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What exactly is a methadone mill? Does it generate high incomes?

Discussion in 'Psychiatry' started by carlosc1dbz, Apr 12, 2010.

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  1. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    I was reading up on the fellowships for psych and someone mentions that if you have a methadone mill you can make a lot of mula. So I am assuming this is done through a addiction fellowship, which seems really interesting to me, since I had never even considered it. There is some guy that did his residency in Pasadena in Internal medicine, and he does some type of addiction clinic. There is a show about it on MTV or somewhere, but are there different paths to addiction medicine? Also is this type of medical practice usually reimbursed by insurance companies and medicare?
  2. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    xxxxxxxx
    Last edited: Apr 12, 2010
  3. Chianti

    Chianti Member

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    I worked as a counselor in a "methadone mill" in NYC for 1 year. The "methadone mill" was in SoHo with a census of between 700-800 people. The kicker was that in NY medicare actually pays for methadone treatment. The doctor who owned the clinic (an anesthesiologist) was making at least $1 million/year from the clinic. And then spent about an hour a month there.

    So yeah, a "methadone mill" can be a goldmine.
  4. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    I would argue that said doctor was running a business, not practicing medicine. It was the effort to prevent this that inspired the DEA to regulate Suboxone so tightly. (Once again I complain: why is it that any yahoo intern with a DEA number can write for 90 Percocet, with refills, but a doctor who wishes to prescribe buprenorphine specifically to get these patients OFF of opiates needs a special certification????) Anyhow--the example above is a good example of the awfulness that is a "methadone mill". Yep--they can make money. Yep, methadone does save lives and reduces some of the harm caused by opiate dependence. But yep--it's still seedy. And those of us who are Addiction Psychiatrists* or in Addiction Medicine* always feel just a little dirty even thinking about it...

    *To OP: correct--there are 2 paths to addiction certification currently. One is an Addiction fellowship after Psychiatry residency, with an additional board exam for certification. The other is an Addiction Medicine fellowship following another ACGME certified residency (IM, FP, etc...), and certification via a different board exam. Yes, chemical dependency treatment is reimbursed by insurance and public payors. No, you will not make a fortune doing it--unless you go the entrepreneurial route (cash-only spa-style treatment centers, etc.)
  5. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    suboxone mills can be a goldmine too.
    the reimbursement for urine drug screens is pretty good.
  6. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    The idea of becoming a pi$$ merchant for profit hadn't yet occured to me, thankfully.

    I'm unclear about how one can run a "Suboxone mill", however, given the 30 patient limit (expandable to 100) per DEA number. Perhaps you know of an exploitable loophole that escaped me?
  7. 235750

    235750

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    Often times one sees 'lol' on the internet, but I honestly did laugh out loud at this comment!!
  8. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    Assume you have each suboxone patient come in once per month, and get a urine drug screen each time. The reimbursement for this would be over $500 per visit for many private insurance plans, most of that being for the UDS. 100 patients per month x $500 x 12 = a revenue of $600,000 per year.

    The best part of this is that frequent urine drug screens are actually encouraged by the Feds (DEA) and state medical boards. You don't have to feel guilty about doing them!

    I did suboxone for a little while, much less than 30 patients per month. I took medicaid and medicare, so it wasn't that profitable for me. I found the idea of being a piss merchant distasteful and so go out of suboxone; I have not prescribed it for over 4 months. I still have prospective patients- well-insured or willing to pay cash- calling my office every week. There's a gold mine out there for those willing to be piss merchants. I am going to stick to sleep studies.
  9. Doc Samson

    Doc Samson gamma irradiated

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    But you're still tied to the 30 pt max, right? So that's 30 pts/month x $500 x 12 = $180,000.
  10. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    After a year at the 30 pt max, you can expand to 100. (Though my RN would kill me--my 15 or so Sbx pts are VERY high maintenance!)
  11. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    100!!! You would need some major help to manage that.
  12. Sneezing

    Sneezing Even Bears do it!

