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bronchospasm

Interventional Pain Physician
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Im starting my practice in 2 weeks. On my way back home today, I get a call from a Dr. T.

Brief background of Dr. T.

Ever since I moved here after finishing my fellowship in June, I have heard about a Dr. T. He is a harvard trained pathologist and guess what he has been practicing since he retired from his pathology practice .... Surprisingly .... "Pain Management". So the guy practices pathology for 35 years ... no patient contact, then at 65 he retires and starts a Cash ONLY Pain Clinic. His favorite drugs are Methadone and Oxycontin. Patients line up from 6 am and he is so well known and that his patients drive over 500 miles from Florida to see him. ...etc etc .... Did I mention, He is legally blind due to macular degeneration and is 80 yrs old. ..Wonder how he does a physical exam before prescribing ????

So Dr. T calls and tells me that he has a "General Practice" in the area and was diagnosed with a T8 compression fracture 4 weeks ago, is really hurting and had heard about me from the hospital recruiter. He wants to see me because there is no "real fellowship trained pain doctors in the area". He also mentions that he does not want any " pain medications because they are really bad for you and they turn you into addicts". All this coming from one of the highest controlled substance prescriber in the state.

He requests that I see him the first day that I open and would greatly appreciate if I can do anything to make him feel better so that "he can go back to caring for his patients". I agree to see him on the first day that I open.

I know how I am going to handle this:

I'm interested in seeing what you guys would do ...How would you best take care of your colleague???

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I'll bite. Is this a trick? What's wrong with doing the vplasty?
 
1. If he wanted a VP, he wouldn't call a fresh, untested pain doc, he'd call someone who has been doing them for years (in NO way is that a slight to you, we all start somewhere, but its a fact). If he did want a VP, he would have asked for it within the first two minutes of your first phone conversation and he'd be on the schedule by now.

2. He can get NSAIDS at walgreens, but he has a history of GI bleeds.

3. Lyrica and neurontin cloud his ability to prescribe narcotics unscrupulously.

4. Calcitonin nasal spray caused him epistaxis.

5. A thoracolumbar support did not help.

6. PT made it worse.

7. The conversation will end with him saying, "Well dang, all that leaves is opioids. Shucks. Well, why don't you just give me a prescription for Oxy 60mg TID with an Rx for short-acing oxy 10mg QID until I get over this pain. A three month supply should do the trick. Let's just keep our fingers crossed that this doesn't become chronic - I sure wouldn't want to be on this for a long time! Gee whiz that would suck! And BTW, keep this on the down-low, I don't want my other colleagues to know I am on this evil stuff. Thanks new guy, you are swell!"

8. He is an addict with an MD behind his name.
 
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Im starting my practice in 2 weeks. On my way back home today, I get a call from a Dr. T.

Brief background of Dr. T.

Ever since I moved here after finishing my fellowship in June, I have heard about a Dr. T. He is a harvard trained pathologist and guess what he has been practicing since he retired from his pathology practice .... Surprisingly .... "Pain Management". So the guy practices pathology for 35 years ... no patient contact, then at 65 he retires and starts a Cash ONLY Pain Clinic. His favorite drugs are Methadone and Oxycontin. Patients line up from 6 am and he is so well known and that his patients drive over 500 miles from Florida to see him. ...etc etc .... Did I mention, He is legally blind due to macular degeneration and is 80 yrs old. ..Wonder how he does a physical exam before prescribing ????

So Dr. T calls and tells me that he has a "General Practice" in the area and was diagnosed with a T8 compression fracture 4 weeks ago, is really hurting and had heard about me from the hospital recruiter. He wants to see me because there is no "real fellowship trained pain doctors in the area". He also mentions that he does not want any " pain medications because they are really bad for you and they turn you into addicts". All this coming from one of the highest controlled substance prescriber in the state.

He requests that I see him the first day that I open and would greatly appreciate if I can do anything to make him feel better so that "he can go back to caring for his patients". I agree to see him on the first day that I open.

I know how I am going to handle this:

I'm interested in seeing what you guys would do ...How would you best take care of your colleague???

I would have deflected this to someone in the area who does VP/KP (assuming you don't). It' way better to nip this in the bud over the phone rather than disappoint someone in person.

Get your no-opioid statement ready. In this case, I would be totally honest. "Let's be frank here sir, you run a pill mill. That alone is reason enough for any physician to be wary of rxing you narcotics. The risks for abuse and misuse are simply too high. I'd be perfectly willing to work with you on non-narcotic options."

