Controlled substances

[Crayola227]

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I second what Clausewitz is saying about a pain period when you inherit a bunch of patients. When I inherit trainwreck patients, I expect to do a lot more documenting.

You document the controlled substances they're already on that were not your idea, in your first visit note. You discuss that on chart review and discussion with patient, they're on xyz drug for xyz reason, started by Dr. Whoever. For xyz reasons, you feel they should taper to lower dose, dc, or switch regimens. You discussed with patient your goal to do this, and to schedule follow up to initiate. You explain that you will only write for the current script once and the next one will be a tapering dose or d/c, whichever is most appropriate. If, say, they are on stims, the choice is d/c or come back in to start your taper and/or alternate therapy. If they are on meds that truly require taper, like benzos, again, there will be taper whether they like it or not.

I never feel like I have to stop scripts I never started, right away. You need to document that you're continuing the script with a goal to taper, so you're not abandoning, nor abetting bad practice.

I see a lot of doctors just stop patients cold on a lot of drugs they don't like writing. Sadly, some of those scripts actually being legit for the patient.

You need to do standard of care and document.

If the charts clearly show you inherited 100 patients on bad meds, and following your records you are slowly but surely reducing that number, than you are not going to be held as a candy doctor. You need to show safe reasonable progress as you clean up what you can prove is someone else's mess. Bonus points if all YOUR patients are being managed appropriately, and the only ones that stand out as being bad were inherited, and you show progress to better.

 

[futuredo32]

But we don't start most of the medical messes we treat, yet it's still our job to treat it. So I'm pretty confused here. I thought we were professional mess cleaners.

There are so many reasons paper charts are a disservice to patients.

I ditto unloading stuff to staff, and I don't technically see an issue having support staff look up controlled substance databases, provided you can trust them to do it correctly and things don't get lost. But if you're really worried about your license and the DEA, it only makes sense to me to DO IT YOURSELF and document that. Whatever you do yourself and document, you're going to find easier to defend, at least that's what attorneys tell me.

And THAT is the beauty of private practice. You don't have to be a "professional mess cleaner". You pick and choose your patients. I tell each new potential patient we will meet for a consult and IF we both agree it's a good fit after a few sessions or one, we can continue. I am not a professional mess cleaner and have no desire to be. I have never had any legal issues and hope I never do. I am leaving before the other psychiatrist does. I am out before the mess begins.
Thanks for all the advice I emailed my 4 week notice that I am resigning. Done. Over. Relieved.

 

[futuredo32]

I’m not sure we disagree at all as I agree with everything above. My point is more along the lines that every patient is different, and no physician is mandated to prescribe meds if they believe a higher LOC is necessary. The jury will want to see a reasonable plan regardless of the decision.

I am avoiding a jury 🙂.

 

[Crayola227]

And THAT is the beauty of private practice. You don't have to be a "professional mess cleaner". You pick and choose your patients. I tell each new potential patient we will meet for a consult and IF we both agree it's a good fit after a few sessions or one, we can continue. I am not a professional mess cleaner and have no desire to be. I have never had any legal issues and hope I never do. I am leaving before the other psychiatrist does. I am out before the mess begins.
Thanks for all the advice I emailed my 4 week notice that I am resigning. Done. Over. Relieved.

You don't think you'll be cleaning up a lot of messes in FM?

That's cool, a lot of docs decide to cherry pick and manage it in primary care fields somehow. I'm glad that admissions look for doctors that are more interested in social mission than cherry picking.

 

[Mass Effect]

I am avoiding a jury 🙂.

No, you're practicing "defensive medicine," which is poor care. I think you'd be served well to actually learn how the legal process works when it comes to medicine and what you can and can't/should and shouldn't do because your reasoning makes very little sense. I get that you quit your job and I think that's great for a number of reasons, but you WILL be put in this position again, especially if you go into FM, and I'd hate to think you'd do the same thing next time that you're doing this time. In FM, you're likely to inherit patients on opiates for legit reasons. Are you going to refuse to see them? You can't run away from every job because you don't understand the rules and you're afraid. @Crayola227 is right that if you document appropriately, you can taper your patients without raising any red flags.

 

[VA Hopeful Dr]

No, you're practicing "defensive medicine," which is poor care. I think you'd be served well to actually learn how the legal process works when it comes to medicine and what you can and can't/should and shouldn't do because your reasoning makes very little sense. I get that you quit your job and I think that's great for a number of reasons, but you WILL be put in this position again, especially if you go into FM, and I'd hate to think you'd do the same thing next time that you're doing this time. In FM, you're likely to inherit patients on opiates for legit reasons. Are you going to refuse to see them? You can't run away from every job because you don't understand the rules and you're afraid. @Crayola227 is right that if you document appropriately, you can taper your patients without raising any red flags.

You can also refuse to write said opiates and refer the patient out and be fine as well.

 

[clausewitz2]

You don't think you'll be cleaning up a lot of messes in FM?

That's cool, a lot of docs decide to cherry pick and manage it in primary care fields somehow. I'm glad that admissions look for doctors that are more interested in social mission than cherry picking.

It was amazing to me rotating with FM on my inpatient medicine months how many seniors had chosen their program based on heavy exposure to a high needs population with a clear sense of mission and had transformed into being super interested in sports medicine (i.e. doctor for healthy people).

I get super bored by bourgie problems but if you're fine with that I'm sure it's a nice life. For psychiatry I am not sure how much I personally can do to help high-functioning neurotic types v a clinical psychologist (i.e. someone with real therapy training) but I guess some people will never agree to engage in psychotherapy.

 

[WisNeuro]

I get super bored by bourgie problems but if you're fine with that I'm sure it's a nice life. For psychiatry I am not sure how much I personally can do to help high-functioning neurotic types v a clinical psychologist (i.e. someone with real therapy training) but I guess some people will never agree to engage in psychotherapy.