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    This keeps cracking me up. I can see a person at a cocktail type party. Some friend of a friend comes up, holding their wine glass, and asks what do you do.... "I'm a piss merchant!":rofl:
  13. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    Assuming that someone else is doing the suggested psychotherapy, 100 suboxone patients would probably average out to 60-80 hours per month of doc time. If the suboxone doc was also doing psychotherapy, it still would be manageable if he didn't do much else.
  14. Faebinder

    Faebinder Slow Wave Smurf

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    30 patients a month = 1.5 patients a day... You can do better than that, see more patients, and make much more.
  15. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Of course, but in the case of buprenorphine, you are capped by the DEA (who HAVE been known to send around their agents to audit you! :eek:) at 30 (or 100, with a year's experience) patients to whom you are currently prescribing the med. If they show up and request your list of prescribees you have to give it to them, and if your DEA# is linked to more than that number of buprenorphine scripts in a month...:scared:

    So, again--even if you are in a practice (and few of us are) where you make extra money billing for urine tests, it's not going to be "methadone mill" level cash flows.
  16. snarfer

    snarfer

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    This urologist? is going to jail after alledgedly having prescribed 54,000 hydrocodone pills in 2008 alone! pocketed $700,000. MJ cardiologist seems like childlike in comparison.

    http://www.drhealysdiet.com/drhealy.html
  17. notdeadyet

    notdeadyet Still in California Moderator

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    Out of curiosity, if you're doing a lot of addiction treatment with buprenorphine, what is the alternative for urine testing? You send them to Quest or somesuch?

    I'm not thinking of profit issues here, or price gouging, I'd just assumed that urine tests would be most conveniently done for the patient during monthly visits.
  18. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    In my case, I'm working within an integrated health care system, so I send them downstairs to our in-house lab for any testing needed. I don't get paid more for it. Also, since these aren't mandated screens, and since my bupe patients are typically opiate-habituated chronic pain/depression patients who are motivated for abstinence, I don't find regular screening to be of much benefit. (I have a couple of young heroin addicts on my list, but they're on probation, so I let their P.O. be the pee-enforcer! Pee Officer? :laugh:) Also, my lab isn't going to witness or validate a screen, so they could be pretty easily subverted. If someone needed that level of urine testing for compliance reasons, I'd probably have them seen in a methadone clinic instead, or in the case of a couple of "fallen" RNs I follow, the state HPSP checks their urine randomly and regularly.
  19. notdeadyet

    notdeadyet Still in California Moderator

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    Ah, that makes a lot of sense. Thanks for the explanation...
  20. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    In Mississippi, BC/BS and medicaid require periodic urine drug screens as well as evidence of receiving counseling for prior approval of suboxone
  21. Psych2014

    Psych2014

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    Regardless of the profit, which I had no idea was so considerable, in my brief exposures, both familial and as a MS4 (happily matched may I add), and being a 2nd career adult, I am looking forward to providing both suboxone and methadone to those who genuinely need it. There's a lot of compassion, and care, dealing with the very needy, and it has the edge that drew me into psychiatry. Methadone has so many valid applications in pain management as well. If I can do that, and med check visits for 40-50 hours/week, I'd be a happy, though possibly tazer gun toting psychiatrist. The clinic's I've seen generally have patients start at 5 am, with their little lock boxes when they've graduated off liquid methadone, and the doc will come about 12 hours per week, generally when fewer of the desparate, methadone abusers are not there, through a secured back door. For the percentage that actually use it well, suboxone and methadone are literally miracle drugs, leading to a normal, healthy lifestyle. I'd love to hear more from experienced docs.
  22. michaelrack

    michaelrack All In at the wrong time SDN Advisor

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    I believe that you need to work for a methadone clinic to prescribe it; it's not something you can do in a private practice.
  23. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Methadone can only be legally prescribed for opiate dependence from a licensed facility. Any DEA-holding prescriber can prescibe it for pain management, however. But it's tricky, deadly tricky...
  24. Psych2014

    Psych2014

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    Yes, I'm aware of both of those settings, and I appreciate your comments. I know addicts of less potent opiates than the synthetic methadone, who are not fully saturated think they can use methadone in small amounts and be safe, and not... Thanks for your input.
  25. Sneezing

    Sneezing Even Bears do it!

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    Are you positive? I saw one patient with Fibromyalgia of all things on Methadone from a PCP. I wasn't under the impressio it was that "tricky."
  26. loveoforganic

    loveoforganic -Account Deactivated-

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    I think he's implying the DEA is prone to crack down on people who attempt to prescribe it for pain.
  27. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    No, I mean that the analgesic response is highly variable in patients and that there is no "easy" conversion from shorter acting analgesics, so that you can very easily put a patient in respiratory depression before they have significant pain relief. Tricky. DEADLY tricky.

    http://www.nytimes.com/2008/08/17/us/17methadone.html
  28. loveoforganic

    loveoforganic -Account Deactivated-

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    Oops, thanks!
  29. whopper

    whopper Former jolly good fellow

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    Hmm, wouldn't be the first, nor last person I've seen with fibromyalgia put on an opioid-based pain med to treat the fibromyalgia, even though several sources cite that you shouldn't put fibromyalgia patients on these types of meds.

