Curbside consult from a primary care doc....

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smq123

John William Waterhouse
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I work as a primary care doc in Florida (everyone's favorite pill mill state).

I have a patient who is seeing a "pain management" doctor in the next county. He is receiving his pain meds from this doctor for a condition that, in my opinion, shouldn't be giving him that much pain. He refuses to see the (non-pain management) specialists that I have advised him to see. We also have no records documenting that he even has this condition.

He did show me the prescriptions that he is getting from the "pain doctor". He gets over 200 8mg Dilaudid tablets every month, as well as Percocet, Valium, and Ambien. The state database shows that he sometimes gets early refills (not sure why - we don't get any consult notes from the "pain doctor").

My question is....should I report this "pain doctor" to the Board of Medicine? Can I be liable if the patient, God forbid, overdoses - could his "pain doctor" point to me and say that I knew about it, didn't do anything about it, and so I'm complicit? What should I do, besides document document document, to protect myself and my office staff?

And I keep calling him a "pain doctor" because he's actually board certified in a completely unrelated field. :rolleyes:

Thanks for any help.

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My question is....should I report this "pain doctor" to the Board of Medicine?

>1000MED with benzodiazepines to boot. Report this.
 
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If he isn't a pain management doctor then you may consider calling him and informing him about the patient's behavior and ask if he is doing PMP reports routinely. If he is not interested in playing ball, then you may consider reporting him. Is he out of line? Absolutely! Dilaudid plus percocet should be a rare occurrance.
 
It's hard to say whether this is a corrupt doctor, a corrupt patient, an uneducated pair, or somethign else. I think your role in this is to comunicate and document your concerns to the patient. It's not that different than the pt doing some other risky behavior.

It would be prudent also to prepare for the inevitable day when the pt says, "My pain doc left town, you gotta help me!" The pt should have absolutely no doubt that you can not take over this mismanagement. I would have a detox facility lined up and encourage the pt to visit said facility in advance.

I don't think the Board will do anything without evidence of a massive exporting enterprise. The activist part of me died a few years ago so I probably wouldn't waste my time.

We need more PCPs like you.
 
to the pcp in the original post--- many times these doctors prescribing medication combos like you stated are not true board certified pain physicians with the primary board being anesthesia or Physical med and rehab. often times these doctors who run "pain clinics" are basically FP, IM, old general surgeons who are writing narcotics to anyone to make money.
Please do not confuse legitimately trained anesthesisia or physical medicine and rehab docs with FPs, IM, old general surgeons who just write narcotics for everyone
 
i would document in your notes that, while you are not a pain management doctor, the doses seem excessive and you counselled the patient about the risks of polypharmacy and the dose of medications that he is on.

Definitely inform the patient that there is no way that you will ever prescribe these medications for him. If you have a good repoire with the patient, ask if he would be willing to sign release so you can see what the "pain doctor" is doing, or whether there is adequate monitoring.


situations like this, and other "pain" "doctors" out there (Tenant, Mohanty, Rinehart) give pain medicine a horrible black eye....
 
I get referrals from PCPs not infrequently that have patients on two short actings. I think it makes no sense at all. That being said, referring these all to the state boards hoping they all lose their licenses is not going to happen.

Heck, it didn't take one, or two overdoses to get this guy looked at, but 16!

http://m.upi.com/story/UPI-53211360938538/

Educating PCPs and limiting who prescribes is greatly needed.
 
Just ask your pt to sign a release of records for this pan doc's notes so you can get better insight into what's going on. You can tell the pt that you have not received any referral notes. If pt refuses, which I highly doubt; but if he does, I would remove myself from this pt's care as this is going nowhere but downhill
 
I would try to get more info first before going to the board. One of my pts recently got an IME and the IME took one urine test out of context and extrapolated that the pt must be selling his meds and me the means. It was total BS. Get all your facts straight first.
 