I am continually amazed at how many people would rather take a medication for the rest of their life, than go to therapy for a few months.

 

[clausewitz2]

I am continually amazed at how many people would rather take a medication for the rest of their life, than go to therapy for a few months.

See, I don't find it hard to understand. Emotional vulnerability is a scary thing to many people. Talking about feelings or thoughts means you are waaaaay more exposed than if you tell your doctor about what you did and did not like about various pills.

 

[WisNeuro]

See, I don't find it hard to understand. Emotional vulnerability is a scary thing to many people. Talking about feelings or thoughts means you are waaaaay more exposed than if you tell your doctor about what you did and did not like about various pills.

Fair. I guess I'm just in a group that is medication averse. My plan is to hold of on having to take any kind of medication for as long as I possibly can in life. Also, I know the treatment response rates for various psychopathology, so my pragmatism would kick in, especially for anxiety disorders. Way too many candymen in my system handing out benzos like candy. Just terrible.

 

[futuredo32]

Epilogue I sent an email of resignation and all of the benzodiazepine patients will be tapered by someone who isn't me. I won't be getting any on psychostimulants. Fairy tale and unexpected ending for me. I wasn't getting a few patients who were nightmares it was over 100. And all at once. Now I am getting zero.

 

[futuredo32]

No, you're practicing "defensive medicine," which is poor care. I think you'd be served well to actually learn how the legal process works when it comes to medicine and what you can and can't/should and shouldn't do because your reasoning makes very little sense. I get that you quit your job and I think that's great for a number of reasons, but you WILL be put in this position again, especially if you go into FM, and I'd hate to think you'd do the same thing next time that you're doing this time. In FM, you're likely to inherit patients on opiates for legit reasons. Are you going to refuse to see them? You can't run away from every job because you don't understand the rules and you're afraid. @Crayola227 is right that if you document appropriately, you can taper your patients without raising any red flags.

Practice in Michigan and then tell me how many controlled substances you are willing to prescribe

 

[futuredo32]

You don't think you'll be cleaning up a lot of messes in FM?

That's cool, a lot of docs decide to cherry pick and manage it in primary care fields somehow. I'm glad that admissions look for doctors that are more interested in social mission than cherry picking.

In Michigan fps refer to pain specialists

 

[Crayola227]

See, I don't find it hard to understand. Emotional vulnerability is a scary thing to many people. Talking about feelings or thoughts means you are waaaaay more exposed than if you tell your doctor about what you did and did not like about various pills.

Fair. I guess I'm just in a group that is medication averse. My plan is to hold of on having to take any kind of medication for as long as I possibly can in life. Also, I know the treatment response rates for various psychopathology, so my pragmatism would kick in, especially for anxiety disorders. Way too many candymen in my system handing out benzos like candy. Just terrible.

For a lot of people, fitting in psychotherapy appts or even affording them can be an issue. I know a lot of insurance is pretty stingy with covering the sort of ongoing therapy the really mentally ill truly need, ie it's great to get 6 visits for acute grief reaction, but I don't know that would be enough for the personality disorder patient that by some miracle was actually open to truly working on that stuff.

Where I live getting into CBT for example, is extremely difficult, insurance aside.

A lot of people I know in healthcare training have interest in getting counseling, but find that they just can't fit it in. (all those poor med students and residents).

A lot of pharmacies have extended evening and weekend hours, and it could be a once a month trip, then 30 s a day to take your meds.

I also know people that have white-knuckled through a lot of mental illness relying on psychotherapy, self-help, 12 Step, etc etc etc, avoiding meds. All that stuff was great, and helped them be functional, but for a lot of people that moment they "give in" to the pills, it's like, darn, why wasn't I doing this all along? So much suffering because people don't want to be medicated.

Whether it's counseling or meds, my understanding is that for a lot of things, both together are more effective than either alone. Or, at least, if you're not happy just on one, it's worth trying the other too if a doc thinks it's indicated.

I don't support white knuckling through mental illness to avoid pills. I believe in using as many reasonable tools as possible to achieve the greatest amount of wellness possible. I think I wrote somewhere some 25 pt plan on this, knowing that it can be overwhelming to put it all in action. In my ideal universe I tell patients, they have exercise, sleep hygiene, light hygiene, lots of water and healthy food, zero use of recreational psychoactive substances such as alcohol, MJ, even limit coffee if needed. Counseling, medication, support groups, a houseplant or beta fish. There's a lot to be done that isn't and IS meds.

You do what you gotta do, sometimes that's pills, therapy, and a shock mat to keep your cats from scratching outside your bedroom door so you can sleep.

 

[WisNeuro]

For a lot of people, fitting in psychotherapy appts or even affording them can be an issue. I know a lot of insurance is pretty stingy with covering the sort of ongoing therapy the really mentally ill truly need, ie it's great to get 6 visits for acute grief reaction, but I don't know that would be enough for the personality disorder patient that by some miracle was actually open to truly working on that stuff.

Where I live getting into CBT for example, is extremely difficult, insurance aside.

You do what you gotta do, sometimes that's pills, therapy, and a shock mat to keep your cats from scratching outside your bedroom door so you can sleep.

I'm more talking about the people with things like fairly uncomplicated anxiety disorders (panic, phobia, mild to moderate OCD) or insomnia who just need sleep retraining. These are like 8-12 week courses that can be effective for a lot of people. Having trouble finding a CBT provider, as long as you aren't in the boonies, is surprising to me. There are too many to count in my area. True, chronic or treatment resistant things (PD, somatoform, fibromyalgia) are different beasts altogether, but it's like pulling teeth to get most people to try therapy/counseling first before deciding on life long medication, which, in some cases will make their condition worse (e.g., insomnia).