    Funny, a relative of mine is an extreme right-wing person diagnosed with fibromyalgia, on opioid-based pain meds to treat it, unemployed and on disability, and well, I guess whenever almighty "Rush" laments people like this, she always agrees with him without having the insight to see she fits the category.

    Not surprisingly, her facebook comments are either a mix of dittoism from Limbaugh or complaints of her psychosomatic and neurotic tendencies.
  30. Addiction

    Addiction

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    Couple of questions:

    1) Regarding a suboxone practice, is anybody aware if most insurances (private, Medicare, Medicaid, etc.) pay for urine drug screens for substance abuse patients? Currently, most urine drug screens are conducted and billed to insurance by pain physicians. Can these same billing codes be used for substance abuse patients?

    2) Is anybody aware of the very recent change to Medicare billing codes regarding urine drug screens in which you need an enzyme/immunoassay machine to be able to charge per drug class (9 or 10 drug classes per urine screen)? From what I understand, you no longer can use the simple $10 urine drug screening kit and bill per drug class. Using these cheap kits would only allow you to bill one time for all drug classes decreasing the reimbursement by 9 or 10 times.

    3) Finally, do most insurances at this point cover suboxone visits excluding the urine screens (reimbursement for the actual patient visit)?
  31. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    I was not aware of number 2. Lets see what others have to say.
  32. caspian

    caspian

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    What exactly is a pill mill?

    This.

    [YOUTUBE]2L1kxT0DqrU[/YOUTUBE]
  33. uclakid

    uclakid Senior Member

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    How are doctors who run these clinics monitored? How can they be sure that their patients really need the pain meds and are not addicts?
  34. caspian

    caspian

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    It's a battle, as I'm guessing you saw in the video. Some ways states are cracking down by establishing prescription databases, limiting in-house pharmacy prescription privileges, and, as we have seen with pseudoephedrine, frank caps on how many pills one can obtain per given unit of time.

    As for how doctors determine which patients have a genuine need for pain management, I direct you to this:

    http://forums.studentdoctor.net/showthread.php?t=709764
  35. uclakid

    uclakid Senior Member

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    I basically believe that any doctor who opens up a "pill mill" is trying to abuse it.
  36. caspian

    caspian

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    The "doctors" charging cash, making $1mil (+)/year are NOT fellowship trained addiction specialists, nor are they anesthesiologists, nor are they fellowship trained in Pain Medicine.

    The path to opening a mill: Get MD, move to south, sell your soul facilitating the demise of others.

    Frankly, I am very curious as to why the OP, who has yet to enter residency is already asking questions about the steps necessary to open up a practice centered on a single opiate/opiate synthetic after hearing about the "mula" one can make.

    I also find it curious that any subsequent questions from the OP center around practical/legal/financial obstacles that could damper the inflow of said "mula."

    Student loans got you down?
    Last edited: Jun 12, 2010
  37. uclakid

    uclakid Senior Member

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    had no idea that ANY MD could do this.
    well, there are some bad people out there.
    just be wary.
  38. carlosc1dbz

    carlosc1dbz Loves Christina Aldana!

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    Hey I saw the video. That was disgusting, from a professional perspective. When I speak ask about methadone, I am asking in regards to how to help people and make a nice dollar. What I saw in that video, was doctors hurting their communities. That was really sad.
  39. That's CNN, so I'm really hoping it's sensationalized and blown out of proportion...key word is "hoping."
  40. kumar28

    kumar28 Senior Member

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    bump,,,,was wondering if anyone could answer the questions posed by Addiction..thanks
  41. whopper

    whopper Former jolly good fellow

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  42. Ceke2002

    Ceke2002 Patient Zero

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    Where I live (South Australia) so called Pill Mills like this were a lot more under the radar, so to speak, than the ones shown in that video, but essentially they still operated in pretty much the same way. The one I used to frequent as a former addict was pretty much divided into users and dealers. Users could turn up and get a limited amount of whatever pill they fancied (Benzos, mainly), so long as they at least went through the pretense of a 'consultation'. Dealers were trusted patients who paid a few hundred dollars, cash up front, to keep things off the record. They would then sell the pills out on the street (at around $5-10 per pill, depending on what it was), and give a percentage of the profits back to the Doctor. This particular clinic had at least ten full time 'dealers' on the books (as in they were pretty much treated, and referred to almost as employees') at one stage ('full time' as in they were there for scripts at least once a day).

