Can I refuse to see patients who have a cold?

[birchswing]

Truth. I inherited him. He finally showered once but "didn't get all the layers off". He is on disability. He's married. The only time he leaves his home is every 3 months to see me. He is so physically deconditioned he is gasping for air after a few breaths. I have begged him to see a Pcp. He usually no shows 2 or 3 times before he comes and I charge full fee. He needs medical care more than psych. I can't force him to see a Pcp. I spend hours with him at every visit and this is actually the most progress he has made. Can't add an SGA because he won't get labs. Guessing the sick role is appealing.

Is the deconditioning why he doesn't shower? Or is it depression? I have to use a shower chair for dysautonomic reasons. I'm not sure how my dysautonomic issues would compare to someone else's deconditioning, but showering can be taxing: lifting arms over the head, bending over, etc. He could benefit from a shower chair and just sitting. Water is better than nothing.

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[aim-agm]

I have no problem with a crisis patient coming in when they are sick.

What I have a problem with is the ones that have a fever, are sneezing and coughing up the wire, just for a refill of their Zoloft. We could have done that over the phone and I could have given you a refill without any problem.

Perhaps the front office can screen the obviously sick out. That is, if someone checks in and is sick they tell the patient to call you to refill the prescription to avoid exposing the staff and other patients.

 

[FFH]

Sounds like you hate being sick, which is totally reasonable. It also sounds like you are handling a lot of responsibilities right now: care for yourself, for your child, and for your patients. "Can't afford to be sick" is an awful situation to be in.
I might be wrong but I think fundamentally you resent the situation not the patients themselves and that the reason you are talking about your situation is because you can't put a stop to the irrational thought process that let you blame the patient instead of the culture and system that does not let people recoup and recover when they need to. Our country really need to have better maternity leave policies and provide better support for parents so that they could care for the next generations properly.
Kinda unrelated but it has been thought that childhood exposures to allergens and pathogens are good for the maturation of the immune system.

 

[NITRAS]

I got sick from my children being in daycare way more than I got sick from being at the hospital.

Good news is that there isn't much flu going on right now, but I have had several cases of RSV, and one norovirus.

I had the benefit of my wife being able to take off on short notice to take care of the chillins when they got sent home. I might suggest you arrange backup childcare in advance. Your child is going to get sick, and it will reduce the stress at the time it happens.

 

[futuredo32]

Is the deconditioning why he doesn't shower? Or is it depression? I have to use a shower chair for dysautonomic reasons. I'm not sure how my dysautonomic issues would compare to someone else's deconditioning, but showering can be taxing: lifting arms over the head, bending over, etc. He could benefit from a shower chair and just sitting. Water is better than nothing.

Based on his weight I would be astonished if he didn't have medical issues. He was at one time very depressed. I think his mood is improved. He came to me on a ton of psychostimulants provigil and benzos which I have been tapering off.

 

[futuredo32]

You realize giving him hours and hours at every visit is directly reinforcing that sick role, right?

Actually it has helped. He finally taken a shower. I spend a good hour on med management and another hour on therapy and psychoeducation. He is coming closer to getting a sleep study and seeing a PCP. I get reimbursed for only 45 min therapy and med management.

 

[cara susanna]

As someone who strongly dislikes our society's obsession with working despite being ill, I always offer patients the opportunity to reschedule their appointment or end early if they aren't feeling well. It's not only that I'm worried about my own exposure, but also that it can be really hard to focus when you aren't feeling well so the session may be wasted anyway. A lot of times they'll say "no, I'm already here," in which case I see them and use clorox wipes afterwards. But I always tell them: in the future, you can just cancel if you aren't feeling well. I don't want people to feel the same pressure that they get from the rest of society with our appointments and I want to promote self care. Maybe staying at home and getting some rest will be more helpful to them that particular week than going through thought records with me.

Of course, I do therapy which has more frequent visits so it's not like I won't see them for another few months. And, of course, I'm not a physician so it's not like I have this expectation of the sentiment above that, yes, doctors see sick people.

