What exactly is a methadone mill? Does it generate high incomes?

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A reason why I like the doctor-going-undercover idea is because a physician can rate another physician. If such a procedure was done, I'd also recommend the doctor-acting-as-a-patient also record the entire interview via a secret recording device.

Reason for this is because patients often times give a negative review simply for a bad outcome or if they didn't get what they wanted. We as doctors know that sometimes bad outcomes cannot be avoided even with the best of treatment, and that sometimes patients want something that is actually going to make them worse, but if we refuse, they get ticked at us.

The reason for the doctor to record everything is to make sure the doctor-acting-as-a-patient that is grading the other doctor doesn't do so unfairly, and if the doctor being graded is unfairly stamped as doing poor practice, they have a means to check why and defend themselves based on real objective evidence. To allow a doctor to be checked off as doing bad practice without objective means to confirm it would actually be worse than what's going on now.

But no one will go with my idea. I know it. So be it, I can only control what I can control.

Originally Posted by whopper

A reason why I like the doctor-going-undercover idea is because a physician can rate another physician. If such a procedure was done, I'd also recommend the doctor-acting-as-a-patient also record the entire interview via a secret recording device.

Reason for this is because patients often times give a negative review simply for a bad outcome or if they didn't get what they wanted. We as doctors know that sometimes bad outcomes cannot be avoided even with the best of treatment, and that sometimes patients want something that is actually going to make them worse, but if we refuse, they get ticked at us.

The reason for the doctor to record everything is to make sure the doctor-acting-as-a-patient that is grading the other doctor doesn't do so unfairly, and if the doctor being graded is unfairly stamped as doing poor practice, they have a means to check why and defend themselves based on real objective evidence. To allow a doctor to be checked off as doing bad practice without objective means to confirm it would actually be worse than what's going on now.

But no one will go with my idea. I know it. So be it, I can only control what I can control.

The closest you are going to get is in med school and residency, when trainees are watched with cameras. However, this is a highly artificial environment and unlikely to be predictive of future practice patterns.

On a related note (i.e. not giving people what they want vs need), I have
a FM pt who is on a very high dose of Fentanyl, and am sloowwly tapering her down. Her catastrophization is stunning. While she states she is in "the worst pain ever", my secretary will see her in the lobby catching a snooze / or almost nodding off. "But doc, you don't understand I didn't sleep well last night" - and all the usual litany of excuses follow when she is confronted with this discordance in her symptoms.

Yup, the taper continues.

xxx

Oh boy, another FM patient who had a doctor stupid enough to put her on an opioid.

Suboxone does have benefits over Methadone, but it still can be abused.

Originally Posted by ghost dog

The closest you are going to get is in med school and residency, when trainees are watched with cameras. However, this is a highly artificial environment and unlikely to be predictive of future practice patterns.

On a related note (i.e. not giving people what they want vs need), I have
a FM pt who is on a very high dose of Fentanyl, and am sloowwly tapering her down. Her catastrophization is stunning. While she states she is in "the worst pain ever", my secretary will see her in the lobby catching a snooze / or almost nodding off. "But doc, you don't understand I didn't sleep well last night" - and all the usual litany of excuses follow when she is confronted with this discordance in her symptoms.

Yup, the taper continues.

BTW - Opioids can cause a lot of central sleep apnea and also worsen OSA. . . also, down regulates adenosine in basal forebrain thus messing with homeostatic sleep/wake system . . . . 85% of people on opioids have insomnia. . . one more reason to taper. . .

Originally Posted by BobA

BTW - Opioids can cause a lot of central sleep apnea and also worsen OSA. . . also, down regulates adenosine in basal forebrain thus messing with homeostatic sleep/wake system . . . . 85% of people on opioids have insomnia. . . one more reason to taper. . .

But Doc, Dilaudid is the ONLY thing that helps me to sleep. I don't sleep at night because of the pain and I need the Dilaudid to take that away.

xxx

I would've loved to have video recorded this particular session and asked colleagues to see if I did anything inappropriate.

I got a patient with a very strong cognitive triad for depression. Per him, he was up and coming to be an NFL athlete, and during his senior year in college, he was falsely accused of a date-rape. Per him, after the incident, the NFL wouldn't touch him with a ten foot pole, even after an investigation showed he didn't do it. He's been depressed ever since and it's been years. His father confirmed that the NFL story was true, but I have my doubts because he's not really bigger than I and I'm not what you'd consider NFL physique. I work out, I got muscles, but I'm 5'7". I've also worked with a few professional athletes, and in general, they are very disciplined people (though yes, there are exceptions).

