How would you handle this? Feral Injectionologist

[244913]

I am hospital employed. I have been painstakingly tapering a patient referred by one of the group PCP's. Female, mid 30's, disabled and cognitively impaired, fibromyalgia with central sensitization, tolerance and hyperalgesia.

She was referred to me on 120 MME and I got her down to 40 in 3 months. She had been doing OK but comes in for follow up today out of meds x 4 days, with a negative UDS for opioids and positive for THC.

She had apparently gone to one of the community ED's, and then was descended on by the pain specialist who works in that system. This is a well known guy in the community, runs a lucrative (less so in recent years) pills for shots model. Only sees new patients, injects same day, no follow ups, meds managed by rotating NP's who usually stay on for a year or less. Predatory symbiosis with local Ortho spine butcher shop.

So this guy, in a span of one week, does a cervical epidural in the ASC under sedation, then brings her back five days later for a TFESI. Mind you- she has no indication for these injections, MRI's show only mild age appropriate changes and her history is as described above.

He boots her out after he's done injecting, no follow up instructions, no med guidance. He knows she's being managed in our hospital. She of course claims the shots made the pain worse and so she overtook meds thereby blowing up my taper and violating her agreement, for which I terminated opioid prescribing.

The ironic thing is- I know this injectionologist well.

Part of me wants to call him up, but I try not to make decisions when angry. Have you guys dealt with **** like this?

- ex 61N

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[lobelsteve]

I am hospital employed. I have been painstakingly tapering a patient referred by one of the group PCP's. Female, mid 30's, disabled and cognitively impaired, fibromyalgia with central sensitization, tolerance and hyperalgesia.

She was referred to me on 120 MME and I got her down to 40 in 3 months. She had been doing OK but comes in for follow up today out of meds x 4 days, with a negative UDS for opioids and positive for THC.

She had apparently gone to one of the community ED's, and then was descended on by the pain specialist who works in that system. This is a well known guy in the community, runs a lucrative (less so in recent years) pills for shots model. Only sees new patients, injects same day, no follow ups, meds managed by rotating NP's who usually stay on for a year or less. Predatory symbiosis with local Ortho spine butcher shop.

So this guy, in a span of one week, does a cervical epidural in the ASC under sedation, then brings her back five days later for a TFESI. Mind you- she has no indication for these injections, MRI's show only mild age appropriate changes and her history is as described above.

He boots her out after he's done injecting, no follow up instructions, no med guidance. He knows she's being managed in our hospital. She of course claims the shots made the pain worse and so she overtook meds thereby blowing up my taper and violating her agreement, for which I terminated opioid prescribing.

The ironic thing is- I know this injectionologist well. I shadowed him years ago when I was deciding to go into IPM. This was of course before I knew how seedy and disgusting most PP pain models are.

Part of me wants to call him up, but I try not to make decisions when angry. Have you guys dealt with **** like this?

- ex 61N

Let the patient file the complaint to the medical board.

 

[101N]

Does he run the typical criminal enterprise model: pills, pee (owns his own UA system), PA's?

 

[Aether2000]

Great that she has a negative UDS- this means she needs NO opioids, since she has already gone through the majority of withdrawal, since opioids are generally detected 3 days out. Now you can concentrate on starting naltrexone treatment for the FMS, counseling every session reinforcing why in your opinion epidural injection therapy is not warranted for FMS- only with radicular symptoms, notify her PCP of such, and if possible a clandestine call to the state medical board about the doctor doing inappropriate injections.

 

[244913]

Great that she has a negative UDS- this means she needs NO opioids, since she has already gone through the majority of withdrawal, since opioids are generally detected 3 days out. Now you can concentrate on starting naltrexone treatment for the FMS, counseling every session reinforcing why in your opinion epidural injection therapy is not warranted for FMS- only with radicular symptoms, notify her PCP of such, and if possible a clandestine call to the state medical board about the doctor doing inappropriate injections.

After our discussion today she stormed out of the office cursing me. I don't think our patient-physician relationship- what remains of it- would survive a naltrexone titration

 

[drusso]

Part of me wants to call him up, but I try not to make decisions when angry. Have you guys dealt with **** like this?

- ex 61N

Definitely pick up the phone and call him. Especially if you have a relationship. There is nothing to lose.

 

[BobBarker]

She is the one responsible for her actions. She sought out treatment from another pain physician. She overtook her medication and used an illegal substance.

 

[101N]

Yes- pills for shots. NP out of sight in back corridors of office. Compounding creams. In office pharmacy. And the kicker- those useless back braces being charged $1000 to medicare. Every LBP patient walks out with one.

He might not have his own UA- but that would be kept out of sight in any case

Board report, they are cumulative and yours probably won't be the first or the last. People like this don't
deserve the benefit of a call, it just identifies you as an enemy.