 

[clausewitz2]

Actually it has helped. He finally taken a shower. I spend a good hour on med management and another hour on therapy and psychoeducation. He is coming closer to getting a sleep study and seeing a PCP. I get reimbursed for only 45 min therapy and med management.

Okay. So he has improved. In what sense is he invested in the sick role?

I am not an analytic type but there is something to insisting on being paid for your time that helps maintain the frame of the relationship.

 

[futuredo32]

Okay. So he has improved. In what sense is he invested in the sick role?

I am not an analytic type but there is something to insisting on being paid for your time that helps maintain the frame of the relationship.

You can't bill for over an hour. I would if I could.

The guy gets a hefty disability check his wife does everything for him and accepts that he "can't wake up" for a freaking appointment even though the no show fee is 175. He's more like a VERY helpless child to his wife than a husband. He has,zero responsibility. He reads and watches tv and likes that. But when he needs his disability forms filled out or he's running low on his psychostimulants or benzodiazepines that I have been weaning him off of he has no problem making it to those appointments . He has,a long standing diagnosis of ADHD and I gently asked him what,he needed the ADHD meds for and he said to watch tv and read. He has zero reason to get better and every reason to stay "sick."

 

[clausewitz2]

You can't bill for over an hour. I would if I could.

The guy gets a hefty disability check his wife does everything for him and accepts that he "can't wake up" for a freaking appointment even though the no show fee is 175. He's more like a VERY helpless child to his wife than a husband. He has,zero responsibility. He reads and watches tv and likes that. But when he needs his disability forms filled out or he's running low on his psychostimulants or benzodiazepines that I have been weaning him off of he has no problem making it to those appointments . He has,a long standing diagnosis of ADHD and I gently asked him what,he needed the ADHD meds for and he said to watch tv and read. He has zero reason to get better and every reason to stay "sick."

Right. So this is what I mean by saying you are reinforcing the sick role by seeing him for hours that are totally unpaid. Not only does he not happy accept the responsibility of fulfilling the payment agreement he consented to, but he gets to be extra special because a doctor makes a bunch of exceptions and special provisions for him for free.

I think this is a place where it might be helpful for you to try and enforce a boundary, like "our appointment is over now, I will see you in (whatever number of months)." You are not going to escape this kind of guy in primary care and it is going to be even more lethal to your practice if you are trying to run a model based on 15 minute appointments.

 

[futuredo32]

Right. So this is what I mean by saying you are reinforcing the sick role by seeing him for hours that are totally unpaid. Not only does he not happy accept the responsibility of fulfilling the payment agreement he consented to, but he gets to be extra special because a doctor makes a bunch of exceptions and special provisions for him for free.

I think this is a place where it might be helpful for you to try and enforce a boundary, like "our appointment is over now, I will see you in (whatever number of months)." You are not going to escape this kind of guy in primary care and it is going to be even more lethal to your practice if you are trying to run a model based on 15 minute appointments.

I do more therapy/med than 15 min med in my own practice. He needs therapy and won't go elsewhere. It take 45 min to explain the med changes to him and his wife who waits outside wants a run down of the changes. I am providing minimal therapy ie once every 3 months gratis but I think it is having a small impact. He finally showered and is considering seeing a,medical Dr. He has no clue he's getting free therapy. Totally clueless . IMO I am helping in a small way by doing so. I don't pay cash for my therapy visits and maxed out my copay in MAY. I am only paying for insurance honestly I differ in the view that patients get more out of therapy if they pay for it. I'm truly concerned about his physical health and he's more open to seeing a Pcp as time goes on . And he pays 350 to 525 in no show fees which are really just a late cancellation and he's always my last appointment so I'm profiting. I get to go home early and still get paid.

 

[clausewitz2]

I do more therapy/med than 15 min med in my own practice. He needs therapy and won't go elsewhere. It take 45 min to explain the med changes to him and his wife who waits outside wants a run down of the changes. I am providing minimal therapy ie once every 3 months gratis but I think it is having a small impact. He finally showered and is considering seeing a,medical Dr. He has no clue he's getting free therapy. Totally clueless . IMO I am helping in a small way by doing so. I don't pay cash for my therapy visits and maxed out my copay in MAY. I am only paying for insurance honestly I differ in the view that patients get more out of therapy if they pay for it. I'm truly concerned about his physical health and he's more open to seeing a Pcp as time goes on . And he pays 350 to 525 in no show fees which are really just a late cancellation and he's always my last appointment so I'm profiting. I get to go home early and still get paid.

