Answering pt calls

[PMR 4 MSK]

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My MOA got a message from the operator on Tuesday this week from a PITA pt (chronically unhappy, recent LE Fx with foot drop due to taking out the peroneal nerve. 60 ish, big guy,morbidly obese, 6', lifetime maintenance worker, now with neuropathic pain. His PCP has been feeding him about 20 - 24 mg Dilaudid/day, I started him on gabapentin after EMG showed near complete peoneal denervation at the knee. Pain is dysesthetic, not allodynic, not looking like CRPS, just neuropathic. He lives over an hour away in the middle of nowhere. I haven't touched the opioids. He even admitted to taking his wife's Kadian a couple times.

MOA calls him, he wants to talk to the doctor (me), I'm gone for the day. Refuses to tell her what it's about. I call him yesterday and he proceeds to bust my balls about giving him "the runaround" and not answering my own calls. Now my MOA had told him our clinic's policy is the nurses and MOA's handle all the calls. "That's not my policy!" he barked at me. "When I call to talk to the doctor, dammit, I want to talk to the doctor!"

At that point I just asked what he wanted. He wanted pain relief. I told him to double the gabapentin and to give it a week. He tells me if I don't care enough to answer my own phone calls then he might need to find himself a new doctor. It was awfully hard not to enourage that.

To me, the operator and MOA are my firewall so that I can see patients and answer phone questions later, and let the staff talk to the patient. If they want to talk directly to me, they make an appt.

How do you guys handle patients who want such personalized attention? This is the kind of guy who'll go off bad mouthing anyone who doesn't give him what he wants. I try not to fire pt's just for being PITA's.

 

[Aether2000]

Some patients demand: 1. free care- the availability of their physician round the clock for non-emergent pain control and encouraged by EMR vendor "patient portals" are methods by which substance abusers can demand instantaneous access and increases in their narcotic load
2. unrealistic expectations: doctor on demand may work for the ED but should never be encouraged by chronic pain treating physicians. We have a policy that non-emergent calls are met with emergency action: the patient must go the ED and be evaluated now for new acute pain or otherwise the patient is simply dischaged for violating the clinic policies precluding non-emergent calls at night. The time at night belongs to you, not to your patients and either they comply or kick their asses to the curb. This hostile substance abusing patient would be told to hit the road in my practice.

 

[Doctodd]

you are more tolerant than i am especially if this is his usual pattern. In contrast to your usually polite patient who has a bad day, this guy really needs some "direction". You could always tell him that what he did was a felony in taking his wife's meds. Or you can order 2 more EMG's.....im still wondering why you needed one, but for him id order one a week.

T

 

[tchoupdoc]

I would tell him to find another doctor who doesn't frustrate him. "The limitations of my practice prevent me from returning patient calls personally." As for firing people just for being PITA, I have learned that I have to do it sometimes. What happened? I discovered that the moment I walked in the hospital, I felt these antlers pounding over my temporalis muscles. Checked my bp on a dynamap and it was 189/122. And I'm a young guy.

Not exactly analogous, but I had a recent patient that requested I come back in the room after the visit was over, to ask me why I was angry at her? I had to understand that her back really did hurt, and it took 1 year (!!!!) off on disability from a private carrier the last time it happened, so of course it would again.

My unplanned response: "Ma'am, I'm not angry at you. I got in town yesterday from a four day medical conference, where I sat in a dark lecture hall all day. I have forty patients to see today. If I seem angry, it's because I don't want to be at work right now. But I will do it, because treating patients is my job."

She immediately became sympathetic.

 

[Tenesma]

All clinical questions go to the RN - if there is no quick easy reply, the patient has two options
1) go to the ER if there is a question of neurologic change
2) schedule an early f/u with me

the problem with phone conversations is that you expose yourself potentially to liability (because as physicians we are fundamentally bad at documenting phone conversations - and also because you are making decisions without evaluating the patient) and you are not even getting reimbursed for your trouble...

One pain practice I know of does the following with spectacular results:

"Phone conversations with the doctor are billed at $50 in 15 minute increments with a 15 minute minimum - and $50 has to be paid by credit card first before the doctor even gets on the line"

When patients flip out - the secretary points out that the patient's insurance contract does not cover phone calls...

typically the patients will just schedule a follow-up...

 

[Mister Mxyzptlk]

I am pretty much in line with the above. If I am not getting paid to talk to a patient then I don't unless it's something serious like a post-procedure patient with a neurological complaint, etc. Otherwise you come in for a visit and pay for my advice.

I have a clause in my CSA that says they will not be rude or abusive to the staff. Sometimes I just send them a letter telling them they have violated the agreement and they are discharged. Other times I will tell them that sometimes a particular doctor and particular patient don't mix, and advise them to find someone more to their liking. A third approach is the "you made me do this" method. You tell the patient that because of their behavior you feel that your clinical judgment would be affected and you must withdraw from their care for ethical reasons.

I would have told this particular guy to take a hike. You don't need the abuse but more importantly you don't need disruptive patients. Just one of those can poison the whole day.

 

[Tenesma]

don't worry about offending referring physicians --- odds are that if the patient is a jerk with you he is jerk with all of his doctors...

whenever i terminate the relationship I always cc: the referring doctor AND the primary doctor...

 

[Mister Mxyzptlk]

I have toyed with the idea of a 900 number direct to me, but I don't know how much I would have to charge to not mind getting calls at all hours. Maybe a sliding scale. After midnight $100 for the first 5 minutes, etc. I would also do their horoscope. Phone sex would be extra. 😀

 

[mille125]

A reasonable patient realizes that if you stopped to answer every phone call that came in the the office that is all that you would do. A reasonable patient would leave a message with my office staff. There have been times when I decided that I personally needed to return a call to the patient. If it is a true concern, the patient will not mind leaving a message. If it concerns a lost prescription or some other BS, then they will usually want to talk to you. I would politely discharge this patient. You must remember that you have very little to gain by keeping noncompliant, drug seeker, or otherwise malevolent patients in your practice. Take the advice of all of us and fire him.

 

[SSdoc33]

....Or you can order 2 more EMG's.....im still wondering why you needed one, but for him id order one a week.

T

EMG is necessary to:

1. objectively establish evidence of nerve damage.
2. delineate which branches of peroneal nerve are affected, and how severely they are affected.
3. form a basis for prognosis of nerve recovery