Also, we own multiple shock mats in our home as well 😉

 

[randomdoc1]

I won't get too far in this discussion, but I understand futuredo's pain. It sucked so bad to inherit an NPs patients who were all on mega doses of stims with Xanax to take the edge off the anxiety. In the unreliable patient, which many where and had comorbid substance use, continuing a benzo, even if you are trying to taper is risk to be taking on. To to mention some were already on opiates and many were personality disordered that could threaten to act out and do who knows what (create a pseudo seizure?) and claim you're the evil doctor who took them off their critical meds. Another issue I ran into is despite my best effort to educate patients about the risks and benefits of certain medications and need for a proper eval first, some just left angry and started trolling on the internet! I had two one star reviews where the patients really changed up the story. It dropped my traffic dramatically and I got health grades to just shut those down. One or two of those patients a day, I can deal. But if I can stop those patients from just getting transferred to me, even better. More headache than it is worth. Or if it turns out I find out later it's just not a fit, I give them enough refill and refer to a new provider that I know has early availability. Done and done.

Regarding the cost for therapy as a barrier, I refer to training clinics. Therapy has been a viable option for the whopping vast majority of patients when I provide them community resources like that.

 

[randomdoc1]

You don't think you'll be cleaning up a lot of messes in FM?

That's cool, a lot of docs decide to cherry pick and manage it in primary care fields somehow. I'm glad that admissions look for doctors that are more interested in social mission than cherry picking.

One thing to OP though, whichever field we are in, we will always have to clean some degree of mess, it's a matter of how much we are willing to deal with. At the end of the day we are only human and have our own limits too. I too entered medical school for altruistic reasons wanting to serve the underserved. But there is a point where if you feel you are working harder than the patient and you have 30+ of those a day, then it's really not worth it. They have to be on board with what you recommend and if they are in precontemplation, I'm not going to be a sitting duck and wait for a crisis or adverse outcome to roll along. Even with great documentation, call me anxious but risk management has taught me that 1) you can be sued/reported for anything, 2) you can be sued/reported for anything, and 3) you can be sued/reported for anything. So many patients come in wanting the quick fix, their benzos, stims, and oxies all at once. They are welcome to return when they are ready to pursue evidence based recommendations but if not, see ya. I'm not their parents and there are plenty of motivated patients waiting for care as well.

No offense crayola, just a friendly somewhat counter argument/my take.

 

[Crayola227]

One thing to OP though, whichever field we are in, we will always have to clean some degree of mess, it's a matter of how much we are willing to deal with. At the end of the day we are only human and have our own limits too. I too entered medical school for altruistic reasons wanting to serve the underserved. But there is a point where if you feel you are working harder than the patient and you have 30+ of those a day, then it's really not worth it. They have to be on board with what you recommend and if they are in precontemplation, I'm not going to be a sitting duck and wait for a crisis or adverse outcome to roll along. Even with great documentation, call me anxious but risk management has taught me that 1) you can be sued/reported for anything, 2) you can be sued/reported for anything, and 3) you can be sued/reported for anything. So many patients come in wanting the quick fix, their benzos, stims, and oxies all at once. They are welcome to return when they are ready to pursue evidence based recommendations but if not, see ya. I'm not their parents and there are plenty of motivated patients waiting for care as well.

No offense crayola, just a friendly somewhat counter argument/my take.

This is all fair.

I don't get attached to outcomes, I'm a professional advice giver and that is all. I put it out there, and patients do as they will.

This has come up on the psych board before, you get the patient, you give the advice, you write the script. They live with it or don't.

I do agree the part where they slam you online and report you and all that jazz, to me that's where I hesitate to take on crappy patients too. Not for the personal bother I have dealing with it in the office, but the very real career consequences, beyond that you inherited crappy patients and will get in trouble with the gov't for their existing regimens.

Of course you have the folks that are half-measures. You take them on, they don't flounce off, and you do enter a power struggle.

Mainly I don't agree with categorically not even seeing a group of patients because you're cleaning up some other doc's practice. A lot of patients will see you once, and they self select if they will come back under your terms or not.

To me it's more difficult when you already have a relationship with them and then need to institute a big change from what you were doing, the resistance is different.

But it probably makes a difference what field you're in. It's probably a higher proportion of folks that you have to get off the "candy" than even in primary care, in psych.

 

[futuredo32]

Yesterday was REALLY slow and I had a chance to look over some of the charts of the retiring psychiatrist. He diagnosed most with MDD and they are on mega high doses of Adderall AND A benzo, no antidepressant. The NP who works at the clinic chatted with me about the situation too. He's not accepting these patients either unless they have Blue Cross, he gets paid a percentage. I'm paid hourly, but I wouldn't be able to deal with such a massive mess no matter how much I was paid.

The psychiatrist who has been prescribing like this has a little over a month to CLEAN UP HIS OWN MESS. I am staying on the condition that I don't get A SINGLE one of these patients. It wouldn't be SO bad if there weren't SO many and he isn't even prescribing the meds appropriately.

I now know why SO many drug seeking patients are at this clinic, the one psychiatrist was a pill mill. Word got out. I don't know how the medical director and clinic owner let this go on for so long. The owner really seems like a good guy. I have never met the medical director who is supposed to be doing chart reviews.
There are tons of therapists at the clinic with openings and they are open until 8 pm Mon-Fri and 8-4 on Saturdays. They take all insurances except Medicaid.