I'll admit I don't understand what is going on. You say you feel he is stuck in the sick role and it is impeding his progress. But also you are spending hours and hours of unreimbursed time with him. But then you're not actually, just taking 45 minutes to explain a med change? And also are doing therapy without him knowing about it? And in some way you feel you have to never challenge him in any way because your therapist hasn't chargedyou in months? It seems like the details or your take on it shift everytime a concern is noted.

Is this what William James meant when he was talking about a "buzzing, booming confusion?" If there are any colleagues/peers who can do some informal consultation/supervision it might be a good idea here.

 

[futuredo32]

I've gotten formal supervision for him from someone spectacular, but thanks. I DO explain the med changes , he came to me on two doses of concerta Adderall and Provigil, Ambien, Klonopin, and Xanax and one antidepressant he is VERY resistant to the changes. He knows it's supportive therapy not that I cant bill for it. My insurance pays my therapist. He is charging my insurance. I maxed out my copay thanks to two surgeries. I am not being unbilled by my therapist, I just maxed my copays and big.

I have no desire to do the 15 min model in FP. I would prefer to be happy, not rich.

 

[clausewitz2]

I've gotten formal supervision for him from someone spectacular, but thanks. I DO explain the med changes , he came to me on two doses of concerta Adderall and Provigil, Ambien, Klonopin, and Xanax and one antidepressant he is VERY resistant to the changes. He knows it's supportive therapy not that I cant bill for it. My insurance pays my therapist. He is charging my insurance. I maxed out my copay thanks to two surgeries. I am not being unbilled by my therapist, I just maxed my copays and big.

I have no desire to do the 15 min model in FP. I would prefer to be happy, not rich.

I really hope the supervision is not coming from your analyst, although the way you are describing this person makes me think it is. It's interesting that you initially mentioned you are concerned about issues of the sick role but don't seem to want to consider you may play a part in that, so I will cut out the feedback.

 

[futuredo32]

I really hope the supervision is not coming from your analyst, although the way you are describing this person makes me think it is. It's interesting that you initially mentioned you are concerned about issues of the sick role but don't seem to want to consider you may play a part in that, so I will cut out the feedback.

Thanks .and it came from an analyst but not mine. I'm obviously not going into great detail here but when I feel the need for supervision o have a superstar to go to.

 

[SmallBird]

Thanks .and it came from an analyst but not mine. I'm obviously not going into great detail here but when I feel the need for supervision o have a superstar to go to.

I sometimes wonder if you are trolling us by describing and then defending what sounds like a poor style of practice around a whole range of common challenges.

 

[WisNeuro]

These little tidbits would be great to include in ethics discussions with residents.

 

[Merely]

I sometimes wonder if you are trolling us by describing and then defending what sounds like a poor style of practice around a whole range of common challenges.

Lol that’s mean...a Doctor is entitled to practice how she feels fit I guess

 

[Amygdarya]

a Doctor is entitled to practice how she feels fit I guess

Oh no, there are legal and ethical, not to mention conventional, limitations to how one should practice, and there are good reasons for these limitations.

 

[futuredo32]

I sometimes wonder if you are trolling us by describing and then defending what sounds like a poor style of practice around a whole range of common challenges.

Lol. May sound bad to you but not my supervisor. Nope I'm a shrink. A few here know my true name. Kinda guessing they would have busted me and if I had time to "troll" I wouldn't pick this forum. I'm hoping for a miracle next year and applying to FP next cycle. Oh I so wish I weren't in psychiatry but I am and I sure wouldn't waste my time here if I weren't so please stop semi accusing me of trolling.
So back to the OPs post.........

