justify in your records why the patient has to be on opiates : for example, patient already on coumadin and ASA with chronic pain or history of bleeding ulcer, kidney problems with elevated creatinine, uncontrolled HTN and so on... Your reputation travels fast, most addicts talk to each other, they know who the " nice " doctors are. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2007 Report Share Posted August 3, 2007 To play devils advocate. There may be a good reason he is closing so quickly, illness, or State board after him. Still poor form, I find most records from offices like this to be mostly worthless, but there may be a law in your State that mandates him to provide records to the patients. Might not hurt to call the State board and find out, they might be interested in his exit strategy ________________________________ From: on behalf of Piergallini Sent: Thu 8/2/2007 9:56 PM To: Subject: Antithesis of IMP A short anectdote as to why the way IMP way is moral and ethicial. And y'all need to keep doing what you are doing. Local doc in my town, in practice forever, has thousands on his panel. Finally decides to retire. How does he do it? Puts sign up on his door, " Office closed in 2 weeks. Period. Done. Goodbye. Like a copy of your medical records? He will print off the notes of your last two encounters, that is all you get. Patients in a scramble, start calling other primary cares in town. " Will you take me? " " Yes, we will, but we DO NOT prescribe narcotics for pain management. " 19 out of 20 callers to our office then hang up, and do not make an appointment. Wow. Can you imagine what is going to happen in 2-3 weeks, when all these patients go into detox? Seriously, should the state board of health be involved? The local hospital ER is going to get crushed. If you have professional or legal advice, send it... -tom Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 3, 2007 Report Share Posted August 3, 2007 This happened about 9 mo ago here. Local DO, lost ability to Rx narcotics after death of patient using too many of too many things. Suddenly lots of narcotic patients with no where to go. Don't worry, or cave in and take them. They will drift off to mostly to large systems where they can go from doctor to doctor, or to very small offices, with like minded doctors who will Rx for them. Unfortunately most won't end up in rehab. Used to work in an IHS clinic with a inpatient detox unit on site, the patients, all know who Rx what, in all the local towns. Still haven't gotten any records from any of the legitimate patients who came to me from that office. Cote'MD Four Corners Family Medicine Maple Valley, Wa 90838 -------------- Original message -------------- To play devils advocate. There may be a good reason he is closing so quickly, illness, or State board after him. Still poor form, I find most records from offices like this to be mostly worthless, but there may be a law in your State that mandates him to provide records to the patients. Might not hurt to call the State board and find out, they might be interested in his exit strategy________________________________From: on behalf of PiergalliniSent: Thu 8/2/2007 9:56 PMTo: Subject: Antithesis of IMPA short anectdote as to why the way IMP way is moral and ethicial.And y'all need to keep doing what you are doing.Local doc in my town, in practice forever, has thousands on his panel.Finally decides to retire.How does he do it?Puts sign up on his door, "Office closed in 2 weeks.Period. Done. Goodbye.Like a copy of your medical records?He will print off the notes of your last two encounters, that is all you get.Patients in a scramble, start calling other primary cares in town."Will you take me?""Yes, we will, but we DO NOT prescribe narcotics for pain management."19 out of 20 callers to our office then hang up, and do not make an appointment.Wow. Can you imagine what is going to happen in 2-3 weeks, when all these patients go into detox?Seriously, should the state board of health be involved? The local hospital ER is going to get crushed.If you have professional or legal advice, send it...-tom Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2007 Report Share Posted August 4, 2007 When the psychiatrist in the building next door had a massive MI, his office closed with no warning at all. That was 6 years ago and I STILL have about a dozen elderly benzo-dependent folks that I inherited from him and have never been able to wean. These last few are not much problem, but it was a nightmare at first because a lot of the folks didn’t even call for appointments; they just camped in the waiting room and refused to leave until they got what they wanted. I was an employee at that point, so I didn’t have the option of refusing to see them. Still makes me shudder to think of it. L. Skaggs, MD Lexington, KY www.fayettefamilymed.com Antithesis of IMP A short