 

[michaelrack]

I am avoiding a jury 🙂.

you're also avoiding a state medical board inquisition in which you would have few legal rights and limited due process

 

[randomdoc1]

you're also avoiding a state medical board inquisition in which you would have few legal rights and limited due process

If the patients are still under the care of the candy man psychiatrist, she’s not required to accept them. She can decide to just build up her own fresh panel. Or what I have my front desk staff do when new patients call is explain to them my general take on controlled substances and my treatment philosophies such as lifestyle changes being an emphasis. We also warn if we determine it is not a fit, we do refer out. We don’t have to keep anyone under our care and I make sure there is no patient abandonment by facilitating a smooth transfer. Noncompliance with recommendations can be grounds for termination too.

 

[Crayola227]

you're also avoiding a state medical board inquisition in which you would have few legal rights and limited due process

don't mention that over in gen res, they don't believe that's a thing

 

[Crayola227]

To be fair, I guess I'm pulling a Devil's Advocate or like where I find all of this very hard to believe,
@futuredo32 describes a situation that is so extreme on both sides of the dystopian/utopian practice spectrum, I find it hard to believe.

But I'm willing to believe this psych was this bad a prescriber and the counseling services this available, the clinic owner so nice a guy and the medical director so negligent. Nothing should surprise me any more.

 

[Mass Effect]

Yesterday was REALLY slow and I had a chance to look over some of the charts of the retiring psychiatrist. He diagnosed most with MDD and they are on mega high doses of Adderall AND A benzo, no antidepressant. The NP who works at the clinic chatted with me about the situation too. He's not accepting these patients either unless they have Blue Cross, he gets paid a percentage. I'm paid hourly, but I wouldn't be able to deal with such a massive mess no matter how much I was paid.

The psychiatrist who has been prescribing like this has a little over a month to CLEAN UP HIS OWN MESS. I am staying on the condition that I don't get A SINGLE one of these patients. It wouldn't be SO bad if there weren't SO many and he isn't even prescribing the meds appropriately.

I now know why SO many drug seeking patients are at this clinic, the one psychiatrist was a pill mill. Word got out. I don't know how the medical director and clinic owner let this go on for so long. The owner really seems like a good guy. I have never met the medical director who is supposed to be doing chart reviews.
There are tons of therapists at the clinic with openings and they are open until 8 pm Mon-Fri and 8-4 on Saturdays. They take all insurances except Medicaid.

If all of this is true, I think it's a bit ridiculous that you chose to stay in the practice, even if you don't get any of these patients. In a practice like that, one psychiatrist isn't known as a "pill mill." Likely the entire practice is known as a "pill mill" and you're so paranoid about the DEA now that you're on the radar, why are you even associated with a place like this? How do you know it's just this one psychiatrist? How do you know it's not the rep of the whole place? There are FBI raids of practices like this and for someone as concerned as you are, I would think you'd get out in a heartbeat. Just my take.

 

[futuredo32]

If all of this is true, I think it's a bit ridiculous that you chose to stay in the practice, even if you don't get any of these patients. In a practice like that, one psychiatrist isn't known as a "pill mill." Likely the entire practice is known as a "pill mill" and you're so paranoid about the DEA now that you're on the radar, why are you even associated with a place like this? How do you know it's just this one psychiatrist? How do you know it's not the rep of the whole place? There are FBI raids of practices like this and for someone as concerned as you are, I would think you'd get out in a heartbeat. Just my take.

I would agree IF the NP and clinic director were willing to take on this doctors patients. There is no one taking over his patients- the owner tried to pawn them all on me and I said I was quitting if that was the case so he relented. I get $150 an hour, I can take time off with little notice, I pick and choose when I want to work and he doesn't care about BE/BC. It's NOT a bad job. Yesterday was super slow, I took a 3 hour nap 🙂. I really think it was just the one psychiatrist and he is leaving, They aren't allowing any new "ADHD" adults.
But thanks.

 

[futuredo32]

To be fair, I guess I'm pulling a Devil's Advocate or like where I find all of this very hard to believe,
@futuredo32 describes a situation that is so extreme on both sides of the dystopian/utopian practice spectrum, I find it hard to believe.

But I'm willing to believe this psych was this bad a prescriber and the counseling services this available, the clinic owner so nice a guy and the medical director so negligent. Nothing should surprise me any more.

I just don't think the clinic owner was aware. He owns several clinics and vacations a lot. I don't think the medical director actually did chart reviews. The medical director calls in A LOT. I think he is kinda stuck for psychiatrists, it's kinda distant, and the only psych clinic for a good 20-30 minutes. Some of the therapists are meh but most seem to care.

 

[clausewitz2]

To be fair, I guess I'm pulling a Devil's Advocate or like where I find all of this very hard to believe,
@futuredo32 describes a situation that is so extreme on both sides of the dystopian/utopian practice spectrum, I find it hard to believe.

But I'm willing to believe this psych was this bad a prescriber and the counseling services this available, the clinic owner so nice a guy and the medical director so negligent. Nothing should surprise me any more.

I feel like in this situation as described the clinic owner is either a ***** or is significantly less pure and saintly than OP believes.

 

[clausewitz2]

I would agree IF the NP and clinic director were willing to take on this doctors patients. There is no one taking over his patients- the owner tried to pawn them all on me and I said I was quitting if that was the case so he relented. I get $150 an hour, I can take time off with little notice, I pick and choose when I want to work and he doesn't care about BE/BC. It's NOT a bad job. Yesterday was super slow, I took a 3 hour nap 🙂. I really think it was just the one psychiatrist and he is leaving, They aren't allowing any new "ADHD" adults.
But thanks.

So what are you going to do when you get a patient who presents for depression and after a few times seeing them, they ask about ADHD or mention their previous medication history as a kid and the history is convincing and it actually explains a fair amount about their particular problems?

Like, is your approach going to be "I think you might have ADHD, gtfo"? This is what I don't get about refusing to treat ADHD. I get outpatient folks not feeling comfortable with someone with a lot of lethality concerns or needs a case manager/service coordinator or maybe is on clozapine and you trained somewhere where you never really learned to do that but it's clearly not the case that you lack the resources or ability to write a script for Adderall.