 

[birchswing]

Lol. May sound bad to you but not my supervisor. Nope I'm a shrink. A few here know my true name. Kinda guessing they would have busted me and if I had time to "troll" I wouldn't pick this forum. I'm hoping for a miracle next year and applying to FP next cycle. Oh I so wish I weren't in psychiatry but I am and I sure wouldn't waste my time here if I weren't so please stop semi accusing me of trolling.
So back to the OPs post.........

You strike me as very conscientious, which is a quality I would like in a provider.

You don't strike me as a troll, and I would probably know . . . (I was the dancing psychiatrist)

I saw a psychiatrist once, and I'm pretty sure nobody would believe me if I described their practice. I may have described it once. But in town, therapists and the community services board consider it a cult. And it's run by a board-certified psychiatrist. I was in it for 6 weeks. It started off great: Move to a new town, call the closest psychiatrist, psychiatrist picks up his own phone, wants you to come in within days to take a tour of the building. Then he describes the process, and you make a joke, "Ha! Sounds like a cult." You go back in and slowly find out it is. He takes insurance for the first visit only. After that you have to be in one of his several groups. Medications are prescribed and changed in group in front of everyone. For the first two weeks, you're not allowed to talk. Every session at the end he goes around the room and asks if you trust him. You're only allowed to say yes or no. If you say no, you have to leave and can never come back. He is adamantly against all holidays and celebrating them. Has a myriad of bizarre social and political positions that he goes on about at length. It's mostly him talking. It's like AM radio whacko stuff. One woman had been going to him for 27 years. He would get people to bring their family members into the groups or have them disconnect from them if they didn't and seemed not "healthy." He would switch people from group to group seemingly randomly. I think he had maybe 3 groups. He said that the great paradox of life was that complete independence requires complete dependence (on him). He said that there were no "healthy" psychiatrists but him. People would talk about leaving and he would predict doom for them if they did. One woman started to leave in a session and they had a long drawn out debate and she eventually sat back down. You had to bring cash to each appt because he charged infractions (in my case if I made a ticcing sound, one time when I spilled a bottle of water). He said most gay people were gay for the attention. He made me throw away a hat I wore in session because he said it made me look like an old Jewish man. I got it out of the garbage as I was leaving and I was reported to him by one of the other members. He made me throw it away again. When I got home I finally had it and realized how crazy it all was and I called and said I was going to file a police report for stolen property if he didn't give me the hat back. He told me I was throwing my life away and I would never be healthy without him. You were not allowed to talk to any other group members ever outside the group. He stood in the parking lot watching people get into their cars, presumably to see if they did.

A few things on why cults/gangs work: He knew my name. He took a very active interest in me. He answered his phone immediately and was immediately available. Some of the criticisms he had of other psychiatrists were valid. And the few times other people in the group got to talk, I actually liked the sense of community.

Anyhow, all that is to say I believe a person such as @futuredo32 can be real because I have seen things that would stretch credibility in the realm of fiction. Edit: I realized this sounded like I was saying if someone can be that bad, I can believe someone "less bad" like futuredo32 exists, which is not what I meant. I meant more that I could believe about anything—I mean there's a plastic surgeon in Miami who live broadcasts the boob jobs he does. So was basically saying nothing much surprises me. I have no particular inclinations as to how any of you practice because frankly I forget who is who most of the time. I remember the stories but lose the association with the user name. But in the case of seeing the patient with extra time outside "the frame" I have no strong feelings.

Back to the original topic, my sister and her husband are coming today for Christmas and they both have colds and suddenly my sympathies have changed dramatically. I've put out bottles of hand sanitizer and I'm going to wear a mask. Merry Christmas!

 

[clausewitz2]

Lol. May sound bad to you but not my supervisor. Nope I'm a shrink. A few here know my true name. Kinda guessing they would have busted me and if I had time to "troll" I wouldn't pick this forum. I'm hoping for a miracle next year and applying to FP next cycle. Oh I so wish I weren't in psychiatry but I am and I sure wouldn't waste my time here if I weren't so please stop semi accusing me of trolling.
So back to the OPs post.........

For someone who hangs out with analysts a lot you seem surprisingly clueless about the dynamics of how you practice.