 

[hyperalgesia]

I would not waste another minute on this situation.

You did your best but this pt should never have been on opioids, even if none of this ever happened. The correct outcome was reached in that she is off opioids. And you potentially avoided a risky situation. She could have OD'd on your meds or crashed her car into a child.

I would only report another doc if I had reviewed the charts and had real evidence of fraud/malpractice. Even then I would want multiple motivated pts whom I could represent with my report. This basket-case of a patient is probably more likely to report YOU to the board.

 

[101N]

The truth is we can help even those who don't want our help. 61 knows this and it's why he/she is conflicted in this case.

I don't get many thank you's - from patients - and I do a lot of this.

 

[lobelsteve]

Had 77 y/o this AM get 100 pills (#40 then #60 Percocet) from shoulder surgeon 2 months ago. I had her on MSIR 15 tid for 4 years prior, no issues. Came in and reviewed PDMP and DCd MSIR but put her on Butrans. She comes back in saying patch does nothing and I gotta give her something. My answer was no. She acted like she did nothing wrong and that she was owed medication. Off to counseling. No soup for you.

 

[244913]

The truth is we can help even those who don't want our help. 61 knows this and it's why he/she is conflicted in this case.

I don't get many thank you's - from patients - and I do a lot of this.

I also posted this because I think it illustrates what is wrong with our specialty, and the work that still needs to be done to clean up this mess. This injectionologist is very well known in the community. He is politically connected, built a small empire in the 1990's-2000's on the backs of chemical copers and needles and by all metrics would be considered "very successful" by the layperson and even the majority of unknowing Physicians in the health system.

How many addicts has he created or nurtured? What percentage of his NP's scripts have wound up on the street, at teenage pill parties? How many car accidents have his narc'd out patients caused?

All in the name of profit. Procedural specialties should not be a "business model." The tendency towards corruption is too great. Ortho, Ortho spine, pain.

Vulnerable patients and unscrupulous practitioners.

- ex 61N

 

[SSdoc33]

I also posted this because I think it illustrates what is wrong with our specialty, and the work that still needs to be done to clean up this mess. This injectionologist is very well known in the community. He is politically connected, built a small empire in the 1990's-2000's on the backs of chemical copers and needles and by all metrics would be considered "very successful" by the layperson and even the majority of unknowing Physicians in the health system.

How many addicts has he created or nurtured? What percentage of his NP's scripts have wound up on the street, at teenage pill parties? How many car accidents have his narc'd out patients caused?

All in the name of profit. Procedural specialties should not be a "business model." The tendency towards corruption is too great. Ortho, Ortho spine, pain.

Vulnerable patients and unscrupulous practitioners.

- ex 61N

this story is as old as time.

of course there are crooks out there getting rich off the backs of vulnerable patients. (many an ortho spine surgeon follow this model).

do the best work you can, and educate your patients about the dangers of certain -- umm -- practioners out there. i wouldnt call the guy. the only thing it will do will cause trouble, and make both of you more angry. i'd equate it to trying to to tell your wife that she loads the dishwasher incorrectly when she is on her period. she really REALLY doesnt want to hear that a frying pan should not be placed parallel to the floor

 

[drusso]

I also posted this because I think it illustrates what is wrong with our specialty, and the work that still needs to be done to clean up this mess. This injectionologist is very well known in the community. He is politically connected, built a small empire in the 1990's-2000's on the backs of chemical copers and needles and by all metrics would be considered "very successful" by the layperson and even the majority of unknowing Physicians in the health system.

How many addicts has he created or nurtured? What percentage of his NP's scripts have wound up on the street, at teenage pill parties? How many car accidents have his narc'd out patients caused?

All in the name of profit. Procedural specialties should not be a "business model." The tendency towards corruption is too great. Ortho, Ortho spine, pain.

Vulnerable patients and unscrupulous practitioners.

- ex 61N

If you have a relationship with him, grab a cup of coffee with him. You have nothing to lose.

 

[lobelsteve]

If you have a relationship with him, grab a cup of coffee with him. You have nothing to lose.

Because Rich angry people never feel like providing you with any retribution.

 

[drusso]

Because Rich angry people never feel like providing you with any retribution.

You guys crack me up. Such an "institutional" mindset...I was on my hospital's peer review committee for 7 years and the local school board for 4 years. I'm a veteran of "Crucial Conversations" and have the T-shirt to prove it.

Isn't the real concern here about unnecessary medical care and community practice standards?

Unnecessary Medical Care: More Common Than You Might Imagine

If the injectionologist is a "well-connected, political animal," then he probably cares about his reputation. Imagine someone reaches out to you and says, "I'm concerned about your reputation." You might be defensive at first, but you would also certainly be very curious about whatever is about to come next. You have one meeting, then another. Sit next to him at next Med Staff meeting, on the chair-lift, or next kids' event...develop rapport.

