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1. Patient 1 Clinic Patient
As an intern, I am often given longer appointment times than counterpart seniors. Hence, I get a lot of "establishing care" patients. Few months back, I had a patient, who was originally seen in our clinic. However, was arrested for selling controlled substance, hx of poly substance abuse and was not able to be seen for several years. The patient reported to me a diagnosis which would require a prescription of a controlled substance. Furthermore, he wanted a brand-new prescription for a chronic problem, because his current prescription which was more than halfway filled was "old" (filled 2 months prior only). My attending refused the first request, instead gave him a referral to a specialty services that could better diagnose and treat this condition. I refused the first, because a 2 month old medication bottle, more than half way filled should not require a brand new prescription.
Anyway, I sent him with a 2 mo f/u, ordered 3 labs and gave him medication for smoking cessation as requested. Patient asked to speak with my supervisor, however, left quietly.
I was notified by the EMR of his lab results, but, I saw something weird. I saw two listings of the same lab results, done on the same day. Where I had done these three labs, there was another provider who had ordered 6 labs, 3 of which were similar. This seemed weird to me and I brought this to the attention of my clinic's charge nurse. She reported that she knew where the second provider practiced and would call and check the issue. I was then told that the patient had three to four days prior gone to another primary care physician's office, requested a medication refill/establish visit and had been granted all the medications (including the controlled substance).
My charge nurse told me she had forwarded this case to the clinic supervisor for potential discharge from our practice, the nurse informed me that she had notified the other practice about the concerning labs and had told them to f/u on them. She had also called the patient and told them to call up about next upcoming appointment with me at our clinic. At this call, she would confront the pt and then the pt. and see if he wishes to continue with us. She also recommended that I bring this to my preceptor's attention.
My preceptor recommends that I see the pt. and simply not worry about the controlled substance issue, however I should see him and f.u concerning labs. Though I agreed, however, this does not sit right with me.
1. If I call him about the lab results and so does the other practice, aren't we both treating the same condition?
2. I am trying to see the best in him and not judge or label him, but, I am scared that if he is following with both of us then isn't he getting two copies of the same meds. these aren't controlled substances, however, I am worried he might sell meds prescribed,
I spoke about this case to my father, he recommends that a bottle of 5 dollar med isn't worth disagreeing with your attending over and I shouldn't be the proverbial hero in this situation,
2. Patient 2 Inpatient , I have a smoking and Drug addict who has a PNA. Patient changes his mind on everything and if we refuse to accede to his wishes, will threaten us with leaving AMA and that I can take out my IV's and leave. Extensive workup and effort has come in from all parties (consultants) involved on this patient. Furthermore, the patient immediately needs a procedure early next week.
the main feedback I have recieved boils down to, accept his demands, because he needs the procedure now. I receive call from the patients nurse every 3-4 hours. Calls that range anywhere from patients dissatisfaction with pain management (in the last week pain mgmt has been changed 3 times). It was extensively explained by me and senior resident that 0 pain isn't possible and that increasing dose can cause side effects, minimal constipation, maximum respiratory arrest. Patient then reported he would take X-lax if needed for consitpation, but needs pain control now. Pain mgmt was adjusted again.
Over the past few days, the patient seems to have realized this capitulation on our part. He requested privileges to walk outside. At said time he smoked outside the hospital and did not pay heed to the admonitions of nursing staff. We explained to the patient that it was not correct to smoke on hospital grounds. So today he sneaked cigarettes under hand towel, stood outside of the facility, closer to the road and smoked. he furthermore, reported that me and the senior resident told him it was okay as long as it wasn't in hospital grounds. The nurse is extremely angry with us at this point and has asked to take his privileges. I promised her I would speak to him about smoking and its dangers.
I am still worried it has taken a lot to get this procedure, which will save his life. From senior attendings to residents have spoken to him about getting procedure done. for him to finally agree. However, at this point I feel like I am being held hostage by said patient, where if his requests are refused then 15-20 minutes later, I will surely get a text of his need for wanting to go AMA. I do not want a bad health outcome and I do not want to dissapoint my seniors with regards to not being able to ensure the patient's continued stay.
I do Not know what to do and find myself within a rock and a hard place. where I cannot accept his request and I cannot let him leave AMA.