 

[Merely]

For someone who hangs out with analysts a lot you seem surprisingly clueless about the dynamics of how you practice.

What do you mean by this? What exactly is the problem with how she’s practicing? Aren’t docs entitled to practice the way consistent with their experience and the needs of their patients?

 

[futuredo32]

For someone who hangs out with analysts a lot you seem surprisingly clueless about the dynamics of how you practice.

Are you trying to be rude? When I joined as a premed psych was the group where rudeness wasn't tolerated. Moderators have changed and so has what is allowed to be posted. I try not to be rude here and in my personal life. I have some questions and I post them. In order to avoid reading your comments and any other rude comments I am going to use the ignore function for you. I'm saying this so you don't waste time replying to any of my comments or posts. I put up with rude attendings in residency . I'm sorry you feel so bad about some aspect of yourself you find it somehow appealing or gratifying to be rude to others. I truly hope you are kinder to your patients.

 

[futuredo32]

You strike me as very conscientious, which is a quality I would like in a provider.

You don't strike me as a troll, and I would probably know . . . (I was the dancing psychiatrist)

I saw a psychiatrist once, and I'm pretty sure nobody would believe me if I described their practice. I may have described it once. But in town, therapists and the community services board consider it a cult. And it's run by a board-certified psychiatrist. I was in it for 6 weeks. It started off great: Move to a new town, call the closest psychiatrist, psychiatrist picks up his own phone, wants you to come in within days to take a tour of the building. Then he describes the process, and you make a joke, "Ha! Sounds like a cult." You go back in and slowly find out it is. He takes insurance for the first visit only. After that you have to be in one of his several groups. Medications are prescribed and changed in group in front of everyone. For the first two weeks, you're not allowed to talk. Every session at the end he goes around the room and asks if you trust him. You're only allowed to say yes or no. If you say no, you have to leave and can never come back. He is adamantly against all holidays and celebrating them. Has a myriad of bizarre social and political positions that he goes on about at length. It's mostly him talking. It's like AM radio whacko stuff. One woman had been going to him for 27 years. He would get people to bring their family members into the groups or have them disconnect from them if they didn't and seemed not "healthy." He would switch people from group to group seemingly randomly. I think he had maybe 3 groups. He said that the great paradox of life was that complete independence requires complete dependence (on him). He said that there were no "healthy" psychiatrists but him. People would talk about leaving and he would predict doom for them if they did. One woman started to leave in a session and they had a long drawn out debate and she eventually sat back down. You had to bring cash to each appt because he charged infractions (in my case if I made a ticcing sound, one time when I spilled a bottle of water). He said most gay people were gay for the attention. He made me throw away a hat I wore in session because he said it made me look like an old Jewish man. I got it out of the garbage as I was leaving and I was reported to him by one of the other members. He made me throw it away again. When I got home I finally had it and realized how crazy it all was and I called and said I was going to file a police report for stolen property if he didn't give me the hat back. He told me I was throwing my life away and I would never be healthy without him. You were not allowed to talk to any other group members ever outside the group. He stood in the parking lot watching people get into their cars, presumably to see if they did.

A few things on why cults/gangs work: He knew my name. He took a very active interest in me. He answered his phone immediately and was immediately available. Some of the criticisms he had of other psychiatrists were valid. And the few times other people in the group got to talk, I actually liked the sense of community.

Anyhow, all that is to say I believe a person such as @futuredo32 can be real because I have seen things that would stretch credibility in the realm of fiction. Edit: I realized this sounded like I was saying if someone can be that bad, I can believe someone "less bad" like futuredo32 exists, which is not what I meant. I meant more that I could believe about anything—I mean there's a plastic surgeon in Miami who live broadcasts the boob jobs he does. So was basically saying nothing much surprises me. I have no particular inclinations as to how any of you practice because frankly I forget who is who most of the time. I remember the stories but lose the association with the user name. But in the case of seeing the patient with extra time outside "the frame" I have no strong feelings.

Back to the original topic, my sister and her husband are coming today for Christmas and they both have colds and suddenly my sympathies have changed dramatically. I've put out bottles of hand sanitizer and I'm going to wear a mask. Merry Christmas!

