Chronic pain....

[BatmanMD]

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Just finished residency and jumped two feet into the fire... so to speak

While its new and fun, now my name is on the bottom line and administrators can come to me with complaints.

Seen a lot of chronic pain pts lately. Mostly sent them out with nothing, some got ~ 5-10 vicodin, but thats it. See your doctor or pain specialist..

Had a guy the other day. Said "My pain specialist sent me in for an MRI and a pain shot". Told him that when doctors send people to the ED, they usually call and let us know someone is coming, bla bla bla...

So I continued to talk to him and explain why he cannot get his MRI and pain shot, and to call him doctor back. He got angry. JUMPED out of bed and stormed out.

Next his son-in-law wants to speak to me. We sit down, he writes my name down, and we chat. The son-in-law is upset b/c I was rude and judgemental toward his father in law. He wasnt even in the room... Told him the same things I told the pt, and he kept focusing on if I was judgmental or bothered b/c he was a pain pt. Told him no, but I am honest and upfront with my pts re: options, imaging, and pain mgmt.

Long story short, sure to get a complaint letter...🙄

How has every one else handled these situations? In residency, I was protected, by the attending, the group, and the hospital. Now I'm in a different state, and the hospital is known for coming down on ED docs for low press ganey scores, and pt complaints.

 

[keeping-it-real]

Just finished residency and jumped two feet into the fire... so to speak

While its new and fun, now my name is on the bottom line and administrators can come to me with complaints.

Seen a lot of chronic pain pts lately. Mostly sent them out with nothing, some got ~ 5-10 vicodin, but thats it. See your doctor or pain specialist..

Had a guy the other day. Said "My pain specialist sent me in for an MRI and a pain shot". Told him that when doctors send people to the ED, they usually call and let us know someone is coming, bla bla bla...

So I continued to talk to him and explain why he cannot get his MRI and pain shot, and to call him doctor back. He got angry. JUMPED out of bed and stormed out.

Next his son-in-law wants to speak to me. We sit down, he writes my name down, and we chat. The son-in-law is upset b/c I was rude and judgemental toward his father in law. He wasnt even in the room... Told him the same things I told the pt, and he kept focusing on if I was judgmental or bothered b/c he was a pain pt. Told him no, but I am honest and upfront with my pts re: options, imaging, and pain mgmt.

Long story short, sure to get a complaint letter...🙄

How has every one else handled these situations? In residency, I was protected, by the attending, the group, and the hospital. Now I'm in a different state, and the hospital is known for coming down on ED docs for low press ganey scores, and pt complaints.

R1 here, but IMO this is an area where ED docs need to band together and say that while patient satisfaction is a great goal, realistically we're not their friends and sometimes the best interest of the patient isn't always the most pleasing to them. Also, hospital administration has no business telling a doctor what he needs to do or how he needs to pander to a patient. All they care about is the $$ and they're not the ones meeting face to face with the patients, trying to figure out sick/not sick and what the best interest of the patient is.

As an aside, the spinelessness of the medical profession is very depressing. No other professional group allows themselves to be treated with such disrespect.

If you're practicing with the best interest of the patient in mind but still getting flak, tell the administration what they can go do with themselves. If they have a problem with how you're doing things, let them come down and run the ER.... and you should go find a job where you're appreciated for the professional that you are. Or you can get on your knees for the suits and just let the cycle perpetuate.

 

[docB]

R1 here, but IMO this is an area where ED docs need to band together and say that while patient satisfaction is a great goal, realistically we're not their friends and sometimes the best interest of the patient isn't always the most pleasing to them. Also, hospital administration has no business telling a doctor what he needs to do or how he needs to pander to a patient. All they care about is the $$ and they're not the ones meeting face to face with the patients, trying to figure out sick/not sick and what the best interest of the patient is.

As an aside, the spinelessness of the medical profession is very depressing. No other professional group allows themselves to be treated with such disrespect.

If you're practicing with the best interest of the patient in mind but still getting flak, tell the administration what they can go do with themselves. If they have a problem with how you're doing things, let them come down and run the ER.... and you should go find a job where you're appreciated for the professional that you are. Or you can get on your knees for the suits and just let the cycle perpetuate.