What doesn't add up for me is why he couldn't just get one of his patients to give him a small supply if that's what he wants. Maybe he is hoping to line up a long term supplier for himself!
 
He is a person and a potential patient.

See him and treat appropriately.

Just because he is a dealer doesn't mean he is not hurting or deserving of care.

And folks, you are a bunch of a-holes for accusing him of just wanting narcotics.

Go break T8 and tell me it doesn't hurt.

My plan: Toradol/Robaxin IM, TLSO, Miaclacin. I have no problem Rx'ing Dilaudid 2-4mg tid for a week and getting him in for kypho.

THIS IS ACUTE PAIN AND NOT CHRONIC NONCANCER PAIN. Different rules apply.
 
He is a person and a potential patient.

See him and treat appropriately.

But be wary. This is not necessarily an addict, but definately a dealer. These are not good people and not to be trusted. If his practice is actually as you described you can bet it's on the radar of the state medical board, local law enforcement, the DEA, and the OIG.
 
Compassion, understanding, respect...

treat as you would any other patient. NSAID, kypho/vert, if those fail consider MBB, miacalcin (instead of miaclacin ;) ), TLSO brace.

maybe short course of nucynta, but definitively let the patient know that only a short course of opioids - ie 4-6 weeks only. no possible changes. UDS prescreen of couse, the usual diligence.
 
Just know this. When he is investigated you will be looked at (with an electron microscope) as a possible connection.

Word to the wise: CYA to the highest level.
 
Prepare for the worst, hope for the best

Def gets my spidey sense going

I will be shocked if it turns out to be straightforward with no funny business

there are details already laid out here that smell funny
 
I agree with DT and Steve. My initial reaction wasn't concern so much about him wanting opioids, but more to size you up to dump some bad apples down the road.
 
I think that if you were blind, and still wanted to practice medicine - pain seems like a logical choice.

And without much training, and if you happen to go to many of the "pain" society courses out there - this guy isn't practicing far from what they preach. (I was blown away at the push for opioid use at my first and last visit to the American Acadamy of Pain Management meeting I went to a few years back).

And it makes sense - if you don't get what you are doing, you may practice like this guy. I'm not so sure it is as sinister as you all make it sound. It is way out of date, but certainly it may not be sinister.

I CLEARLY remember a psychiatrist drilling into my 3rd year medical school head - that pain patients DO NOT get addicted to pain medicines if they have pain. This was the mantra - this was the practice - this was the thought - and probably what this old codger believes.

Having said that, I am suspicious of EVERYONE that asks for opioids, regardless of injury or pain -that is just my paranoid view. I hate the drugs (but am growing to really appreciate nucynta and butrans).
 
It's tough to not be judgmental..

Anyways,

He gets a TLSO, Muscle relaxant, NSAID, Etc for 6 weeks
Then Kypho..

Then bye bye... No narcs....

Might throw in some diclofenac gel if he is really nice
:smuggrin:
 
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It's tough to not be judgmental..

Anyways,

He gets a TLSO, Muscle relaxant, NSAID, Etc for 6 weeks
Then Kypho..

Then bye bye... No narcs....

Might throw in some diclofenac gel if he is really nice
:smuggrin:

If you are doing topical, throw in all those things those reps try to sell me daily in their compounding creams. NSAIDS, TCA's, AEDs, ketamine, muscle relaxants, anti-aging, motor oil, etc.
 
You are just starting out. Consider sitting down with a healthcare attorney (preferably an MD/JD) to discuss the world's wicked ways. You don't know what might come of this suspicious and curious presentation. We live in an era of flux, and this pathologist to "pain doc" visiting someone "just starting out" has a funky vibe to it. Why you?

What will an attorney say? Document everything? No Medicaid? Tramadol yes, Oxycodone no?
 
I have no idea what the attorney would say. I'm not an attorney, but after several decades have seen enough **** to make me less likely to believe in coincidence

Words to live by.:thumbup:
 
If I were a gambling man, I bet this pt will be a perfect gentleman. He will not ask for narcs and will seem like the best pt you ever had. What better way to disarm the worst threat he has ever faced?

I had a NS pt a few months ago. He works for a chiropractor and was starting to do US guided MBBs. Huh? Anyway, a few weeks ago another pain doc was asking me about him and I found myself so guarded talking about it. His practice and methods were discussed in confidence after all. If he weren't my pt, I would've ripped him a new one.

So I bet that's all this pathologist is doing. Keeping his friends close, his enemies closer.
 