anectdote as to why the way IMP way is moral and ethicial. And y'all need to keep doing what you are doing. Local doc in my town, in practice forever, has thousands on his panel. Finally decides to retire. How does he do it? Puts sign up on his door, " Office closed in 2 weeks. Period. Done. Goodbye. Like a copy of your medical records? He will print off the notes of your last two encounters, that is all you get. Patients in a scramble, start calling other primary cares in town. " Will you take me? " " Yes, we will, but we DO NOT prescribe narcotics for pain management. " 19 out of 20 callers to our office then hang up, and do not make an appointment. Wow. Can you imagine what is going to happen in 2-3 weeks, when all these patients go into detox? Seriously, should the state board of health be involved? The local hospital ER is going to get crushed. If you have professional or legal advice, send it... -tom Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 4, 2007 Report Share Posted August 4, 2007 Annie,What would happen if you unilaterally decided to wean them off benzos? If you said, this month you get only 100, then next month 50 then next month 25, etc with no exceptions? SetoSouth Pasadena, CAWhen the psychiatrist in the building next door had a massive MI, his office closed with no warning at all. That was 6 years ago and I STILL have about a dozen elderlybenzo-dependent folks that I inherited from him and have never been able to wean. These last few are not much problem, but it was a nightmare at first because a lot of the folks didn’t even call for appointments; they just camped in the waiting room and refused to leave until they got what they wanted. I was an employee at that point, so I didn’t have the option of refusing to see them. Still makes me shudder to think of it. L. Skaggs, MDLexington, KYwww.fayettefamilymed.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 They’d go elsewhere. Back when this started, I was an employee, and was expected to keep the patients happy, so we just continued everybody on what they were already taking. Over the years, and now that I am on my own, the non-compliant and otherwise difficult ones have been driven off one-by-one, but the handful that are left are stable and well behaved, so I have a hard time justifying changing the plan on them. Most of them have been taking that 5mg Valium TID for more years than I’ve been alive, so it’s hard for me to say there is something wrong with that. Would you cut them off if they don’t seem to be having falls or other problems? L. Skaggs, MD Lexington, KY www.fayettefamilymed.com Re: Antithesis of IMP Annie, What would happen if you unilaterally decided to wean them off benzos? If you said, this month you get only 100, then next month 50 then next month 25, etc with no exceptions? Seto South Pasadena, CA When the psychiatrist in the building next door had a massive MI, his office closed with no warning at all. That was 6 years ago and I STILL have about a dozen elderlybenzo-dependent folks that I inherited from him and have never been able to wean. These last few are not much problem, but it was a nightmare at first because a lot of the folks didn’t even call for appointments; they just camped in the waiting room and refused to leave until they got what they wanted. I was an employee at that point, so I didn’t have the option of refusing to see them. Still makes me shudder to think of it. L. Skaggs, MD Lexington, KY www.fayettefamilymed.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 I know what you mean, Annie. I've got a few patients like that, too. They aren't on an ideal regimen, but don't seem to be going up in their usage, rarely call early, and are otherwise nice people. It would seem like there are other battles to fight than tapering them unilaterally off their Benzo. Unless they come in saying they are ready, then I've just left them on the regimen. Of course, I had one of these patients leave the valley and go to another state...and of course the new doctor was like -- "What the Hell? I'm not continuing that regimen." So I know what it feels like to be looked upon as the "other doctor" who closed his clinic....but I would say I don't have more than a handful of these patients, so I wouldn't unleash them on the community if I crumped. I guess it gets back to the --- I know what should be done versus what I'md doing and what is practical sometime. Cheers Locke, MD From: [mailto: ] On Behalf Of Annie SkaggsSent: Saturday, August 04, 2007 4:08 PMTo: Subject: RE: Antithesis of IMP They’d go elsewhere. Back when this started, I was an employee, and was expected to keep the patients happy, so we just continued everybody on what they were already taking. Over the years, and now that I am on my own, the non-compliant and otherwise difficult ones have been driven off one-by-one, but the handful that are left are stable and