That sounds great but it's just not reality. If you tell an administrator get bent and come run the ED they will quickly and truthfully reply "No. I'll just give your contract to another EM group to run it." They also won't say it to you. They'll say it to your director and it will be phrased more like "Get rid of Dr. Keeping-It-Real or your contract is terminated."

Pain patients are a real problem for EDs. Our basic approach to them is that we'll deal with emergencies and chronic pain is almost never an emergency. Hospital administrators look at this VERY differently. They see it as a situation where all of Dr. Pain's patients are insured (or else they wouldn't have a pain doc) and giving narcotics and imaging and general butt kissing are all services we provide in our ED. If we're doing those things for the homeless then we damn sure better be doing them for the paying patients. The fact that Dr. Pain recently had a meeting with the hospital administrator and promised to send in all of his patients for their outpatient imaging, labs, back surgeries and so on definitely puts the lowly contract doc in a bad spot.

As for the OP when these situations come up it's important to document well. Dictate or use extra sheets if necessary. Explain the situation. Why whatever they wanted was not indicated. Why they became upset. I usually note that the patient became angry at having to answer questions which are part of the H and P. It's not a bad idea to make some notes and keep them so you can remember the case when your director comes to you about it in a few weeks (remove all patient identifiers of course). It's also better not to contradict the patients (Your doctor would have called if he sent you in.) but to verify their stories (I'll call your doctor and see what they are looking for.) because it's less confrontational.

The basic problem is that these people are frustrated, angry, addicted (they may be addicted to prescription meds and treating real pain but they are addicted) and are filled with unresonable expectations. Deny them what they want and they behave like addicts. Their pain docs and PMDs frequently tell them to go to the ER for their shots and they'll call so there'll be no questions and they'll be in and out in 15 minutes. This is why so many EPs get beaten down and give in. Why would you lose 40 minutes talking with an angry patient, then their angry family and then deal with your director, a complaint letter and being on administration's radar over 4 mg of IM Dilaudid? It's a tough call after the idealism wears off.

 

[Old_Mil]

...son in law is the drug dealer, father in law is using the medicare card to get the drugs. Son in law cuts father in law in on a small piece of the action... How close am I to the truth?

...as far as hospital administration and Press Ganey scores...if they're looking for a drug dealer to work their ER, they can save a lot of money hiring one off the street corner at midnight.

 

[BatmanMD]

I did document all over the chart, so if the administration read it, there would be no question. Still, it gets frustrating...

DocB, thats exactly how i feel. Dont want to waste 40 minutes with these patients, but I have an extremely hard time giving anything to them either. I just dont believe in positive reinforcement. I feel that the next time they need something, they wont go to their doc, they'll just come to the ED (not necessarily mine but someones) b/c its easier. Also, he's exactly right about the contract. The administrator will talk to the director and tell him/her to get them out of their ED or you lose the contract... I've been talking to other docs and they have been through this at this hospital. A couple almost lost their job.

 

[xaelia]

Seems my impression of life-beyond is, while in residency, the chronic pain etc. patient is usually a homeless uninsured addict hassle on a busy shift. In the real world, it's a patient you can see, document, treat, disposition - and get paid for - in seconds. If you're getting paid based on productivity, no point in wasting your time determining whether the patient is lying to you, arguing with them, making careful notes, etc. Pain shot, pat on the back, "must have been a communications breakdown, have your pain doc call next time."

 

[keeping-it-real]

That sounds great but it's just not reality. If you tell an administrator get bent and come run the ED they will quickly and truthfully reply "No. I'll just give your contract to another EM group to run it." They also won't say it to you. They'll say it to your director and it will be phrased more like "Get rid of Dr. Keeping-It-Real or your contract is terminated."

Pain patients are a real problem for EDs. Our basic approach to them is that we'll deal with emergencies and chronic pain is almost never an emergency. Hospital administrators look at this VERY differently. They see it as a situation where all of Dr. Pain's patients are insured (or else they wouldn't have a pain doc) and giving narcotics and imaging and general butt kissing are all services we provide in our ED. If we're doing those things for the homeless then we damn sure better be doing them for the paying patients. The fact that Dr. Pain recently had a meeting with the hospital administrator and promised to send in all of his patients for their outpatient imaging, labs, back surgeries and so on definitely puts the lowly contract doc in a bad spot.