Screening out people won't keep you entirely insulated from people who may have ADHD. You're just going to ignore it? We're not a field that has so much detailed technical knowledge that it would be irresponsible to treat this without hyperspecialized training.

 

[randomdoc1]

So what are you going to do when you get a patient who presents for depression and after a few times seeing them, they ask about ADHD or mention their previous medication history as a kid and the history is convincing and it actually explains a fair amount about their particular problems?

Like, is your approach going to be "I think you might have ADHD, gtfo"? This is what I don't get about refusing to treat ADHD. I get outpatient folks not feeling comfortable with someone with a lot of lethality concerns or needs a case manager/service coordinator or maybe is on clozapine and you trained somewhere where you never really learned to do that but it's clearly not the case that you lack the resources or ability to write a script for Adderall.

Screening out people won't keep you entirely insulated from people who may have ADHD. You're just going to ignore it? We're not a field that has so much detailed technical knowledge that it would be irresponsible to treat this without hyperspecialized training.

I believe this has been discussed in other threads. If we do not feel we are adequately trained to manage a certain disorder, my training program was also pretty bad about managing ADHD persisting into adulthood, we don't have to keep the patient and can refer to someone with more extensive training. Fortunately and unfortunately with the explosion of the treatment of pseudo ADHD in the community and Adderall over prescribing, many of even my established patients have approached me inquiring me about this. I simply explain the natural history and clinical presentation of ADHD after I gather their history. I then say I think a thorough assessment is required before even considering a schedule II. This does include a requirement for having a source to get a reliable outside party to weigh in on their developmental history. I use the Barkley and will usually approach parents about this. In addition, ruling out sleep apnea, getting TSH and UDS are also critical roles in the assessment as well as a review of current medications. I also explain part of the reasoning is that using stimulants without a complete picture, especially if there is not ADHD is poor practice and introduces a lot of longterm and unnecessary risk in a patient's clinical course. We're already in medicine in general facing this epidemic of polypharmacy, we shouldn't be adding to it. The American Journal of Psychiatry has discussed the inquiries about ADHD in adults quite a bit, and both in my personal experience and from literature I have read (don't have titles off the top of my head) adults who inquire about it and have little inquiry made in childhood, the majority do not have ADHD. They did have one article about adults complaining of severe inattention and association with depression and suicidality, especially in face of not a very convincing developmental history. Hitting all the symptoms in DSM V does not mean ADHD unless there is clear pediatric history. I had two very interesting cases in light of this. One was a 35 yo male, never complained of inattention until his 30's, became severely depressed and got hell bent on being diagnosed with ADHD then back peddling and saying he had all symptoms as a child too. Two weeks later, he had two suicide attempts. Concentrational sx remitted after his depression did. Another is a woman in her 20's complaining of acute inattention, also got fixated on being started on stims, no convincing pediatric history but very insistent she has ADHD. Remitted with MAOI and no executive complaints since. Plus, the neuropsychologist I work with (who published many of the main ADHD texts) recommends specified psychotherapy and talks often about how underutilized it is as well as need to manage the comorbidities as comorbid disorders tend to be the norm rather than the exception in true ADHD. That being said, the patient has to be ready for both the comprehensive assessment and treatment.

That aside, I have encountered some true cases of ADHD in my practice. @clausewitz2, you are right about your thread on "ADHD personality" they are often not the people who are loud about their inattention and insisting they must have ADHD, despite their glaringly obvious developmental history that they rattled off which sound like a story that could come out of a textbook. Those are indeed some of the most rewarding cases I've come across and helping them in their career path has been fantastic. I have also found them to be quite responsible with their stimulants and to do quite well on reasonable doses. The pseudo ADHD often have unrealistic expectations, often comorbid personality disorders, and are patients who in the wrong hands could end up on things like 70mg vyvanse with 30mg adderall and xanax to take the edge off.

 

[clausewitz2]

I believe this has been discussed in other threads. If we do not feel we are adequately trained to manage a certain disorder, my training program was also pretty bad about managing ADHD persisting into adulthood, we don't have to keep the patient and can refer to someone with more extensive training. Fortunately and unfortunately with the explosion of the treatment of pseudo ADHD in the community and Adderall over prescribing, many of even my established patients have approached me inquiring me about this. I simply explain the natural history and clinical presentation of ADHD after I gather their history. I then say I think a thorough assessment is required before even considering a schedule II. This does include a requirement for having a source to get a reliable outside party to weigh in on their developmental history. I use the Barkley and will usually approach parents about this. In addition, ruling out sleep apnea, getting TSH and UDS are also critical roles in the assessment as well as a review of current medications. I also explain part of the reasoning is that using stimulants without a complete picture, especially if there is not ADHD is poor practice and introduces a lot of longterm and unnecessary risk in a patient's clinical course. We're already in medicine in general facing this epidemic of polypharmacy, we shouldn't be adding to it. The American Journal of Psychiatry has discussed the inquiries about ADHD in adults quite a bit, and both in my personal experience and from literature I have read (don't have titles off the top of my head) adults who inquire about it and have little inquiry made in childhood, the majority do not have ADHD. Meeting all the symptoms in DSM V does not mean ADHD unless there is clear pediatric history. Plus, the neuropsychologist I work with (who published many of the main ADHD texts) recommends specified psychotherapy and talks often about how underutilized it is as well as need to manage the comorbidities as comorbid disorders tend to be the norm rather than the exception in true ADHD. That being said, the patient has to be ready for the comprehensive treatment.