    Basic level users could sometimes get stuff off the record as well, usually a bit extra than what they'd otherwise be prescribed (40 pills of Xanax, as opposed to 20 of Serepax, for example, maybe a couple of vials of Pethidine thrown in for good measure), if they were willing to provide sexual favours. Usually within the first 3-4 visits, once you'd been scoped out, you found out whether the Doctor was willing to pay for services rendered when he locked the door and strongly implied that if you'd just like to hop up on the exam table *nudge nudge wink wink*, there'd be a little something extra in it for you.

    In my experience, just speaking from my own observations as a past client of these sorts of clinics, there tended to be 3 main types of Doctors you came across that were pulling scams like this. Either a: Doctors who just didn't give a rat's, and were basically criminals with medical licenses, b: Doctors who had serious drug habits of their own (I have sat through a 'consultation' with a Doctor on the nod to the point of his head basically being on the desk, with a nice stream of drool coming out of his mouth, whilst a freshly used, uncapped syringe lay in plain site in a wash basin nearby - and of course none of his patients are going to care, or report him, because, hey, we're all addicts too, and this dude keeps us supplied with happy pills), or c: Doctors who have gotten caught up in the image of the hip, and trendy Doctor with a rock star lifestyle (fast cars, fast women, lots of partying).

    Trust me, those 'Pill Mills' are a reality, and for all CNN's apparent beat up and sensationalistic journalism, what they showed in that video is pretty much the way things go down. It's dark, it's degrading, it's ugly, and I am so very, very glad to be out of it.
  43. notdeadyet

    notdeadyet Still in California Moderator

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  44. whopper

    whopper Former jolly good fellow

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    I have a few Suboxone patients, and they told me their direct link was through someone getting their meds through a Florida quack, er, cough cough, pain clinic.

    This Florida phenomenon is not esoteric and hardly-known to drug abusing patients. It's common knowledge in a lot of parts of the country.

    It's highly transparent that the doctors at these pain clinics are for the most part quacks.

    To qoute Scent of a Woman, If I were the man I was 20 years ago, I would take a blow torch to this place!"

    You just cannot give out benzos and opioids liberally. All of these should only be given out after a heck of a lot of scrutiny, and hardly ever given out long-term. This is just another example, IMHO, that state medical boards are too liberal in their regulations of doctors already in practice. When a doctor I know of was actively having sex with patients for decades, and it took a patient working through the courts, not the state medical board, to get his license removed, despite that everyone who worked with this guy knew what he was doing...there's something wrong with that.

    Anyone whoever talks about the data that patients are under-treated for pain needs to factor in this emerging pill mill phenomenon.

    And this is something I never understood. For patients with chronic pain, I find very few doctors using meds that treat this type of pain that are not addictive such as amitriptyline, Cymbalta, gabapentin, Lamictal, etc. Why the heck is that? Why are so many docs so quick to give out Percocet long-term?
  45. OldPsychDoc

    OldPsychDoc Senior Curmudgeon Moderator Emeritus SDN Advisor

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    Because it takes 30 seconds to say "Yes". And 30 minutes to say "No".
  46. ghost dog

    ghost dog

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    This is an excellent question, which I will try to answer.

    In my neck of the woods ( Canada), it is difficult (if not impossible) to
    access certain chronic pain resources such as a psychotherapy. The socialized health care system simply will not pay for this treatment modality for pts who fall under the welfare system (which a lot of pts with chronic pain do, as they are unable to work).

    Physiotherapy is also not covered for this population.

    Failing this, the family MD is left in the unenviable position of throwing
    pills at the problem. And they have 10-15 minutes to perform a comprehensive evaluation in which to attempt to do so.

    Having seen many treatment intractable pain pts over the years, it becomes apparent that a large portion of this population has co-morbid psychiatric pathology (I'm thinking of Fibromyalgia here, as it is a very common pain problem). Opioids likely aren't a great idea, with little if any evidence to support them.

    OldPsychDoc makes a good point, as most people want a " quick fix " when this simply does not exist. A good practioner discusses mindful meditation , gentle aerobic exercise and the principle of hurt versus harm with these patients ( possibly for the first time ). And yes, the usual trial of non-opioid medications are prescribed if they haven't been attempted already.

    I see so many consults where pts are on ridonculous amounts of opioids for no good reason / rationale.