The guy refuses psychotherapy, he does get better on SSRIs, but each time he sees me he's run out of SSRIs for a few months, and he demands Xanax and I refuse. I remind him that even per him the SSRIs work, but he continues his demands to the point where he becomes irate in the office. I also told him that IMHO, the biggest reason why he can't get over his depression is because he completely measures his life based on his failure to get in the NFL, and that was apparently robbed by a false accusation. That event will never be changed and he has to move on. Psychotherapy will help in that regard.

I told him something to the effect that if he asks for a benzo again, to not even to bother showing up to the office. Now this is after several meetings where 80% of the meeting is me politely trying to direct him to utilize psychotherapy in addition to SSRIs, and him telling me he's not going to use SSRIs anymore in what I perceived to be an attempt that he believed would force my hand into giving him Xanax (he said, "If I don't take the Citalopram, now you got to give me the Xanax because you have to treat my depression.") Ask once, I'll explain why my answer is no, ask five times, somewhere between the 3rd and the fifth, I'm going to tell the guy to stop it because he already knows what I'm going to say.

The guy left the office pretty ticked. In fact, there were a few times I was about to stand up and go in a defensive stance because I thought he was going to get violent.

Originally Posted by whopper

he demands Xanax and I refuse. I remind him that even per him the SSRIs work, but he continues his demands to the point where he becomes irate in the office.

Tell him your job is to get people OFF of Xanax, not ON Xanax. If he challenges you, follow up by asking him where he went to Medical School.

Whopper,

I usually go non-directive, diffusion of responsibility in my language in these cases --
"Benzo's are not the medication considered first line for anxiety, SSRI's are."
"The medical board could get me in trouble if that's all I prescribed."

In an MI perspective, he's still contemplative about choosing therapy or meds, or that he needs professional help for his sx's. He still thinks he knows best.

Originally Posted by whopper

I would've loved to have video recorded this particular session and asked colleagues to see if I did anything inappropriate.

I got a patient with a very strong cognitive triad for depression. Per him, he was up and coming to be an NFL athlete, and during his senior year in college, he was falsely accused of a date-rape. Per him, after the incident, the NFL wouldn't touch him with a ten foot pole, even after an investigation showed he didn't do it. He's been depressed ever since and it's been years. His father confirmed that the NFL story was true, but I have my doubts because he's not really bigger than I and I'm not what you'd consider NFL physique. I work out, I got muscles, but I'm 5'7". I've also worked with a few professional athletes, and in general, they are very disciplined people (though yes, there are exceptions).

The guy refuses psychotherapy, he does get better on SSRIs, but each time he sees me he's run out of SSRIs for a few months, and he demands Xanax and I refuse. I remind him that even per him the SSRIs work, but he continues his demands to the point where he becomes irate in the office. I also told him that IMHO, the biggest reason why he can't get over his depression is because he completely measures his life based on his failure to get in the NFL, and that was apparently robbed by a false accusation. That event will never be changed and he has to move on. Psychotherapy will help in that regard.

I told him something to the effect that if he asks for a benzo again, to not even to bother showing up to the office. Now this is after several meetings where 80% of the meeting is me politely trying to direct him to utilize psychotherapy in addition to SSRIs, and him telling me he's not going to use SSRIs anymore in what I perceived to be an attempt that he believed would force my hand into giving him Xanax (he said, "If I don't take the Citalopram, now you got to give me the Xanax because you have to treat my depression.") Ask once, I'll explain why my answer is no, ask five times, somewhere between the 3rd and the fifth, I'm going to tell the guy to stop it because he already knows what I'm going to say.

The guy left the office pretty ticked. In fact, there were a few times I was about to stand up and go in a defensive stance because I thought he was going to get violent.

Click-clack boom !

He is fired. I have no patience for people like this; I have no idea how you guys do it.

Originally Posted by ghost dog

Click-clack boom !

He is fired. I have no patience for people like this; I have no idea how you guys do it.

I actually agree. But here's the devil's advocate approach -- if you're a family med doc, do you fire a diabetic pt. that doesn't take his meds, refuses to check his BG's, gets irritable at insistence to change his diet?

I recognize whopper's case is more extreme (violent, risk of harm). Panic button needs to be handy.

I neglected to mention this, and this is somewhat understandable as to why the guy doesn't get psychotherapy. He can't afford one. He has no insurance, and no means to pay for psychotherapy. He's literally living in the parents' basement. He doesn't have any of the community assistance one typically gets to go to a community mental health center. Him refusing psychotherapy isn't just him being bullheaded, though he is that. It's something he can't afford.