As for the OP when these situations come up it's important to document well. Dictate or use extra sheets if necessary. Explain the situation. Why whatever they wanted was not indicated. Why they became upset. I usually note that the patient became angry at having to answer questions which are part of the H and P. It's not a bad idea to make some notes and keep them so you can remember the case when your director comes to you about it in a few weeks (remove all patient identifiers of course). It's also better not to contradict the patients (Your doctor would have called if he sent you in.) but to verify their stories (I'll call your doctor and see what they are looking for.) because it's less confrontational.

The basic problem is that these people are frustrated, angry, addicted (they may be addicted to prescription meds and treating real pain but they are addicted) and are filled with unresonable expectations. Deny them what they want and they behave like addicts. Their pain docs and PMDs frequently tell them to go to the ER for their shots and they'll call so there'll be no questions and they'll be in and out in 15 minutes. This is why so many EPs get beaten down and give in. Why would you lose 40 minutes talking with an angry patient, then their angry family and then deal with your director, a complaint letter and being on administration's radar over 4 mg of IM Dilaudid? It's a tough call after the idealism wears off.

What you've just described is a good example of how our healthcare system is so screwed up. The suits have taken over primary control and doctors have been more than happy to bend over, take it, and just do what they're told by the administration. There is no physician unity to prevent abuse from the system.

Hospitals being profit driven and QA driven have negatively impacted medicine. Of course the goal should always be efficiency and best quality of care, but should this be determine by patients or even by suits with online degrees? What a patient wants isn't always what is necessary, and what the administration wants isn't always the best medical care. Physicians somehow accept a secondary role when it comes to this, though, and are more than happy to take orders and directions from their less qualified "colleagues."

Maybe doctors like being disrespected and having their reimbursements cut, though. I guess we'll see how long they can boil the frog.

 

[keeping-it-real]

I did document all over the chart, so if the administration read it, there would be no question. Still, it gets frustrating...

DocB, thats exactly how i feel. Dont want to waste 40 minutes with these patients, but I have an extremely hard time giving anything to them either. I just dont believe in positive reinforcement. I feel that the next time they need something, they wont go to their doc, they'll just come to the ED (not necessarily mine but someones) b/c its easier. Also, he's exactly right about the contract. The administrator will talk to the director and tell him/her to get them out of their ED or you lose the contract... I've been talking to other docs and they have been through this at this hospital. A couple almost lost their job.

What you're describing is no different than a drug pimp shaking down their dealers to make sure they're still keeping the customers hooked and happy. If you're fine with that, good for you, but I doubt it is the best care that we can be providing.

And if the admin talks to the director, your director should tell them to go fly a kite and that he/she will not allow management to dictate poor/unreasonable care. If they threaten to change groups, tell them you quit... and go find a job where you're actually respected for the 11+ years of education you've put into ensuring you can provide great care to people. This won't happen, though, and in the end everyone will just shut their mouth, kiss the ass of the administration, and continue to provide unnecessary care just so that they greenbacks keep coming in. In the end, the risk of losing a job outweighs the risk of unfavorable working conditions and the management can just rinse-wash-repeat because they know this about doctors.

 

[GeneralVeers]

I always tell the painers that I can't give them anything without the explicit Okay of their pain doctors. Most pain doctors have patients sign contracts with them, and often become angry when EPs violate this contract. If possible I call the pain doctor and work out a plan with them. That way I can go back to the patient and say "You want a shot of X, but your pain doctor wants you to have Y".

It has worked well so far whenever I've done this.

 

[BatmanMD]

had to reply just to that....😀

never heard that term before.

Where's it from?

🙂

 

[Apollyon]

had to reply just to that....😀

never heard that term before.

Where's it from?

🙂

There's a myth that, if you put a frog in warm water, and slowly, slowly raise the temperature to boiling, the frog will not jump out, but will remain and die.

It's not true - it's been tested. Frogs will jump out of water that is too warm for them, irrespective of the time it takes to heat it up.

 

[docB]

What you've just described is a good example of how our healthcare system is so screwed up. The suits have taken over primary control and doctors have been more than happy to bend over, take it, and just do what they're told by the administration. There is no physician unity to prevent abuse from the system.