well behaved, so I have a hard time justifying changing the plan on them. Most of them have been taking that 5mg Valium TID for more years than I’ve been alive, so it’s hard for me to say there is something wrong with that. Would you cut them off if they don’t seem to be having falls or other problems? L. Skaggs, MD Lexington, KY www.fayettefamilymed.com -----Original Message-----From: [mailto: ] On Behalf Of SetoSent: Saturday, August 04, 2007 3:32 PMTo: Subject: Re: Antithesis of IMP Annie, What would happen if you unilaterally decided to wean them off benzos? If you said, this month you get only 100, then next month 50 then next month 25, etc with no exceptions? Seto South Pasadena, CA When the psychiatrist in the building next door had a massive MI, his office closed with no warning at all. That was 6 years ago and I STILL have about a dozen elderlybenzo-dependent folks that I inherited from him and have never been able to wean. These last few are not much problem, but it was a nightmare at first because a lot of the folks didn’t even call for appointments; they just camped in the waiting room and refused to leave until they got what they wanted. I was an employee at that point, so I didn’t have the option of refusing to see them. Still makes me shudder to think of it. L. Skaggs, MD Lexington, KY www.fayettefamilymed.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 We had a guy here in town who I guess is a "pain management" doctor who closed his doors and now just does hospital work and give talks about how it is malpractice not to provide adequate pain relief. At any rate, I usually have a conversation with these patients who are chronically on benzos or narcotics and discuss why I don't think it is a good plan. I don't stop people though, and I work through a weaning program when they are ready to do it (this in the little old people only). I just recently had an 83 yr old guy who had been on Valium since his son died in Vietnam. I kept getting little reminder notes from his drug plan that it wasn't a good plan in the elderly. He was getting confused over the past 5-6 m or so and we dc'd it. He cleared up quite a bit, not back to his 40 yr old base line, but pretty good. Anyway, I think it is worth talking to the patients about it when they come in for their refills, in a gentle way. Get a sneak peek of the all-new AOL.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 I think it really depends on why they are on the benzo. SSRIs do not work for everyone with GAD or panic and do have their own side effects. Benzos really are cleaner. Just document that they are stable on their feet, mentally clear, stable dose as prescribe by psychiatrist umpteen years ago. The sedation goes away long term anyway. They do work and keep people functional. They really aren’t bad just sometimes misused. Kathy Saradarian, MD Branchville, NJ Solo low-staff practice since 4/03 In practice since 9/90 Practice Partner User since 5/03 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 Kathy, thanks for pointing this out. There are patients for whom chronic BDs are indeed the best answer for their GAD and they do not " get a buzz " or develop tolerance. I have had patients for whom chronic opiates are the best answer, including those with chronic pancreatitis, reflex sympathetic dystrophy, Gaucher's disease, recurrent vertebral compression fractures, and spinal stenosis. Sometimes it's because the patient is not a good surgical candidate or NSAID candidate, and sometimes it's because it's the only thing that works. Again, these patients do not get a buzz or develop tolerance, though their dose need may go up if the condition worsens. They don't accidentally spill their pills into the toilet. If you have a patient you suspect of medication abuse there are indeed pain " agreements " (I was told not to call it a contract) that you can have them sign that makes them agree to numerous conditions including (1) you will be the only person to prescribe his or her opiate medication, (2) he or she will use only one pharmacy, and (3) if he or she runs out of medication early the refill will not happen until the scheduled time. If you're really suspicious you can have the DEA run a name search and find out if your patient has been getting scripts from multiple physicians and/or pharmacies. Please make use of pain treatment consultants if you have them available to you. Please keep in mind that they are often overwhelmed with patients and that they typically do not like to do long-term prescription management for patients on stable medication regimens, so you should expect to get your patients back and be the one to chronically manage their medications. In my pre-IMP faculty practice I got saddled with more than a few patients who had been referred to the faculty's anesthesia pain clinic from the community and then their community PCP would