That aside, I have encountered some true cases of ADHD in my practice. @clausewitz2, you are right about your thread on "ADHD personality" they are often not the people who are loud about their inattention and insisting they must have ADHD, despite their glaringly obvious developmental history that they rattled off which sound like a story that could come out of a textbook. Those are indeed some of the most rewarding cases I've come across and helping them in their career path has been fantastic. I have also found them to be quite responsible with their stimulants and to do quite well on reasonable doses. The pseudo ADHD often have unrealistic expectations, often comorbid personality disorders, and are patients who in the wrong hands could end up on things like 70mg vyvanse with 30mg adderall and xanax to take the edge off.

See your approach seems perfectly reasonable and I would only be quibbling on minor points. What I don't get is a blanket refusal to engage with a diagnostic category without qualification.

 

[randomdoc1]

See your approach seems perfectly reasonable and I would only be quibbling on minor points. What I don't get is a blanket refusal to engage with a diagnostic category without qualification.

Just for friendly/curious discussion, what is your (or anyone's) feeling about someone who has nearly a full practice but is no longer interested in taking new patients inquiring about adult ADHD (especially if they can refer to a child and adolescent psychiatrist)? As you can see, the work up can be quite exhaustive and time consuming. I certainly would not be able to keep up with a day full of adult ADHD inquiries as the after visit work would keep me in the office until 10pm =/.

 

[futuredo32]

So what are you going to do when you get a patient who presents for depression and after a few times seeing them, they ask about ADHD or mention their previous medication history as a kid and the history is convincing and it actually explains a fair amount about their particular problems?

Like, is your approach going to be "I think you might have ADHD, gtfo"? This is what I don't get about refusing to treat ADHD. I get outpatient folks not feeling comfortable with someone with a lot of lethality concerns or needs a case manager/service coordinator or maybe is on clozapine and you trained somewhere where you never really learned to do that but it's clearly not the case that you lack the resources or ability to write a script for Adderall.

Screening out people won't keep you entirely insulated from people who may have ADHD. You're just going to ignore it? We're not a field that has so much detailed technical knowledge that it would be irresponsible to treat this without hyperspecialized training.

At this clinic from here on out the owner has decided no new adult patients with ADHD PERIOD. It's not my call. We refer them out at this clinic now. I think this clinic currently has a reputation as a pill mill. Seriously I think a good 2/3 of my brand new off the street consults are for adult ADHD. That's really high. It wasn't my call but I am glad the call was made. Perhaps after the pill mill Dr has been gone for awhile we can treat new ADHD patients but the word has to get out that it's not a pill mill anymore.

 

[futuredo32]

I feel like in this situation as described the clinic owner is either a ***** or is significantly less pure and saintly than OP believes.

He is just very trusting. He is far from a *****. He is so kind. He didn't even check my references. I think his fault is that he owns a lot of clinics and isn't doing enough oversight. He added me to his malpractice and I am supposed to pay for it and I keep reminding him to take it out of my check. He is so kind and he's everyone's favorite therapist from the patients I have seen and he really does care about the well being of the patients at the clinic. He cares about his employees as well.

 

[clausewitz2]

He is just very trusting. He is far from a *****. He is so kind. He didn't even check my references. I think his fault is that he owns a lot of clinics and isn't doing enough oversight. He added me to his malpractice and I am supposed to pay for it and I keep reminding him to take it out of my check. He is so kind and he's everyone's favorite therapist from the patients I have seen and he really does care about the well being of the patients at the clinic. He cares about his employees as well.

To be honest if I was intending to run a pill mill I would also hire literally anyone with an active medical license, no questions asked. Actually I would especially prefer people with fewer other options because they're way more likely to play ball. There is a serious disconnect between being a very successful enterepeneuer but also having no clue he was employing the Candyman. But you are fairly firm in your convinction that he is entirely blameless and it is all the fault of the evil departing psychiatrist so I'll leave that be too.

 

[futuredo32]

To be honest if I was intending to run a pill mill I would also hire literally anyone with an active medical license, no questions asked. Actually I would especially prefer people with fewer other options because they're way more likely to play ball. There is a serious disconnect between being a very successful enterepeneuer but also having no clue he was employing the Candyman. But you are fairly firm in your convinction that he is entirely blameless and it is all the fault of the evil departing psychiatrist so I'll leave that be too.

At the time he hired me and until next June 30 I still fall in the BE range. There are places that don't care if you are BE\BC. You'd have to know him. There are some really kind people left in the world. Maybe the pill mill Dr is actually being fired? I don't ask it's not my business. It's obvious I won't "play ball" He makes about 150 a week off of me, this past Wed he totally lost money on me. He makes money off of the therapists not the medical director or other people who can prescribe. Think about that.
Anyway, it really doesn't matter. The issues are being handled. I am staying and don't have to write for any more controlled substances. Thanks to all who contributed helpful suggestions.

 

[NITRAS]

, I pick and choose when I want to work and he doesn't care about BE/BC. It's NOT a bad job. .
But thanks.

Just curious. Did you not complete a residency in psychiatry?

 

[futuredo32]

Yes I did I just failed the boards twice probably 3x 🙂. I don't care, I am applying to FP next year and hoping for a miracle.

 

[randomdoc1]

No offense op, but there is often more to the story in situations like these. The practice I was at was a pill mill before I came along. At first owner and manager looked reasonable. I found out the owner and manager only cared for money at all costs. They are very lazy, no supervision at all of staff. Now they run primarily a TMS mill. Everyone with a pulse gets it, many patients leave disappointed hoping it was a miracle cure. They have lpc maybe PhD doing Evals and clearing people for it, I thought standard of care is for md to do it? Md does mapping. ZERO medical staff on site for when treatments are administered. They have no seizures protocol. They treat people with active aoda.

