Surgery center pain crooks are driving me insane

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Gasworks

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Title says it all. I cover a small center that seems to actively seek out the most crooked pain doctors in the state. Now I am not a psychic to know what goes on in peoples minds, but after a few hundred of these cases I can't help but to think these guys are stringing along hardcore addicts who are willing to subject themselves to countless procedures in order to get unbelievably massive narcotic refills. Here are some fun thing I have experienced in the past few months:

1. Pts who come in so wasted on narcs that they can barely keep their eyes open.
2. Pts who ran out of pills 2-3 days ago and are now in the throws of withdrawal. No refills without needles seems to be the law of the land.
3. Pts who walk in all smiles, change into their gowns and crawl into the preop area crying for dilaudid.
4. Pts who get a 1 level TFE and cry for 10mg of dilaudid before going home.
5. Preop calls and postop checks answered by relatives "he died of an overdose". Three times in the past six months.
6. Pain doc who holds "midnight clinic" refilling prescriptions until 1-2am.
7. Pts doing victory dance in the parking lot waving their prescriptions around.
8. Pts in the parking lot waiting for the car service, openly on their cellphones trying to sell the meds they just scored. Car service drivers tell me this happens every day.

All of that I can get past, but I am expected to go in there with a straight face and give IV general to these patients one after the next. I would guess that the average pt getting 2 needles requires 3-4 bottles of diprivan to keep them from flying off the table. Practically none are NPO, many vomit, all of them complain and I'm starting to feel that its just a matter of time before I land in jail or lose my license if I keep this up. Another member of my group was threatened with physical violence because a pt felt burning from diprivan. The kicker here is that everyone attached to these guys is making so much money that there is effectively no way out of this for me without quitting my job. We are talking about 50-60 cases per week, all covered by workers comp, private insurance or no-fault. Just about all are out of network so you can imagine what kind of killing the center is making on the facilities fees.

I'm stuck, frustrated and questioning if this is really what I have to do in order to have a good paying anesthesia job. Sometimes I just want to get in my car and drive to the state attorney generals office but I'm sure the only person to suffer from that will be me. Any advice??
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Ask yourself why you went to medical school.

I could have easily bypassed 8 years of schooling and made enormous sums of cash peddling drugs on the street corner. It sounds like some of these guys maybe took the longer route.

I also feel like you already know the answer to your dilemma.
 
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Just ask yourself one simple question:

Do you suspect diversion?

If so, you have a legal obligatin to report that asshat to the DEA.
If his patient's are just impaired- then the medical board deserves a call.
If they are driving home (or to) the ASC, or even driving at all appearing the way you describe- won't you feel bad you didn't blow the whistle before one of those narcheads runs over some poor 3 y/o child?

I believe we have a larger societal responsibility as far as what ought to be done.
 
Gasworks said:
Title says it all. I cover a small center that seems to actively seek out the most crooked pain doctors in the state. Now I am not a psychic to know what goes on in peoples minds, but after a few hundred of these cases I can't help but to think these guys are stringing along hardcore addicts who are willing to subject themselves to countless procedures in order to get unbelievably massive narcotic refills. Here are some fun thing I have experienced in the past few months:

1. Pts who come in so wasted on narcs that they can barely keep their eyes open.
2. Pts who ran out of pills 2-3 days ago and are now in the throws of withdrawal. No refills without needles seems to be the law of the land.
3. Pts who walk in all smiles, change into their gowns and crawl into the preop area crying for dilaudid.
4. Pts who get a 1 level TFE and cry for 10mg of dilaudid before going home.
5. Preop calls and postop checks answered by relatives "he died of an overdose". Three times in the past six months.
6. Pain doc who holds "midnight clinic" refilling prescriptions until 1-2am.
7. Pts doing victory dance in the parking lot waving their prescriptions around.
8. Pts in the parking lot waiting for the car service, openly on their cellphones trying to sell the meds they just scored. Car service drivers tell me this happens every day.

All of that I can get past, but I am expected to go in there with a straight face and give IV general to these patients one after the next. I would guess that the average pt getting 2 needles requires 3-4 bottles of diprivan to keep them from flying off the table. Practically none are NPO, many vomit, all of them complain and I'm starting to feel that its just a matter of time before I land in jail or lose my license if I keep this up. Another member of my group was threatened with physical violence because a pt felt burning from diprivan. The kicker here is that everyone attached to these guys is making so much money that there is effectively no way out of this for me without quitting my job. We are talking about 50-60 cases per week, all covered by workers comp, private insurance or no-fault. Just about all are out of network so you can imagine what kind of killing the center is making on the facilities fees.