not take them back. It was even worse in my practice because I had several colleagues who didn't " believe " in prescribing opiate medication for anything, so I got more than my fair share of these patients. And yes I too have been burned by patients even though I feel pretty comfortable looking for red flags of abuse, but I don't hold that against all my patients. If you are worried about your state medical board or the DEA just make sure that you perform a " good faith exam " and make comprehensive documentation of symptoms, objective pathology, diagnoses, response to past treatments (procedures, non-controlled meds, BDs, opiates), and on-going management. You may want or need to have a periodic f/u consultation with a specialist. You shouldn't have any trouble if you do these things. Marty I think it really depends on why they are on the benzo. SSRIs do not work for everyone with GAD or panic and do have their own side effects. Benzos really are cleaner. Just document that they are stable on their feet, mentally clear, stable dose as prescribe by psychiatrist umpteen years ago. The sedation goes away long term anyway. They do work and keep people functional. They really aren't bad just sometimes misused. Kathy Saradarian, MD Branchville, NJ Solo low-staff practice since 4/03 In practice since 9/90 Practice Partner User since 5/03 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted August 5, 2007 Report Share Posted August 5, 2007 I think the only patient that moved to another doctor because they were unhappy with me was because I didnt support their ongoing valium use. But I have several that have been successfully transitioned to SSRIs or other more benign or appropriate agents. Ron E > > > > > > > > I know what you mean, Annie. > > I've got a few patients like that, too. > > They aren't on an ideal regimen, but don't seem to be going up in their > usage, rarely call early, and are otherwise nice people. > > It would seem like there are other battles to fight than tapering them > unilaterally off their Benzo. > > Unless they come in saying they are ready, then I've just left them on the > regimen. > > Of course, I had one of these patients leave the valley and go to another > state...and of course the new doctor was like -- " What the Hell? I'm not > continuing that regimen. " > > So I know what it feels like to be looked upon as the " other doctor " who > closed his clinic....but I would say I don't have more than a handful of > these patients, so I wouldn't unleash them on the community if I crumped. > > I guess it gets back to the --- I know what should be done versus what I'md > doing and what is practical sometime. > > Cheers > > Locke, MD > > > > ________________________________ > From: > [mailto: ] On Behalf Of Annie Skaggs > Sent: Saturday, August 04, 2007 4:08 PM > To: > Subject: RE: Antithesis of IMP > > > > > > They'd go elsewhere. > > Back when this started, I was an employee, and was expected to keep the > patients happy, so we just continued everybody on what they were already > taking. Over the years, and now that I am on my own, the non-compliant and > otherwise difficult ones have been driven off one-by-one, but the handful > that are left are stable and well behaved, so I have a hard time justifying > changing the plan on them. Most of them have been taking that 5mg Valium > TID for more years than I've been alive, so it's hard for me to say there is > something wrong with that. > > > > Would you cut them off if they don't seem to be having falls or other > problems? > > > > > L. Skaggs, MD > > Lexington, KY > > www.fayettefamilymed.com > > > > Re: Antithesis of IMP > > > > > > Annie, > > > What would happen if you unilaterally decided to wean them off benzos? If > you said, this month you get only 100, then next month 50 then next month > 25, etc with no exceptions? > > > > > > Seto > > > South Pasadena, CA > > > > > > > > > > > > > > > > > When the psychiatrist in the building next door had a massive MI, his office > closed with no warning at all. That was 6 years ago and I STILL have about > a dozen elderlybenzo-dependent folks that I inherited from him and have > never been able to wean. These last few are not much problem, but it was a > nightmare at first because a lot of the folks didn't even call for > appointments; they just camped in the waiting room and refused to leave > until they got what they wanted. I was an employee at that point, so I > didn't have the option of refusing to see them. Still makes me shudder to > think of it. > > > > > L. Skaggs, MD > > Lexington, KY > > www.fayettefamilymed.com > > > > > > Quote Link to comment Share on other sites More sharing options...
Recommended Posts
Join the conversation
You are posting as a guest. If you have an account, sign in now to post with your account.
Note: Your post will require moderator approval before it will be visible.