 

[futuredo32]

No offense op, but there is often more to the story in situations like these. The practice I was at was a pill mill before I came along. At first owner and manager looked reasonable. I found out the owner and manager only cared for money at all costs. They are very lazy, no supervision at all of staff. Now they run primarily a TMS mill. Everyone with a pulse gets it, many patients leave disappointed hoping it was a miracle cure. They have lpc maybe PhD doing Evals and clearing people for it, I thought standard of care is for md to do it? Md does mapping. ZERO medical staff on site for when treatments are administered. They have no seizures protocol. They treat people with active aoda.

I don't think so just because no other prescriber wants his patients and he has said no more NEW adult ADHD patients. He makes 150 off of me a day at best. I get paid hourly. Even if you are correct and I REALLY don't think so, it doesn't impact me, I am not prescribing controlled substances nor am I inheriting any of the retiring doc's patients, so I am good. But based on the fact that it was ONE provider ONLY I really don't think so. He makes his money off of the therapists.

 

[randomdoc1]

I don't think so just because no other prescriber wants his patients and he has said no more NEW adult ADHD patients. He makes 150 off of me a day at best. I get paid hourly. Even if you are correct and I REALLY don't think so, it doesn't impact me, I am not prescribing controlled substances nor am I inheriting any of the retiring doc's patients, so I am good. But based on the fact that it was ONE provider ONLY I really don't think so. He makes his money off of the therapists.

Which psychiatrists are a great referral source for. He’s indirectly making money. I’m not saying if you should stay or not. But I generally try to go into situations like this with an open mind. Hopefully the therapists actually do therapy and don’t spend the sessions just enabling the patients. As long as they respect your boundaries, I would be satisfied with that but cautious.

 

[clausewitz2]

At the time he hired me and until next June 30 I still fall in the BE range. There are places that don't care if you are BE\BC. You'd have to know him. There are some really kind people left in the world. Maybe the pill mill Dr is actually being fired? I don't ask it's not my business. It's obvious I won't "play ball" He makes about 150 a week off of me, this past Wed he totally lost money on me. He makes money off of the therapists not the medical director or other people who can prescribe. Think about that.
Anyway, it really doesn't matter. The issues are being handled. I am staying and don't have to write for any more controlled substances. Thanks to all who contributed helpful suggestions.

I mean most community mental health agencies make their money off their therapists as well and are mostly breaking even on psychiatrists. It is a common business model.

 

[clausewitz2]

Which psychiatrists are a great referral source for. He’s indirectly making money. I’m not saying if you should stay or not. But I generally try to go into situations like this with an open mind. Hopefully the therapists actually do therapy and don’t spend the sessions just enabling the patients. As long as they respect your boundaries, I would be satisfied with that but cautious.

Actually I am seeing the genius of this model. First, require anyone seeing your practice psychiatrist to be in regular therapy at your practice. Then, Addys and Xannys for everyone. Then, no scripts if you don't show for therapy. High show rate, very little patient turnover, winning.

 

[futuredo32]

The patients don't have to go to therapy to get medications. The ADHD patients don't. He has an average no show rate.

 

[Mass Effect]

He is just very trusting. He is far from a *****. He is so kind. He didn't even check my references. I think his fault is that he owns a lot of clinics and isn't doing enough oversight. He added me to his malpractice and I am supposed to pay for it and I keep reminding him to take it out of my check. He is so kind and he's everyone's favorite therapist from the patients I have seen and he really does care about the well being of the patients at the clinic. He cares about his employees as well.

That's not called being kind. That's called either being too naive for his own good or being a lot smarter and manipulative than you give him credit for.

 

[futuredo32]

That's not called being kind. That's called either being too naive for his own good or being a lot smarter and manipulative than you give him credit for.

And you know this because you have met him? He's really down to earth and we just clicked.

I'm all set. Thanks to those who contributed thoughtful comments. Have a nice weekend.

 

[Jules A]

I don't normally write a word about controlled substances, I feel that having the MAPS is sufficient.

I do my own but even if I didn't I would document it was done on XX date by whoever did it and add any remarkable findings. It actually sounds easier to keep doing it myself.

Odd that you gave notice without informing them you would resign if the load isn't distributed among the three psychiatrists.

 

[futuredo32]

I do my own but even if I didn't I would document it was done on XX date by whoever did it and add any remarkable findings. It actually sounds easier to keep doing it myself.

Odd that you gave notice without informing them you would resign if the load isn't distributed among the three psychiatrists.

I didn't know negotiating was an option.
I didn't want ANY. None of the remaining providers are taking his pill mill patients, it's on the owner to direct them elsewhere and/or the leaving psychiatrist to taper them before he goes. Either way it's no longer my problem. I did email him a lot expressing my unhappiness and concern but it took the resignation email to get what I wanted. There are MAPS in each file I sign and date.. I get TONS of similar job offers daily but this one is kinda nice, I pick my days and hours. It's all good now. I got what I wanted he has a psychiatrist. 🙂

 

[Trismegistus4]

@futuredo32 is catching a lot of flak in this thread, and perhaps he's excessively concerned with litigation, but overall, I share his sentiments. In my area, there is a large group practice which recently stopped taking Medicare. I am getting several new patients every week transferring from them, and 90% of them are on a chronic, daily controlled substance. And they are most emphatically not coming to me to get off of it. In their minds they are there to get "their" medicine which they have been on for 10 years and is working for them. The people I'm seeing as new patients now were given their appointments back in July, and have been waiting over 4 months to see me. They've often been told by their past psychiatrist or their PCP "I will continue your Xanax/Adderall/whatever, but only until the day you see the new psychiatrist. From then on, you need to see him for that issue!" So they are coming in after 4 months of waiting and being led to believe that I am there to give them what they want; I am their last resort, their lifeline, which makes it very difficult simply to say "sorry, I'm not comfortable with that."