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Thanks for the input, everyone. :)

I'll ask to get the "pain doctor"'s notes. I highly highly highly doubt that appropriate monitoring is being done because, like I said, the state database shows a lot of early refills. The database also shows that they're using multiple different pharmacies over the past year - my assumption is because, at some point, the pharmacist gets a little leery of filling these scripts and eventually refuses.

to the pcp in the original post--- many times these doctors prescribing medication combos like you stated are not true board certified pain physicians with the primary board being anesthesia or Physical med and rehab. often times these doctors who run "pain clinics" are basically FP, IM, old general surgeons who are writing narcotics to anyone to make money.
Please do not confuse legitimately trained anesthesisia or physical medicine and rehab docs with FPs, IM, old general surgeons who just write narcotics for everyone

To clarify, if someone did not complete a pain medicine fellowship after either a gas or a PMR residency, I do not think that they are a genuine pain management doctor, and we do not refer patients to anyone who does not meet that criteria.

That being said, a lot of my patients are self-pay and uninsured (I work in an underserved clinic), so I can't control where they choose to go. I can strongly discourage them from going to a "pain clinic," but that's sometimes an exercise in futility.

I did call this doctor's office, just to get a feel for what was up. His secretary answered the phone with "Urologist's office!" When I said that I was confused, because I heard he did pain management, she cheerfully said, "Well, he does that too. You know, gotta pay the bills somehow!"

<facepalm>
 
To clarify, if someone did not complete a pain medicine fellowship after either a gas or a PMR residency, I do not think that they are a genuine pain management doctor

This is 100% wrong. Pain Medicine is an official Subspecialty not only of Anesthesiology and PMR, but also of Neurology and Psychiatry. In fact, no specialty is barred from ACGME accredited Pain fellowships or from taking the same Pain Board exam as written by the American Board of Anesthesiology. Also, there are many very good and ethical Pain physicians who have done ACGME Pain fellowships and have passed the only true Board Exam in Pain Medicine (ABMS) that are from specialties other than these four. (It doesn't sound like the urologist in your example did). This includes people on the faculty of prestigious academic institutions, from specialties such as Internal Medicine, Emergency Medicine, Orthopedics, Neurosurgery, Emergency Medicine and others. Pain Medicine is a crossroads specialty and many clinical specialties other than the official four bring their own unique backgrounds and knowledge to their practices, their patients and the field.

One of them is myself. Prior to even entering fellowship, I was in practice for a decade in Emergency Medicine and had taken care of approximately 21,000 patients in Pain and approximately 12,000 patients with chronic Pain disorders, along with many patients that had overdosed on pain medicines. I consider it somewhat tragic, that Emergency Physicians have not demanded or been given a greater role in the growth of Pain Medicine as a field. I have to believe that if the ones taking care of prescription drug overdose cardiac arrests and breaking the news to the family members on a daily basis were given a greater role in the development of Pain Medicine as a Subspecialty, that we may not be at a place in our society and specialty, where we have >15,000 people dying yearly from prescription drug overdose deaths.

Fortunately, I found an excellent ACGME accredited Pain fellowship that accepted me, and gave me excellent training. I took the same ABA Pain Board exam (as registered through the American board of PM&R) as any other Pain Fellow, and passed. I now carry the most official Pain Board certification there is. I use my unique background and knowledge, along with what I learned in my fellowship to benefit my Pain patients every day. My first goal is to do no harm, with my prescribing pen and all other treatments, procedures included.

As a physician, you are free to refer or not refer to whomever you want, however, to come to a public forum of Pain physicians, and publicly declare that people who have completed ACGME accredited Pain fellowships and have gained ABMS Pain board certification are not legitimate, is wrong. Since you identified yourself as not from within the Pain community, I'll give you the benefit of the doubt that you just are not aware.

In fact, you might want to consider referring to a ACGME-fellowship trained, ABMS-boarded Pain physician with a newer, more balanced approach.

We need a new way of doing things. Look at where "the old way" has gotten us.
 
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This is 100% wrong. Pain Medicine is an official Subspecialty not only of Anesthesiology and PMR, but also of Neurology and Psychiatry. In fact, no specialty is barred from ACGME accredited Pain fellowships or from taking the same Pain Board exam as written by the American Board of Anesthesiology. Also, there are many very good and ethical Pain physicians who have done ACGME Pain fellowships and have passed the only true Board Exam in Pain Medicine (ABMS) that are from specialties other than these four. This includes people on the faculty of prestigious academic institutions, from specialties such as Internal Medicine, Emergency Medicine, Orthopedics, Neurosurgery, Emergency Medicine and others. Pain Medicine is a crossroads specialty and many clinical specialties other than the official four bring their own unique backgrounds and knowledge to their practices, their patients and the field.