I'm stuck, frustrated and questioning if this is really what I have to do in order to have a good paying anesthesia job. Sometimes I just want to get in my car and drive to the state attorney generals office but I'm sure the only person to suffer from that will be me. Any advice??
Click to expand...

Would you be able to put in an anonymous tip? It seems like the state attorney general would have to do plenty of his/her own investigation before any charges were filed, so you may not get dragged into it. Dunno, though, I supposed you'd have to be prepared for that to happen...
 
I personally think most of pain medicine is a sham. There are a few services it provides that are useful, such as those involve chronic cancer pain, or pain from nerve injury such as one patient I saw after an inguinal hernia. That is why I refuse to participate in this kind of behavior. I mean, you can find a real anesthesia job where you actually help people and improve mankind, but you will have to work your tail off to make the 350k with overnights and weekends doing those ruptured AAAs in the middle of the night.
But yeah, if you want the easy money, it doesn't exist.
 
Gasworks said:
Title says it all. I cover a small center that seems to actively seek out the most crooked pain doctors in the state. Now I am not a psychic to know what goes on in peoples minds, but after a few hundred of these cases I can't help but to think these guys are stringing along hardcore addicts who are willing to subject themselves to countless procedures in order to get unbelievably massive narcotic refills. Here are some fun thing I have experienced in the past few months:

1. Pts who come in so wasted on narcs that they can barely keep their eyes open.
2. Pts who ran out of pills 2-3 days ago and are now in the throws of withdrawal. No refills without needles seems to be the law of the land.
3. Pts who walk in all smiles, change into their gowns and crawl into the preop area crying for dilaudid.
4. Pts who get a 1 level TFE and cry for 10mg of dilaudid before going home.
5. Preop calls and postop checks answered by relatives "he died of an overdose". Three times in the past six months.
6. Pain doc who holds "midnight clinic" refilling prescriptions until 1-2am.
7. Pts doing victory dance in the parking lot waving their prescriptions around.
8. Pts in the parking lot waiting for the car service, openly on their cellphones trying to sell the meds they just scored. Car service drivers tell me this happens every day.

All of that I can get past, but I am expected to go in there with a straight face and give IV general to these patients one after the next. I would guess that the average pt getting 2 needles requires 3-4 bottles of diprivan to keep them from flying off the table. Practically none are NPO, many vomit, all of them complain and I'm starting to feel that its just a matter of time before I land in jail or lose my license if I keep this up. Another member of my group was threatened with physical violence because a pt felt burning from diprivan. The kicker here is that everyone attached to these guys is making so much money that there is effectively no way out of this for me without quitting my job. We are talking about 50-60 cases per week, all covered by workers comp, private insurance or no-fault. Just about all are out of network so you can imagine what kind of killing the center is making on the facilities fees.

I'm stuck, frustrated and questioning if this is really what I have to do in order to have a good paying anesthesia job. Sometimes I just want to get in my car and drive to the state attorney generals office but I'm sure the only person to suffer from that will be me. Any advice??
Click to expand...



Take a deep breath and look around you: these kinda of things are not too different from those useless "surgeries" that you would provide anesthesia for on a daily basis: lap chole's, lap appy's, "diagnostic laps," etc, etc.... It's a cultural problem, we are a society addicted to instant gratification: "I want my surgery and I want it now! I want my pill and I want it now!" You get my drift.... Asking doctors to curb societal problems is a bit much: you can lead a horse to the water, but you cannot force it to drink....
 
IN2B8R said:
Take a deep breath and look around you: these kinda of things are not too different from those useless "surgeries" that you would provide anesthesia for on a daily basis: lap chole's, lap appy's, "diagnostic laps," etc, etc.... It's a cultural problem, we are a society addicted to instant gratification: "I want my surgery and I want it now! I want my pill and I want it now!" You get my drift.... Asking doctors to curb societal problems is a bit much: you can lead a horse to the water, but you cannot force it to drink....
Click to expand...

An appy is a useless surgery?! Those people with acute appendicitis, always wanting instant gratification!
 
Regardless of whether or not you have an ethical responsibility to blow whistles- it sounds like you are going to work each day feeling like you are part of something bad. We've trained too long and too hard to feel like this in our occupation of choice. You have options-- pursue them. Life is hard enough even when you feel like you are doing something good in your job. One of the few things we have significant control over.
 
michigangirl said:
Regardless of whether or not you have an ethical responsibility to blow whistles- it sounds like you are going to work each day feeling like you are part of something bad. We've trained too long and too hard to feel like this in our occupation of choice. You have options-- pursue them. Life is hard enough even when you feel like you are doing something good in your job. One of the few things we have significant control over.
Click to expand...