Hospitals being profit driven and QA driven have negatively impacted medicine. Of course the goal should always be efficiency and best quality of care, but should this be determine by patients or even by suits with online degrees? What a patient wants isn't always what is necessary, and what the administration wants isn't always the best medical care. Physicians somehow accept a secondary role when it comes to this, though, and are more than happy to take orders and directions from their less qualified "colleagues."

Maybe doctors like being disrespected and having their reimbursements cut, though. I guess we'll see how long they can boil the frog.

No one is saying we like this situation. It is just how it is.

What you're describing is no different than a drug pimp shaking down their dealers to make sure they're still keeping the customers hooked and happy. If you're fine with that, good for you, but I doubt it is the best care that we can be providing.

And if the admin talks to the director, your director should tell them to go fly a kite and that he/she will not allow management to dictate poor/unreasonable care. If they threaten to change groups, tell them you quit... and go find a job where you're actually respected for the 11+ years of education you've put into ensuring you can provide great care to people. This won't happen, though, and in the end everyone will just shut their mouth, kiss the ass of the administration, and continue to provide unnecessary care just so that they greenbacks keep coming in. In the end, the risk of losing a job outweighs the risk of unfavorable working conditions and the management can just rinse-wash-repeat because they know this about doctors.

It certainly is frustrating but keep this in perspective. You have to pick your battles. I have enough of a position in my hospitals now that I can practice the way I want and use discression about treating chronic pain. However that means you can't draw a line in the sand and say "Never!" You also will never find a hospital where administration doesn't have any issues.

 

[Apollyon]

What you've just described is a good example of how our healthcare system is so screwed up. The suits have taken over primary control and doctors have been more than happy to bend over, take it, and just do what they're told by the administration. There is no physician unity to prevent abuse from the system.

Hospitals being profit driven and QA driven have negatively impacted medicine. Of course the goal should always be efficiency and best quality of care, but should this be determine by patients or even by suits with online degrees? What a patient wants isn't always what is necessary, and what the administration wants isn't always the best medical care. Physicians somehow accept a secondary role when it comes to this, though, and are more than happy to take orders and directions from their less qualified "colleagues."

Maybe doctors like being disrespected and having their reimbursements cut, though. I guess we'll see how long they can boil the frog.

Whoa! Refrain from the invective, please, and then return to the real world.

Are you familiar with the term "Irish diplomacy"? It means to tell someone to go to hell, and have them look forward to the trip. I have colleagues that don't give in to the drug seekers, and get good surveys every month.

 

[DrQuinn]

I did document all over the chart, so if the administration read it, there would be no question. Still, it gets frustrating...

DocB, thats exactly how i feel. Dont want to waste 40 minutes with these patients, but I have an extremely hard time giving anything to them either. I just dont believe in positive reinforcement. I feel that the next time they need something, they wont go to their doc, they'll just come to the ED (not necessarily mine but someones) b/c its easier. Also, he's exactly right about the contract. The administrator will talk to the director and tell him/her to get them out of their ED or you lose the contract... I've been talking to other docs and they have been through this at this hospital. A couple almost lost their job.

Yeah bro it does get a little frustrating, and honestly when I was a new grad like you (I am a woo-wee two years ahead of you now), I had the same approach.

Now that I have a FEW extra gray hairs, I generally will say things along the lines of what has alreayd been said:

Pain management doctors have contracts with you and the hospital. Let me call them and see what Dr. pain wants to do.

USUALLY they call back. If they do, I will just document what Dr. P wants give it, and DC. If they don't call back I'll usually give them a round and then maybe 1-2 days worth, if its a weekend thing. Document the heck out of the chart, and document no red flags.

MRIs are a different story. I would basically never do them, because I don't think they are useful at all in any chronic pains unless you have new neuro findings.

I have had TWO complaints in my 26 months-
One postal worker who wanted a week off of work beacuse he had bad allergic rhinitis and was too tired to get prescriptions after work. I told him no. He wrote me up.

Two, a fat albino with bronchitis wanted to be admitted to the hospital for her bronchitis. I told her no. She wrote me up.

I find that if you just explain the thought process, i.e. "Dr. Pain called back, here's your four of dilaudid, call his office tomorrow, we don't do MRIs here unless you have a stroke or fell off a horse like Christopher Reeves," you won't get many complaints. Its all about expectations.

Q