I have recommended he get a job, and that too would help his notion of self-worth, but he told me he's tried to get literally 30 in the past 6 months and none of them gave him an offer. That I suspect may be a bit exaggerated, but I don't know it for a fact. In any case, this guy believes he's a loser, will always be one, and that his best days were behind him.

Oh well. Seriously, I don't mean that sarcastically. I don't know what to do with this guy. I just know Xanax ain't the answer.

Originally Posted by whopper

I don't know what to do with this guy. I just know Xanax ain't the answer.

Yea you do. Your recommendations are psychotherapy. Period. You're a clinician. Your job is to provide recommendations and treatment. It's not up to you to to figure out how he's going to get psychotherapy or how he's going to pay for it. Not to sound like an insensitive jackass, but really what are you going to do? In the short term if you're doing med management you can't coach him to buff up his resume or boost his interview skills or social skills so he can land a job, nor can you intervene at his home and help him develop a better relationship with his parents so they can offer to help pay for his psychotherapy. I can tell you really want to help this guy and I see your limitations as a clinician to getting this guy the help he needs.

Originally Posted by OldPsychDoc

The idea of becoming a pi$$ merchant for profit hadn't yet occured to me, thankfully.

This made me think of Pratchett's character Harry King.

If he challenges you, follow up by asking him where he went to Medical School.

Not sure if you were being facetious, but wouldn't it be better to build your role as the expert in a slightly less confrontational way, e.g. information-giving?

Originally Posted by loveoforganic

Not sure if you were being facetious, but wouldn't it be better to build your role as the expert in a slightly less confrontational way, e.g. information-giving?

I was...the point is, patients have some control and autonomy over their treatment, however, they are not medically trained professionals and should not be dictating their treatment. As Oldpsycdoc has stated several times in these threads, it takes 5 minutes to say YES and 30 minutes to say NO. By that he means you need to take the time to educate patients and provide your rationale for your proposed treatment. If the patient disagrees, they can always get a second opinion as we're not the only doctor on this planet. Just because a patient asks you for Dilaudid or Xanax does not necessarily mean that it is clinically indicated and may actually be contraindicated or harmful to the patient if he/she has a history of substance abuse/dependence. I've received a plethora patient referrals from mental health and primary care providers giving high doses of Xanax to raging alcoholics that apparently no longer know what to do pharmacologically with the patient because they are taking excessively high doses of Xanax and STILL HAVE ANXIETY. WTF is all I have to say to that. As clinicians we need to remember that we have 7+ years of medical training and we need to be able to trust our own clinical judgment and do what is best for the patient regardless if the patient disagrees.

Originally Posted by nitemagi

I actually agree. But here's the devil's advocate approach -- if you're a family med doc, do you fire a diabetic pt. that doesn't take his meds, refuses to check his BG's, gets irritable at insistence to change his diet?

I recognize whopper's case is more extreme (violent, risk of harm). Panic button needs to be handy.

That's a good question.

Typically my patients are well behaved in this sort of setting. When I counsel them that high sugars result in diabetic retinopathy (blindness), nephropathy ( kidney failure / dialysis), and MI ( heart attacks) they tend to get with the program.

If not... well. I just might be tempted to fire such a patient. If they don't want to follow my advice: what the heck is their reason for coming to see me?

The advantage here is that I have a concrete marker for compliance: the HgbA1C.

Originally Posted by michaelrack

suboxone mills can be a goldmine too.
the reimbursement for urine drug screens is pretty good.

How do you figure this? Looking at the billing codes for a urine drug screen, 80104, you're looking at an average reimbursement of $20-23.

http://www.alfascientific.com/wp-con...-Jan.-2011.pdf

http://blogs.aafp.org/fpm/gettingpai...s_have_changed

Originally Posted by freaker

How do you figure this? Looking at the billing codes for a urine drug screen, 80104, you're looking at an average reimbursement of $20-23.

http://www.alfascientific.com/wp-con...-Jan.-2011.pdf

http://blogs.aafp.org/fpm/gettingpai...s_have_changed

If you invest in a chemistry analyzer machine you can bill for the higher code which is either 80101 or G0431. 80101 used to be paid per drug class but Medicare created G0431 as a bundled payment for one UDS to replace per drug class billing to obviously save money. Private insurances are beginning to adopt G0431 including Aetna and some BSBC carriers which presently is reimbursed by Medicare at ~$100.