Don't be a wuss. Step up to the plate and do the right thing.
 
I would encourage you to contact the state medical society and voice your concerns. This is a serious problem that may come back on you if you don't with regard to liability. Also, you may want to consider posting this on the pain forum. There are a lot of experienced folks with regard to this type of thing and they may be able to give you more specific advice.
 
PMPMD said:
An appy is a useless surgery?! Those people with acute appendicitis, always wanting instant gratification!
Click to expand...

When was the last time you actually saw a real appendicitis? 7/10 usually have a normal appendix in PP--the same **** for a Lap chole; yeah, that abdominal pain that prompted the useless surgery will still be there....
 
IN2B8R said:
When was the last time you actually saw a real appendicitis? 7/10 usually have a normal appendix in PP--the same **** for a Lap chole; yeah, that abdominal pain that prompted the useless surgery will still be there....
Click to expand...

The path report is only useful in hindsight; are you really going to refuse to take them to the OR?
 
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IN2B8R said:
When was the last time you actually saw a real appendicitis? 7/10 usually have a normal appendix in PP--the same **** for a Lap chole; yeah, that abdominal pain that prompted the useless surgery will still be there....
Click to expand...

I might agree about some of the diagnostic laps for chronic pelvic pain, seems like every one of them is negative. I sure see a lot of nasty gall bladders though, and the appys ... not much to do there. We do a lot of stupid things to practice defensively. At its core, a soft appy for vague RLQ pain and an OK story and inconclusive imaging is the epitome of defensive medicine.

Some of the pain procedure mills take it to a level that would make even chiropractors uncomfortable though.
 
PMPMD said:
The path report is only useful in hindsight; are you really going to refuse to take them to the OR?
Click to expand...

You are totally missing the intent of my post: yes, some surgeries are warranted, no question there. Yes, some pain procedures are warranted, no question there either.... But, many pain and surgical procedures are not warranted. Why are they still done? Simple: patients want and demand that they be done! Patients want that instant gratification, that magic pill.... And no, I ain't in the business of "refusing" to take a patient to the OR, or giving a hoot 'bout a path report for that matter! Listen to what pgg wrote: lots of crap happens in the real world, you just gotta deal with it, or else find another job. And in response to the OP, if it makes him/her feel so bad to see these pain clinics as such, then either report them or, better yet, don't just stop the reporting there, report all sham jobs, be they a surgeon or a pain doc....

regards
 
pgg said:
I might agree about some of the diagnostic laps for chronic pelvic pain, seems like every one of them is negative. I sure see a lot of nasty gall bladders though, and the appys ... not much to do there. We do a lot of stupid things to practice defensively. At its core, a soft appy for vague RLQ pain and an OK story and inconclusive imaging is the epitome of defensive medicine.

Some of the pain procedure mills take it to a level that would make even chiropractors uncomfortable though.
Click to expand...

Could not agree more: these folks are nothing but the ****** of medicine.
 
Gasworks-

I feel your pain-ha! pun intended.

I have also been in the exact same unfortunate situation. The majority of anesthesia groups are businesses period. Even though 95% of pain procedures don't require a board certified anesthesiologist to administer their sedation, they get it...because it pays oh so well. I had a check diverted to me by accident and was shocked...no I didn't keep it. Make no mistake, you are doing GA with an unprotected airway, eventually you'll get dinged. Its what the pain docs want and money talks.

I was out by 3 everyday and made over the median salary for gas nationwide....and I quit. It wasn't worth it to me. I make less and work more but I would NEVER go back. Its bad medicine, period.

I would speak to your superiors and explain its not where you want to go professionally. If they react badly then you have your answer on what to do.

You have to pick your poison or get out. I wanted to be a physician not a propofol monkey. My advice, cut your expenses, steer clear of the business first practices (most of them) and find a place that practices medicine.

Maybe socializing medicine is not such a bad thing? :D
 
Don't know what your situation is, family, kids, tied to area, no other jobs, etc... That being said, even if I had some anchors weighing me down, I don't know how much of that sh.t I could put up with. Hopefully you've built up a decent FU account to buy you some time.

Quit.
 
I've heard of cardiologists putting stents in waaaaaaaay to many "diagnostic caths". Sickening, dangerous and fraudulent. But a money maker for the hospital which = "golden boy" and all sorts of "awards."
 
michigangirl said:
Regardless of whether or not you have an ethical responsibility to blow whistles- it sounds like you are going to work each day feeling like you are part of something bad. We've trained too long and too hard to feel like this in our occupation of choice. You have options-- pursue them. Life is hard enough even when you feel like you are doing something good in your job. One of the few things we have significant control over.
Click to expand...