I would just see your patient as any other patient. Well he is warming up to your pattern of practice as a the new player in town. He might want to slowly unload some of his narc dumb, he is holding on to. I would be politically correct and be open minded. As long as you have your ducks in row and have red lines for prescriptions. You should be safe. You can assume things and be paranoid. I usually review my new patients before I give them appointments. I have trained scheduler now who is skilled to pick the dumps. I have started using SOAP-R on my high risk opioid patients. But I still have some which fall though the cracks. I am not sure if you started writing an operational manual or policy manual for your clinic. It would help reflect on your decisions on how you would handle a THC + initial visit, to name a few.
 
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If I were a gambling man, I bet this pt will be a perfect gentleman. He will not ask for narcs and will seem like the best pt you ever had. What better way to disarm the worst threat he has ever faced?

I had a NS pt a few months ago. He works for a chiropractor and was starting to do US guided MBBs. Huh? Anyway, a few weeks ago another pain doc was asking me about him and I found myself so guarded talking about it. His practice and methods were discussed in confidence after all. If he weren't my pt, I would've ripped him a new one.

So I bet that's all this pathologist is doing. Keeping his friends close, his enemies closer.

ding ding ding
 
If I were a gambling man, I bet this pt will be a perfect gentleman. He will not ask for narcs and will seem like the best pt you ever had. What better way to disarm the worst threat he has ever faced?

I had a NS pt a few months ago. He works for a chiropractor and was starting to do US guided MBBs. Huh? Anyway, a few weeks ago another pain doc was asking me about him and I found myself so guarded talking about it. His practice and methods were discussed in confidence after all. If he weren't my pt, I would've ripped him a new one.

So I bet that's all this pathologist is doing. Keeping his friends close, his enemies closer.


BINGO

he's trying to establish Patient/Physician relations. That way essentially you can not say anything.

I wouldn't go down this road.

Also, if he get's caught up for any DEA prescribing issues. He will then say that it's because of the meds and/or opioids YOU wrote for him that did not allow him to think clearly,etc......
 
[/B]

BINGO

he's trying to establish Patient/Physician relations. That way essentially you can not say anything.

I wouldn't go down this road.

Also, if he get's caught up for any DEA prescribing issues. He will then say that it's because of the meds and/or opioids YOU wrote for him that did not allow him to think clearly,etc......

Total nonsense. The time course states otherwise.

Still treat this guy, if you don't Rx opiates then you don't. Brace, Miacalcin, NSAID, tramadol, kypho.

If it menas you cannot testify against him later when the DEA shuts him down, so what, there are 100's of docs who will tell it like it is. You have no downside here.
 
You should treat this pt with respect and just like any other pt. All judgments should be left at the door. Like I said, it wouldn't surprise me if he's trying to get to know you and get you to know him on a personal level. But this is completely irrelevant to your responsibility to treat (if you choose to accept it - like you should). Professional conduct is sacred and should be firewalled.
 
Yep. There's that too. You truly don't know what to expect--this is a known unknown--sketchy backstory, lousy reputation; seriously who, at 80 with great credentials takes a ride down the shady side? Taken individually, elements regarding the man's character don't mean as much as they do together--the constellation suggests something sinister. Consider an 80 year old at the end of his career doing pill mill sh#t who may have "issues" with regulatory boards, the law, maybe facing fines, penalties--maybe prison--with a nest egg. Maybe this blind, GP, is looking to set some innocent up in any of dozens of scenarios you'd never imagine. Desperate folks do very desperate, often innocuous looking things. This is a compelling tale especially in times when pill mills, ACA issues, under prescribing, overprescribing, healthcare fraud, abuse, Medicare "problems," are all items that are newsworthy. You can do everything "right," by-the-book, and six months-a year down the road walk into a world of misery. If you're not considering a healthcare lawyer, you are documenting concerns online. It'll be interesting to read how thus unfolds. If anything it makes for a nice short story.

Yep, this dude is no different than Walt on breaking bad. Be wary.
 
Maybe this pt needs to go on a "vacation" to "Belize"...

anybody else having trouble concentrating on their patients because they are thinking about last night's episode. WTF? i cant even sleep im so fired up.
 
Saw Dr. T today. He was actually getting better. Back did not hurt as much as it did 4 weeks ago.

He did enquire about a Kyphoplasty. He is doing better with conservative regimen so No Kypho.

He did enquire about pain meds. His PCP had prescribed norco, I politely declined to prescribe him any controlled substance, suggesting that he get them from his PCP.