So I'm real and conscientious but less bad? Um. .. ok lol.

 

[ryerica22]

I'll admit I don't understand what is going on. You say you feel he is stuck in the sick role and it is impeding his progress. But also you are spending hours and hours of unreimbursed time with him. But then you're not actually, just taking 45 minutes to explain a med change? And also are doing therapy without him knowing about it? And in some way you feel you have to never challenge him in any way because your therapist hasn't chargedyou in months? It seems like the details or your take on it shift everytime a concern is noted.

Is this what William James meant when he was talking about a "buzzing, booming confusion?" If there are any colleagues/peers who can do some informal consultation/supervision it might be a good idea here.

I feel sorry for this man's wife he hasn't showered in 6 years. That has gotta be grounds for divorce.

More to the point, have you suggested that he try going for a swim if bathing is too overwhelming? This is a serious hygiene issue. He can get cellulitis from not showering.

 

[Old&InTheWay]

More to the point, have you suggested that he try going for a swim if bathing is too overwhelming?

But hopefully not in a pool.

 

[clausewitz2]

I feel sorry for this man's wife he hasn't showered in 6 years. That has gotta be grounds for divorce.

More to the point, have you suggested that he try going for a swim if bathing is too overwhelming? This is a serious hygiene issue. He can get cellulitis from not showering.

I am guessing you meant to reply to @futuredo32

 

[clausewitz2]

What do you mean by this? What exactly is the problem with how she’s practicing? Aren’t docs entitled to practice the way consistent with their experience and the needs of their patients?

She talks about a patient who she worries is invested in the sick role. Then she details the almost perfect way she is acting to sustain and encourage that sick role. It is frustrating when someone who clearly cares and who is sort of aware something is not right just refuses to listen to anyone. I have no doubt she can do better.

 

[birchswing]

So I'm real and conscientious but less bad? Um. .. ok lol.

There was an edit I made to the post.

It wasn't meant to say less bad.

It was meant to say that the world is stranger than fiction so I'm not sure why someone would jump to the conclusion you're not real.

Honestly, unless I were to scroll back up all I can remember from what you wrote is that you spend more time with an unshowered man than other people think you should. That is the entirety of my recall. My opinions on that are as strong as my opinions on the cost of tea in China. I mean I guess it's nice; it's just not something I relate to, so I don't have an opinion. So it wasn't a value judgment; it was a judgment on the plausibility.

 

[futuredo32]

There was an edit I made to the post.

It wasn't meant to say less bad.

It was meant to say that the world is stranger than fiction so I'm not sure why someone would jump to the conclusion you're not real.

Honestly, unless I were to scroll back up all I can remember from what you wrote is that you spend more time with an unshowered man than other people think you should. That is the entirety of my recall. My opinions on that are as strong as my opinions on the cost of tea in China. I mean I guess it's nice; it's just not something I relate to, so I don't have an opinion. So it wasn't a value judgment; it was a judgment on the plausibility.

Ok. I have seen many patients without insurance gratis. I should worry about money more than I do. He was inherited on provigil 2 doses of concerts Adderall Klonopin Xanax Ambien and Trintellix . I'm weaning slowly and won't REFILL unless he comes. He schedules a few weeks in advance and cancels same day because his wife can't wake him up. I always make him the last patient of the day and his wife calls to cancel so I feel kinda bad charging 175 repeatedly . The Ambien was nixed immediately .If an extra hour 4x a year gets him to shower maybe see a PCP it's worth it to me. Baby steps. I'm really concerned about his physical health.

 

[ryerica22]

But hopefully not in a pool.

Not in a public pool.

I seriously wonder how the poor wife is coping.

Also, doesn't he need to be on a neuroleptic, what's his diagnosis, futuredo?

 

[futuredo32]

I feel sorry for this man's wife he hasn't showered in 6 years. That has gotta be grounds for divorce.

More to the point, have you suggested that he try going for a swim if bathing is too overwhelming? This is a serious hygiene issue. He can get cellulitis from not showering.