But first you have to break out of an institutional mind-set and embrace a relationship-based way of working. And, you have to really want to give a **** and not just complain about it.

 

[lobelsteve]

I trust no one. No one is looking out for me. Most are looking to figure out how to screw me and better their position.
I have been taken advantage of too many time.

The truth is out there.

 

[jsaul]

whats the big deal here, If he is injections for pills as you say he is, then this patient should go back to him for pills and injections.,, it's off your hands. I am sure his PA can and will refill meds everymonth if he is what you say he is....

Is it your place to bring down his whole practice? I am sure is he has been this unscrupulous since the 90s he would have had major complaints to the board by now

 

[drusso]

I trust no one. No one is looking out for me. Most are looking to figure out how to screw me and better their position.
I have been taken advantage of too many time.

The truth is out there.

You have trust issues.

 

[244913]

You have trust issues.

It's a jungle out there. With reimbursement cuts there is tremendous competition for new patients to maintain procedure revenue. I have seen this in my area and it is very cutthroat. What I see is local injectionologists needling everything that walks in the door- like my patient with fibromyalgia above who I was tapering.

I don't think Steve is off base with his assessment. Folks around here are really having to squeeze the last bit of toothpaste out of the bottle

- ex 61N

 

[Disciple]

I trust no one. No one is looking out for me. Most are looking to figure out how to screw me and better their position.
I have been taken advantage of too many time.

The truth is out there.

#MeToo

Sad but true.

 

[VA Hopeful Dr]

You have trust issues.

There's plenty of doctors out there who have been repeatedly screwed over by trusting employers, hospitals, or even other doctors.

The way things are now, trusting anyone is likely to bite you in the ass

 

[lobelsteve]

You have trust issues.

Chiro stole my ssn and took out 50k in medical loans from ge healthcare in my name and forging my signature. My former boss. And that's just for starters.

 

[SeniorWrangler]

Talking to the guy seems pretty reasonable if you have a concern. He probably has no idea what happened, whether or not he gives a damn. At the very least, you might get him to be more cautious and appropriate with your patients.

On the other hand, reporting him to the authorities seems inappropriate: I'm sure I've injected people that somebody else would not have, and vice versa, and if we all reported each other to the Epidural Cops, it would be a bad thing.

 

[101N]

Imagine your a person in the know, in a state that's been hard hit by the epidemic, and this panderer has been hiding in plain sight in your back yard for years.
There's no friendly call that's going to change his business model. Straight to the medical board or better yet to the DEA.

 

[Ducttape]

You guys crack me up. Such an "institutional" mindset...I was on my hospital's peer review committee for 7 years and the local school board for 4 years. I'm a veteran of "Crucial Conversations" and have the T-shirt to prove it.


But first you have to break out of an institutional mind-set and embrace a relationship-based way of working. And, you have to really want to give a **** and not just complain about it.

the one thing harder to break than an institutional mind-set is breaking a financial mind-set.

 

[drusso]

the one thing harder to break than an institutional mind-set is breaking a financial mind-set.

I'd start by asking him for feedback on this report:

https://www.wacommunitycheckup.org/media/47156/2018-first-do-no-harm.pdf

 

[Ducttape]

im curious as to how the Choosing Wisely program is going to affect his care plan. the only aspect of that campaign that would involve his practice is the "no MRI within 6 weeks of onset of pain".

anyways, i suspect he isn't ordering personally the MRI, his midlevels are. unless he owns the MRI machine...

 

[drusso]

im curious as to how the Choosing Wisely program is going to affect his care plan. the only aspect of that campaign that would involve his practice is the "no MRI within 6 weeks of onset of pain".

anyways, i suspect he isn't ordering personally the MRI, his midlevels are. unless he owns the MRI machine...

It would be a great conversation starter.

 

[jonnylingo]

Chiro stole my ssn and took out 50k in medical loans from ge healthcare in my name and forging my signature. My former boss. And that's just for starters.

 

[101N]

I wonder if these injectionists are members of ASIPP. It would be useful to know.

 

[geauxg8rs]

I wonder if these injectionists are members of ASIPP. It would be useful to know.

All card carrying members of
American society of series of three

 

[DrCommonSense]

I wonder if these injectionists are members of ASIPP. It would be useful to know.

I suggest adding some Shaman treatment, Suboxone and maybe acupuncture for her cure. No cash, no problem! She can use one of the local credit unions to pay the bill!

All of this treatment will be administered by our naturopaths and Dr Nurses who are very compassionate as well!

 

[Ducttape]

You jest... but the EBM for some of this charlatan hocus may be as high quality as those for a lot for your injections.

Being someone who rails against procedural medicine... well most spine injections probably fall in the same category of useless procedures as those you despise.

 

[lonelobo]

If we all practiced strictly by EBM...the number of injections we performed would take a drastic cut