As an intern, I am often given longer appointment times than counterpart seniors. Hence, I get a lot of "establishing care" patients. Few months back, I had a patient, who was originally seen in our clinic. However, was arrested for selling controlled substance, hx of poly substance abuse and was not able to be seen for several years. The patient reported to me a diagnosis which would require a prescription of a controlled substance. Furthermore, he wanted a brand-new prescription for a chronic problem, because his current prescription which was more than halfway filled was "old" (filled 2 months prior only). My attending refused the first request, instead gave him a referral to a specialty services that could better diagnose and treat this condition. I refused the first, because a 2 month old medication bottle, more than half way filled should not require a brand new prescription.
Anyway, I sent him with a 2 mo f/u, ordered 3 labs and gave him medication for smoking cessation as requested. Patient asked to speak with my supervisor, however, left quietly.
I was notified by the EMR of his lab results, but, I saw something weird. I saw two listings of the same lab results, done on the same day. Where I had done these three labs, there was another provider who had ordered 6 labs, 3 of which were similar. This seemed weird to me and I brought this to the attention of my clinic's charge nurse. She reported that she knew where the second provider practiced and would call and check the issue. I was then told that the patient had three to four days prior gone to another primary care physician's office, requested a medication refill/establish visit and had been granted all the medications (including the controlled substance).
My charge nurse told me she had forwarded this case to the clinic supervisor for potential discharge from our practice, the nurse informed me that she had notified the other practice about the concerning labs and had told them to f/u on them. She had also called the patient and told them to call up about next upcoming appointment with me at our clinic. At this call, she would confront the pt and then the pt. and see if he wishes to continue with us. She also recommended that I bring this to my preceptor's attention.
My preceptor recommends that I see the pt. and simply not worry about the controlled substance issue, however I should see him and f.u concerning labs. Though I agreed, however, this does not sit right with me.
1. If I call him about the lab results and so does the other practice, aren't we both treating the same condition?
2. I am trying to see the best in him and not judge or label him, but, I am scared that if he is following with both of us then isn't he getting two copies of the same meds. these aren't controlled substances, however, I am worried he might sell meds prescribed,
I spoke about this case to my father, he recommends that a bottle of 5 dollar med isn't worth disagreeing with your attending over and I shouldn't be the proverbial hero in this situation,
2. Patient 2 Inpatient , I have a smoking and Drug addict who has a PNA. Patient changes his mind on everything and if we refuse to accede to his wishes, will threaten us with leaving AMA and that I can take out my IV's and leave. Extensive workup and effort has come in from all parties (consultants) involved on this patient. Furthermore, the patient immediately needs a procedure early next week.
the main feedback I have recieved boils down to, accept his demands, because he needs the procedure now. I receive call from the patients nurse every 3-4 hours. Calls that range anywhere from patients dissatisfaction with pain management (in the last week pain mgmt has been changed 3 times). It was extensively explained by me and senior resident that 0 pain isn't possible and that increasing dose can cause side effects, minimal constipation, maximum respiratory arrest. Patient then reported he would take X-lax if needed for consitpation, but needs pain control now. Pain mgmt was adjusted again.
Over the past few days, the patient seems to have realized this capitulation on our part. He requested privileges to walk outside. At said time he smoked outside the hospital and did not pay heed to the admonitions of nursing staff. We explained to the patient that it was not correct to smoke on hospital grounds. So today he sneaked cigarettes under hand towel, stood outside of the facility, closer to the road and smoked. he furthermore, reported that me and the senior resident told him it was okay as long as it wasn't in hospital grounds. The nurse is extremely angry with us at this point and has asked to take his privileges. I promised her I would speak to him about smoking and its dangers.
I am still worried it has taken a lot to get this procedure, which will save his life. From senior attendings to residents have spoken to him about getting procedure done. for him to finally agree. However, at this point I feel like I am being held hostage by said patient, where if his requests are refused then 15-20 minutes later, I will surely get a text of his need for wanting to go AMA. I do not want a bad health outcome and I do not want to dissapoint my seniors with regards to not being able to ensure the patient's continued stay.
I do Not know what to do and find myself within a rock and a hard place. where I cannot accept his request and I cannot let him leave AMA.