No scheduled F/u, Just call if it gets worse, then we will consider Kypho.

Suggested TLSO brace, he said that his son in law is in the brace and pain cream business....


Did talk to him about his Pain Clinic to which he said that he believes in medication management and that he gives patients what they want and need. Wanted to refer some patients to me ... again I agreed to do interventions only and politely declined to do any medication management for his patients.

Easy breezy ... In and out in 30 minutes... Discussion was limited to his back problem.
 
Saw Dr. T today. He was actually getting better. Back did not hurt as much as it did 4 weeks ago.

He did enquire about a Kyphoplasty. He is doing better with conservative regimen so No Kypho.

He did enquire about pain meds. His PCP had prescribed norco, I politely declined to prescribe him any controlled substance, suggesting that he get them from his PCP.

No scheduled F/u, Just call if it gets worse, then we will consider Kypho.

Suggested TLSO brace, he said that his son in law is in the brace and pain cream business....


Did talk to him about his Pain Clinic to which he said that he believes in medication management and that he gives patients what they want and need. Wanted to refer some patients to me ... again I agreed to do interventions only and politely declined to do any medication management for his patients.

Easy breezy ... In and out in 30 minutes... Discussion was limited to his back problem.

He was totally feeling you out. I doubt his back even hurt him. D-bag
 
what did the images show? or were there any...i suspect less easy and breezy. sounds more like just making sure you werent a candy man, and taking some of the "patients that need and want narcotics" away from. He is probably pleased as punch you dont throw narcs at pts. more for him...



Saw Dr. T today. He was actually getting better. Back did not hurt as much as it did 4 weeks ago.

He did enquire about a Kyphoplasty. He is doing better with conservative regimen so No Kypho.

He did enquire about pain meds. His PCP had prescribed norco, I politely declined to prescribe him any controlled substance, suggesting that he get them from his PCP.

No scheduled F/u, Just call if it gets worse, then we will consider Kypho.

Suggested TLSO brace, he said that his son in law is in the brace and pain cream business....


Did talk to him about his Pain Clinic to which he said that he believes in medication management and that he gives patients what they want and need. Wanted to refer some patients to me ... again I agreed to do interventions only and politely declined to do any medication management for his patients.

Easy breezy ... In and out in 30 minutes... Discussion was limited to his back problem.
 
why is this dude banned. He seemed ok?

Yep. There's that too. You truly don't know what to expect--this is a known unknown--sketchy backstory, lousy reputation; seriously who, at 80 with great credentials takes a ride down the shady side? Taken individually, elements regarding the man's character don't mean as much as they do together--the constellation suggests something sinister. Consider an 80 year old at the end of his career doing pill mill sh#t who may have "issues" with regulatory boards, the law, maybe facing fines, penalties--maybe prison--with a nest egg. Maybe this blind, GP, is looking to set some innocent up in any of dozens of scenarios you'd never imagine. Desperate folks do very desperate, often innocuous looking things. This is a compelling tale especially in times when pill mills, ACA issues, under prescribing, overprescribing, healthcare fraud, abuse, Medicare "problems," are all items that are newsworthy. You can do everything "right," by-the-book, and six months-a year down the road walk into a world of misery. If you're not considering a healthcare lawyer, you are documenting concerns online. It'll be interesting to read how thus unfolds. If anything it makes for a nice short story.
 
Maybe he is Walt... Or maybe just a stubborn, old school 80 y/o guy with no clue. The only way to know for sure is to put a GPS tracker under his car...
 
Maybe he is Walt... Or maybe just a stubborn, old school 80 y/o guy with no clue. The only way to know for sure is to put a GPS tracker under his car...

If the outcome of your care is ODD, does it matter if you are a well meaning hack or a dealer?
 
why is this dude banned. He seemed ok?

Why did rayday5 get banned?

Disclosing such information is a violation of SDN's privacy policy.

Users aren't banned willy-nilly by any stretch of the means. Whatever the reason is, I can assure you that it is a good one.
 
what did the images show? or were there any...i suspect less easy and breezy. sounds more like just making sure you werent a candy man, and taking some of the "patients that need and want narcotics" away from. He is probably pleased as punch you dont throw narcs at pts. more for him...
He has a PCM so he got a ct scan... Could not gat any STIR images to differentiate acute vs chronic but he did have a Wedge comp fracture at T8 with 1/3 loss of height anteriorly. I was glad that he did not code in my office. ...

On a side note, I called him on Sunday evening and asked him to come on Monday afternoon instead of being the first patient of my pain practice. ...
 
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