I'm guessing she stays for the money. He had,a,great paying job and now,a big pension . I did try working with her but something was off. If I had to bet as crappy as it sounds she has a boyfriend . He can hardly walk a few feet he'd drown if he swam and no pool would take him a lake may have bacteria. I'm worried about OSA DM his heart lungs bp

 

[futuredo32]

He's on one dose of concerts lower doses of Adderall provigil and lower doses of Klonopin and Xanax .He takes Trintellix. I can't put him on a SGA or lithium he won't get labs. I'd be really surprised if he doesn't have apnea. One reason I'm weaning the benzos. I'm afraid to divulge a lot more on a public forum. I'm not disclosing his name but ...... I don't know how to help him other than what I'm doing. I've gotten suggestions to dump him but I don't feel that's appropriate. I asked in another thread about cytomel .

 

[birchswing]

Can you as a psychiatrist prescribe an at home sleep test? They seem common enough I would think you could.

You also might want to consider that people may enjoy living and dying a certain way. I'm not sure if the diagnosis is depression, in which case that may not be true. Barring depression, maybe he's content. I mean what do people go on cruise ships for. To be drugged and lie around in their own filth.

The apnea thing, though. That could be something. I've heard people have complete turn-arounds and get a pep-in-their step after getting treatment. And the apnea overnight can relate to obesity hypoventilation syndrome affecting him in the daytime as well.

 

[futuredo32]

Can you as a psychiatrist prescribe an at home sleep test? They seem common enough I would think you could.

You also might want to consider that people may enjoy living and dying a certain way. I'm not sure if the diagnosis is depression, in which case that may not be true. Barring depression, maybe he's content. I mean what do people go on cruise ships for. To be drugged and lie around in their own filth.

The apnea thing, though. That could be something. I've heard people have complete turn-arounds and get a pep-in-their step after getting treatment. And the apnea overnight can relate to obesity hypoventilation syndrome affecting him in the daytime as well.

According to both him and his wife that needs to come from a PCP his medical insurance is Blue Cross but paid for by his malpractice . At least in Michigan there are tons of Blue Cross and some for reasons I don't know I'm not paneled for. I always tell new patients to call their insurance companies and verify first. If they don't and I don't fall in their insurance they get billed full fee. But he won't go to a PCP . I've ordered labs he won't get them. I can only do so much

 

[futuredo32]

Can you as a psychiatrist prescribe an at home sleep test? They seem common enough I would think you could.

You also might want to consider that people may enjoy living and dying a certain way. I'm not sure if the diagnosis is depression, in which case that may not be true. Barring depression, maybe he's content. I mean what do people go on cruise ships for. To be drugged and lie around in their own filth.

The apnea thing, though. That could be something. I've heard people have complete turn-arounds and get a pep-in-their step after getting treatment. And the apnea overnight can relate to obesity hypoventilation syndrome affecting him in the daytime as well.

He was hospitalized years ago and required ECT. I think at that time he was severely depressed. But now I think he's comfy with the sick role.

 

[ryerica22]

He was hospitalized years ago and required ECT. I think at that time he was severely depressed. But now I think he's comfy with the sick role.

He was hospitalized and they didn't even give him a sponge bath? your original post mentioned no shower for 6 years.

 

[ryerica22]

He's on one dose of concerts lower doses of Adderall provigil and lower doses of Klonopin and Xanax .He takes Trintellix. I can't put him on a SGA or lithium he won't get labs. I'd be really surprised if he doesn't have apnea. One reason I'm weaning the benzos. I'm afraid to divulge a lot more on a public forum. I'm not disclosing his name but ...... I don't know how to help him other than what I'm doing. I've gotten suggestions to dump him but I don't feel that's appropriate. I asked in another thread about cytomel .

At this point, you need to weigh the risks vs the benefits. I feel like adding a SGA like Latuda may be helpful regardless of labs. Maybe paranoia surrounding labs will get better.

This sounds like a horrible situation. I feel like contacting adult protective services may be warranted.

 

[futuredo32]

At this point, you need to weigh the risks vs the benefits. I feel like adding a SGA like Latuda may be helpful regardless of labs. Maybe paranoia surrounding labs will get better.