:thumbup:
 
sevoflurane said:
I've heard of cardiologists putting stents in waaaaaaaay to many "diagnostic caths". Sickening, dangerous and fraudulent. But a money maker for the hospital which = "golden boy" and all sorts of "awards."
Click to expand...

Seen this happen as well. Big $$$ for the hospital, it makes it easier for them to look the other way.
 
proman said:
Like all fraud, that works until you're caught.
Click to expand...

An interesting wrinkle - one of the chiefs from my year in residency admitted a guy for PNA (although no infiltrate on Xray), and the patient got a (not needed) stent from this guy. The patient expired, and my EM colleague was sued for "not wide spectrum enough antibiotics". My colleague lost. I'm not sure who he had for a shyster, but not someone I would use.
 
Interesting to hear these stories of corrupt pain docs and cardiologists. Everyone seems to agree they are corrupt and practicing bad medicine far out of bounds for what is considered normal standard of care, however, no one is talking about criminal prosecution. This relates to the Conrad Murray thread. Is what he did really any worse than these practices?
It sounds as though deaths are involved from OD's. Any time you are doing unnecessary stents, I suspect that there will be related complications that could lead to death. Maybe not the same day, but when they forget their plavix for a few days in a row and have a massive MI, it is a direct causation.

So, do these doctors need to have their license yanked or go on trial for manslaughter? Their activity seems more egregious than Dr. Murray's if these facts are to be believed as true.
 
IN2B8R said:
Take a deep breath and look around you: these kinda of things are not too different from those useless "surgeries" that you would provide anesthesia for on a daily basis: lap chole's, lap appy's, "diagnostic laps," etc, etc.... It's a cultural problem, we are a society addicted to instant gratification: "I want my surgery and I want it now! I want my pill and I want it now!" You get my drift.... Asking doctors to curb societal problems is a bit much: you can lead a horse to the water, but you cannot force it to drink....
Click to expand...

:thumbup:

It's a cultural problem too with our expectations, our sense of entitlement, and our expectations. More and more, we, i.e. patients/society, are not happy with the diagnoses (and in turn, treatments) that can be provided by simple history, physical exam, and maybe basic laboratory workup, because "there's still a chance that we might find something" or "there's still a chance treatment X might work" or somesuch nonsense. New chemo are a great example.

And in turn, as we rely more on advanced and invasive testing and procedures, medical school training in basic H+P, differential diagnosis formulation, clinical reasoning, likelihood ratios, etc, gets worse and worse.
 
fakin' the funk said:
:thumbup:

It's a cultural problem too with our expectations, our sense of entitlement, and our expectations. More and more, we, i.e. patients/society, are not happy with the diagnoses (and in turn, treatments) that can be provided by simple history, physical exam, and maybe basic laboratory workup, because "there's still a chance that we might find something" or "there's still a chance treatment X might work" or somesuch nonsense. New chemo are a great example.

And in turn, as we rely more on advanced and invasive testing and procedures, medical school training in basic H+P, differential diagnosis formulation, clinical reasoning, likelihood ratios, etc, gets worse and worse.
Click to expand...

Very well said, sir.:thumbup:
 
Apollyon said:
An interesting wrinkle - one of the chiefs from my year in residency admitted a guy for PNA (although no infiltrate on Xray), and the patient got a (not needed) stent from this guy. The patient expired, and my EM colleague was sued for "not wide spectrum enough antibiotics". My colleague lost. I'm not sure who he had for a shyster, but not someone I would use.
Click to expand...

Not only did the patients suffer, but the hospital, St Joseph's of Baltimore has paid $22 million in penalties. I imagine that appropriate use of interventional cardiac procedures is on top of CMS priority list now. Emergent intervention seems more appropriate, I remember a press release recently looking at the difference.

I don't know when it become criminal. He may still face charges of Medicare fraud. Maybe the lesson is that it's ok to harm patients as long as they aren't famous, just don't steal from the government (like Scott Reuben who got 6 months in prison).
 
IN2B8R said:
You are totally missing the intent of my post: yes, some surgeries are warranted, no question there. Yes, some pain procedures are warranted, no question there either.... But, many pain and surgical procedures are not warranted. Why are they still done? Simple: patients want and demand that they be done! Patients want that instant gratification, that magic pill.... And no, I ain't in the business of "refusing" to take a patient to the OR, or giving a hoot 'bout a path report for that matter! Listen to what pgg wrote: lots of crap happens in the real world, you just gotta deal with it, or else find another job. And in response to the OP, if it makes him/her feel so bad to see these pain clinics as such, then either report them or, better yet, don't just stop the reporting there, report all sham jobs, be they a surgeon or a pain doc....

regards
Click to expand...