Like this lady who's on my schedule for tomorrow. She's transferring from the outside practice, and we have their notes scanned in. I was able to review them briefly today. She's in her seventies, is a retired lawyer, practiced corporate law for 25 years--and was "diagnosed" with ADHD by a PCP in her sixties, and has been on a stimulant ever since then! Ridiciulous! If I had the power, I never would have agreed to see this person.

Working at this place for a little over two years has made me realize that to practice outpatient psychiatry in a sane way, you need a few things:

1. The ability to do therapy yourself, or access to a network of skilled therapists whose skills you can vouch for firsthand to refer to. If you have someone with panic disorder who claims benzos are the classic "only thing that works," you need to be able to tell them they have to do therapy, and if the therapists in your organization are LCSWs whose quality varies widely, they may not get very far.
2. Enough authority over the practice to screen and decline referrals. I know there's been some controversy over this practice on this forum, but you absolutely cannot keep your sanity and practice good psychiatry when you're getting this unending deluge of new patient referrals who have been waiting months to see you and you are their last, best hope for getting the controlled substance they are absolutely irrevocably convinced they need and cannot live without. I am not comfortable prescribing a stimulant to retired sixtysomethings who got through law school and practiced corporate law for 25 years, and had no childhood history of ADHD. Thus, if a person's very reason for coming in is that they are absolutely convinced that is what they need and that I am there to give it to them, there is no point in establishing a doctor-patient relationship with them.
3. Also enough authority over the practice to dismiss a patient who exhibits malingering/drug-seeking behavior, like claiming they've already tried every non-controlled-substance treatment modality under the sun and they've all caused intolerable side effects. You need to be able to tell these people "I'm sorry, there's nothing more I can do for you. I recommend seeking treatment elsewhere." When you're in an employed position, in an organization that, however subtly, sees patients as paying customers, some of these people will give up, but others will just keep scheduling follow-ups with you and coming back until they wear you down, and you prescribe "their" damn controlled substance just to get them to leave you alone.

 

[randomdoc1]

There is an interesting article on doximity about how doctors are fleeing this somewhat abusive environment of medicine.
Doctors Are Fleeing Abusive Medicine
We really should be allowed to set appropriate boundaries without fear of retaliation. We make our recommendations based on the literature and because we are looking out for the patient. Unfortunately this consumer atmosphere is also present in other specialties just like how patients demand antibiotics from their pcps. If we are put in a position where we can set healthy boundaries, it can lead to better outcomes for patients. For example, I’ve seen some patients where I was the third psychiatrist they consulted requesting benzo mono therapy for their ptsd. Only tried one ssri at a microscopic dose and reported intolerable side effects. It was obvious some made up their minds about ssris without even trying. But when I said sorry, my recommendation is the same as the previous two psychiatrists to do therapy, try ssri. They started considering the evidence based route. Some were well in their 60s. At the very least, we are in a better position to minimize further harm and really allow the patient to make true progress. And yes, a good therapist is vital.

 

[futuredo32]

@futuredo32 is catching a lot of flak in this thread, and perhaps he's excessively concerned with litigation, but overall, I share his sentiments. In my area, there is a large group practice which recently stopped taking Medicare. I am getting several new patients every week transferring from them, and 90% of them are on a chronic, daily controlled substance. And they are most emphatically not coming to me to get off of it. In their minds they are there to get "their" medicine which they have been on for 10 years and is working for them. The people I'm seeing as new patients now were given their appointments back in July, and have been waiting over 4 months to see me. They've often been told by their past psychiatrist or their PCP "I will continue your Xanax/Adderall/whatever, but only until the day you see the new psychiatrist. From then on, you need to see him for that issue!" So they are coming in after 4 months of waiting and being led to believe that I am there to give them what they want; I am their last resort, their lifeline, which makes it very difficult simply to say "sorry, I'm not comfortable with that."

Like this lady who's on my schedule for tomorrow. She's transferring from the outside practice, and we have their notes scanned in. I was able to review them briefly today. She's in her seventies, is a retired lawyer, practiced corporate law for 25 years--and was "diagnosed" with ADHD by a PCP in her sixties, and has been on a stimulant ever since then! Ridiciulous! If I had the power, I never would have agreed to see this person.

Working at this place for a little over two years has made me realize that to practice outpatient psychiatry in a sane way, you need a few things:

1. The ability to do therapy yourself, or access to a network of skilled therapists whose skills you can vouch for firsthand to refer to. If you have someone with panic disorder who claims benzos are the classic "only thing that works," you need to be able to tell them they have to do therapy, and if the therapists in your organization are LCSWs whose quality varies widely, they may not get very far.
2. Enough authority over the practice to screen and decline referrals. I know there's been some controversy over this practice on this forum, but you absolutely cannot keep your sanity and practice good psychiatry when you're getting this unending deluge of new patient referrals who have been waiting months to see you and you are their last, best hope for getting the controlled substance they are absolutely irrevocably convinced they need and cannot live without. I am not comfortable prescribing a stimulant to retired sixtysomethings who got through law school and practiced corporate law for 25 years, and had no childhood history of ADHD. Thus, if a person's very reason for coming in is that they are absolutely convinced that is what they need and that I am there to give it to them, there is no point in establishing a doctor-patient relationship with them.
3. Also enough authority over the practice to dismiss a patient who exhibits malingering/drug-seeking behavior, like claiming they've already tried every non-controlled-substance treatment modality under the sun and they've all caused intolerable side effects. You need to be able to tell these people "I'm sorry, there's nothing more I can do for you. I recommend seeking treatment elsewhere." When you're in an employed position, in an organization that, however subtly, sees patients as paying customers, some of these people will give up, but others will just keep scheduling follow-ups with you and coming back until they wear you down, and you prescribe "their" damn controlled substance just to get them to leave you alone.

Thanks. I'm a she but thanks.