This sounds like a horrible situation. I feel like contacting adult protective services may be warranted.

I considered it. Body habits of someone with heart disease diabetes an he makes the crying sound but nada comes out. I worry about the stimulants and benzodiazepines wrt his health I'm using that as honest raionale. He can walk such a small distance without gasping for air. Heart? Lung? Other? His wife enables him like crazy. I'm waiting til I go low enough on the benzodiazepines and stimulants til he says adios.

 

[futuredo32]

He was hospitalized and they didn't even give him a sponge bath? your original post mentioned no shower for 6 years.

This was well over 10 years ago. He does spomhebath for appointments but he reeks

 

[futuredo32]

At this point, you need to weigh the risks vs the benefits. I feel like adding a SGA like Latuda may be helpful regardless of labs. Maybe paranoia surrounding labs will get better.
He passes capacity he isn't a child or senior and not being abused.
This sounds like a horrible situation. I feel like contacting adult protective services may be warranted.

 

[futuredo32]

He's not paranoid about labs. Rather "too tired" to see another Dr. But he finds his pep for his disability forms . I Wrote the weakest comments possible .I think he was severely depressed but better now. Maybe a desk job due to his physical health .

 

[WisNeuro]

One does not need to be a child or senior to be a vulnerable person. One can exhibit significant enough signs of self-neglect secondary to a variety of factors to qualify as a vulnerable adult. Also, you clearly intimated that the wife enables this behavior and "stays for the money" which can be construed as financial abuse depending on circumstances. We'd need a lot more details to make the call, but from what you say, I'm not sure that this person doesn't meet criteria as a vulnerable adult.

 

[birchswing]

I find this interesting as a patient to see the care taken in considering a neuroleptic. I was put on one for specious reasons (tourette's tics/OCD) at a very questionable dose (50 mg), and I was never told of any side effects. It was many years later I asked for a fasting blood glucose, and I was called a spaz for wanting it. But it was pre-diabetic. I actually have full blown metabolic syndrome now, though (central obesity, very low testosterone (88), low HDL, high fasting insulin, pre-diabetes). How much is from the Seroquel is hard to say. I took Paxil before any neuroleptics and it caused about 20 lbs weight gain, but I was young (14 or 15) and was still normal weight. Then Zyprexa around age 19 which made me get stretch marks and probably another 50 lbs. Then was switched to the Seroquel. It was never rational prescribing, because the dose of Zyprexa was huge relative to the dose of Seroquel. It's often given at these small doses to help people sleep, but I took it at night because I could not stay awake in the day with it. And so now it's sort of been grandfathered in and I take it to help regulate my sleep cycle because I got used to it doing that. And honestly it does make me feel better, or at the least going off it makes me feel worse. I've tried going without it and while my physical health improves (appetite decreases to normal) my mental health deteriorates. I know at that dose it's primarily or nearly exclusively acting as an anti-histamine, so I can't explain why it helps mentally, except perhaps due to its effect of decreasing the clearance of Ativan by about 20%. When I'm feeling better I titrate down to 25 mg Seroquel and go up if needed. I know that probably sounds more neurotic than a realistic non-placebo outcome, but it's real for me. Anyhow, that was a long digression to say I've never seen such care/concern about whether to prescribe an SGA or not. I was once in the ER very anxious (not the reason I went to the ER but the way I get pretty much just leaving the house let alone being in an ER) and the ER doctor wanted me to start taking Abilify. I said, "What about the Seroquel I'm already on, aren't they sort of the same thing?" And he said he didn't know, but he thought Abilify would calm me down. I think at least some doctors see these drugs as fairly benign. (That one in particular also said I should be on 12 mg Ativan due to my weight which while heavy is at its peak 250 lbs . . . ) I personally have never in about 16 years being on neuroleptics had a single lab requested of me. I've never had an EKG for QTc requested. I've gotten them myself of my own volition. But not once has anyone ever said oh you should have your glucose or lipids checked. Hard to know how much is from the drugs though because my dad has metabolic syndrome numbers, though not as bad as mine, and is sans meds.