    Of interest, I believe there is some evidence to show that patients with psychiatric disorders are more likely to be prescribed opioids than pts w/o.
    Last edited: Oct 19, 2011
  47. whopper

    whopper Former jolly good fellow

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    I'm pretty much reiterating what I've said before.

    When a doctor is practicing unethically, to the degree where everyone in the local community that's a drug addict knows to go to this guy for the good stuff, all of the guy's local colleagues in his profession believe the guy is a quack, local hospitals and offices are frequently taking in patients due to the poor practice causing iatrogenic problems, and the authority that's supposed to be regulating doctors is the state medical board and they're doing nothing about it, that clearly shows something is wrong.

    I haven't had enough personal dealings with people in medical boards nor served on one to know why this phenomenon is going on to the degree where I can judge them. I certainly have sometimes wondered that medical boards do next to nothing in these regards.

    I will say that IMHO, patients should have more open access to report possible wrong-doing on the part of doctors. And I've said this in the past, and pissed off a lot of other doctors in other threads in the the nonpsychiatric forums. The state medical boards should have doctors pose as patients and check these places out to investigate them. Some doctors have blown up in anger when I brought this up stating that a patient's relationship with a doctor is sacred. Yeah, well doctors, just like priests have abused their powers. Only way to keep this is check, just like any system, is to have checks and balances. There's no reason why a doctor is somehow better than a priest, the g'damned Pope, or the President of the United States in this regard. Besides, in this case, there is no real relationship because the doctor posing as the patient is not really a patient, even if you consider them a patient, a patient is free to report anything they want, and if doctors are doing nothing wrong, they should have nothing to fear so long as the evaluation is competent.
    Last edited: Oct 19, 2011
  48. ghost dog

    ghost dog

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    I believe you're referring to the incompetent and truly malicious docs trying to take advantage of patients. I'm pretty sure (or would hope at least!) that these physicians are a very small minority of doctors.

    What about the other MDs who aren't doing a very good job? I support this type of standardized patient system - 100%.

    I try to review my patient care every day, in attempt to ensure that I provide multi-disciplinary care. But who knows, as we are rarely objective observers of ourselves.
  49. whopper

    whopper Former jolly good fellow

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    They are rare, but from my experience not extremely rare. I've also noticed they tend to fit certain demographics more often than not, but if I state them I could be accused of x-ism, so I won't.

    I hate saying this but this is only in regards to the methadone mill phenomenon. In terms of bad practice that IMHO doesn't meet the standard of care, I'd go as far as to say up to 1/3 to 1/2 of doctors I've seen practice in this manner. I'm not kidding. E.g. I have patients all the time that had previous doctors that put patients on lithium and no lithium lab was ever ordered, or if one was ordered, only one of the three needed. I work as a court expert witness once a week, and weekly after reviewing on average about 8 cases, there's at least one where the doctor is completely screwing up to the point I find offensive.

    E.g. patient with Keppra induced psychosis, the doctor didn't take her off Keppra, kept her on it to treat a seizure disorder (despite that an EEG was negative) and decided to treat the psychosis with Lamictal, and tapered up the dosage to 100 mg within 3 days of giving it.

    Hmm, the person was likely not having a seizure disorder to begin with, the first step should've been to get her off the Keppra, and Lamictal doesn't really treat psychosis (arguably it could help with psychosis secondary to bipolar disorder but she clearly was not that), and the taper up was to a degree where it was violating the manufacturer's guidelines. This patient was lucky she didn't get Stevens Johnson syndrome.

    I had another patient that was manic and had multiple myeloma. The psychiatrist treating her in the unit didn't bother to check if the patient needed treatment for the MM. Turned out she was supposed to be on a cancer medication and this guy never bothered to find out despite that he knew she just had surgery due to the MM.

    In both cases, when I was in the hospital to evaluate, the treating psychiatrist was not present, despite the doctor being on duty hours requiring they be there, when beeped, they did not call back, and when I left my contact information they never called me back.

    The above are just a few examples. I see this stuff literally every single week.

    I've said this before. Medstudents and residents know several of their colleagues would not make good clinical doctors. Yes, most of those people do end up graduating and practicing. These are the people I'm talking about.
    Last edited: Oct 21, 2011
  50. NoNoNoNo

    NoNoNoNo

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    This is a little off topic, but it reminds me of Oxycodone Express (http://www.youtube.com/watch?v=kEA5GBRRSVA ) if anyone hasn't seen that. Of course, that was before stricter regulations in Florida and such, but to see how some doctors practice....damn. Also, the "going undercover" part was what primed the memory for me.

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