One of them is myself. Prior to even entering fellowship, I was in practice for a decade in Emergency Medicine and had taken care of approximately 21,000 patients in Pain and approximately 12,000 patients with chronic Pain disorders, along with many patients that had overdosed on pain medicines. I consider it somewhat tragic, that Emergency Physicians have not demanded or been given a greater role in the growth of Pain Medicine as a field. I have to believe that if the ones taking care of prescription drug overdose cardiac arrests and breaking the news to the family members on a daily basis were given a greater role in the development of Pain Medicine as a Subspecialty, that we may not be at a place in our society and specialty, where we have >15,000 people dying yearly from prescription drug overdose deaths.

Fortunately, I found an excellent ACGME accredited Pain fellowship that accepted me, and gave me excellent training. I took the same ABA Pain Board exam (as registered through the American board of PM&R) as any other Pain Fellow, and passed. I now carry the most official Pain Board certification there is. I use my unique background and knowledge, along with what I learned in my fellowship to benefit my Pain patients every day. My first goal is to do no harm, with my prescribing pen and all other treatments, procedures included.

As a physician, you are free to refer or not refer to whomever you want, however, to come to a public forum of Pain physicians, and publicly declare that people who have completed ACGME accredited Pain fellowships and have gained ABMS Pain board certification, are not legitimate, is wrong. Since you identified yourself as not from within the Pain community, I'll give you the benefit of the doubt that you just are not aware.

In fact, you might want to consider referring to a ACGME fellowship trained, ABMS boarded Pain physician with a newer, more balanced approach.

We need a new way of doing things. Look where following "the old way" has gotten us.


Dr. Wanabe to the fluoro suite. Paging Dr. Wanabe.
 
This is 100% wrong. Pain Medicine is an official Subspecialty not only of Anesthesiology and PMR, but also of Neurology and Psychiatry. In fact, no specialty is barred from ACGME accredited Pain fellowships or from taking the same Pain Board exam as written by the American Board of Anesthesiology. Also, there are many very good and ethical Pain physicians who have done ACGME Pain fellowships and have passed the only true Board Exam in Pain Medicine (ABMS) that are from specialties other than these four. (It doesn't sound like the urologist in your example did). This includes people on the faculty of prestigious academic institutions, from specialties such as Internal Medicine, Emergency Medicine, Orthopedics, Neurosurgery, Emergency Medicine and others. Pain Medicine is a crossroads specialty and many clinical specialties other than the official four bring their own unique backgrounds and knowledge to their practices, their patients and the field.

One of them is myself. Prior to even entering fellowship, I was in practice for a decade in Emergency Medicine and had taken care of approximately 21,000 patients in Pain and approximately 12,000 patients with chronic Pain disorders, along with many patients that had overdosed on pain medicines. I consider it somewhat tragic, that Emergency Physicians have not demanded or been given a greater role in the growth of Pain Medicine as a field. I have to believe that if the ones taking care of prescription drug overdose cardiac arrests and breaking the news to the family members on a daily basis were given a greater role in the development of Pain Medicine as a Subspecialty, that we may not be at a place in our society and specialty, where we have >15,000 people dying yearly from prescription drug overdose deaths.

Fortunately, I found an excellent ACGME accredited Pain fellowship that accepted me, and gave me excellent training. I took the same ABA Pain Board exam (as registered through the American board of PM&R) as any other Pain Fellow, and passed. I now carry the most official Pain Board certification there is. I use my unique background and knowledge, along with what I learned in my fellowship to benefit my Pain patients every day. My first goal is to do no harm, with my prescribing pen and all other treatments, procedures included.

As a physician, you are free to refer or not refer to whomever you want, however, to come to a public forum of Pain physicians, and publicly declare that people who have completed ACGME accredited Pain fellowships and have gained ABMS Pain board certification are not legitimate, is wrong. Since you identified yourself as not from within the Pain community, I'll give you the benefit of the doubt that you just are not aware.

In fact, you might want to consider referring to a ACGME-fellowship trained, ABMS-boarded Pain physician with a newer, more balanced approach.

We need a new way of doing things. Look at where "the old way" has gotten us.

This is you giving someone the benefit of the doubt? Damn, I'd hate to see what actually pissed off looks like.
 
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