Actually I wasn't aware that they're doing so many normal appies/choles in PP. I have plenty experience being pressured into unnecessary/futile care in the SICU - patients/family wants "everything done," etc.
 
PMPMD said:
Actually I wasn't aware that they're doing so many normal appies/choles in PP. I have plenty experience being pressured into unnecessary/futile care in the SICU - patients/family wants "everything done," etc.
Click to expand...

Yep: there's pressure on surgeons (all doctors) as well. Call it whatever you want: family pressures, defensive medicine, productivity pressures in order to maintain livelihood, etc, etc.... Bottom line is, there are countless procedures that are performed daily in PP that are not warranted. I call it senseless medicine. Not necessarily driven by greed, but rather driven by societal, systemic pressures that are, often, outside the control of the physician.... At the core of our medical system problems reside certain unchanged facts: we are a society of instant gratification. We cannot and choose not to confront death. We have a system that is not limited to a "doctor-patient relationship." Rather, we have something called "patient-doctor-lawyer-JACHO-hospital administration relationship." In such a setting, the physician is greatly and purposely marginalized from decision (real decisions) making.... Yes, none of this was ever "taught" or remotely emphasized in medical school or residency, but it is the reality within which we exist. Gone are the days of delivering medicine the way medicine should be delivered: you were a hard working physician who was respected by society and was well treated. You provided the patient with the best of all care, stopping when things were futile. Now it is all of the above, a setup that is screwing the physician and the patient and benefiting lawyers, shareholders, and administrations. Welcome to reality.
 
Last edited:
IN2B8R said:
Yep: there's pressure on surgeons (all doctors) as well. Call it whatever you want: family pressures, defensive medicine, productivity pressures in order to maintain livelihood, etc, etc.... Bottom line is, there are countless procedures that are performed daily in PP that are not warranted. I call it senseless medicine. Not necessarily driven by greed, but rather driven by societal, systemic pressures that are, often, outside the control of the physician.... At the core of our medical system problems reside certain unchanged facts: we are a society of instant gratification. We cannot and choose not to confront death. We have a system that is not limited to a "doctor-patient relationship." Rather, we have something called "patient-doctor-lawyer-JACHO-hospital administration relationship." In such a setting, the physician is greatly and purposely marginalized from decision (real decisions) making.... Yes, none of this was ever "taught" or remotely emphasized in medical school or residency, but it is the reality within which we exist. Gone are the days of delivering medicine that way medicine should be delivered: you were a hard working physician who was respected by society and was well treated. You provided the patient with the best of all care, stopping when things were futile. Now it is all of the above, a setup that is screwing the physician and the patient and benefiting lawyers, shareholders, and administrations. Welcome to reality.
Click to expand...

It takes energy to bring order out of entropy. We need to do the right thing.
 
cincincyreds said:
I personally think most of pain medicine is a sham. There are a few services it provides that are useful, such as those involve chronic cancer pain, or pain from nerve injury such as one patient I saw after an inguinal hernia. That is why I refuse to participate in this kind of behavior.
Click to expand...

Kind of a broad brush you're painting with there, eh?

I worked for of these con artist quacks in my last practice, and if that's all I had to go on, I suppose I'd agree with you. MAC was seen as a cash cow, and yes, I was required to provide it for junkies who were clearly trading injections for pills, although this was not explicit. Ditching that place was one of the best decisions I ever made.

Real pain medicine is highly effective despite our lack of supportive literature. I believe the reason we lack supportive literature is mainly due to the difficulty in proper patient selection for studies. If you're suffering with severe pain, are you going to sign up for a double-blind study, or are you going to want that ESI/MBB/kypho right now? The folks who say yes probably aren't the best candidates for our procedures in the first place.

Useful services I provide as a pain doc (to non-cancer pain patients, and those without "nerve injuries", who comprise 99%+ of my practice):

1) Provide musculoskeletal diagnosis for countless patients no one else could diagnose without our unique toolset (fluoro, US, blocks).
2) ESI for radicular pain.
3) RF ablations for painful facet joints.
4) TPs for myofascial and ligamentous pain (I do them differently than most, and yes, they do work in most patients)
5) Kyphoplasty for compression fractures.
6) Various peripheral nerve blocks for diagnostic purposes that are often therapeutic as well.
7) SCS
8) Consultation on appropriate medication management of pain problems.
 
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