Homecoming

[FrustratedFamDoc]

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We all have em. The patient you haven't seen in well over a year that was supposed to follow up in a month last time you saw them. I've now begun to call these encounters as homecoming. Only thing missing is the letter jacket. Greeted with a cigarette smoke odor upon entering the room, out of all meds, no labs in over a year, BP is jacked up, way behind on other health maintenance items. Are they here for any of that.... of course not, what fun would that be? It's usually a real dandy. chest pain, passing out, abdominal pain, fatigue, or the "I just don't feel good."

It's been a real homecoming week for me. Just needed to vent a little, I guess.

 

[deleted87716]

If they are ignoring potentially serious conditions (e.g., CAD, DM, severe HTN, etc.) that will only happen once in my practice. After putting them on notice the first time, they're dismissed the second time. They don't need me to help them take crappy care of themselves.

 

[JustPlainBill]

If they are ignoring potentially serious conditions (e.g., CAD, DM, severe HTN, etc.) that will only happen once in my practice. After putting them on notice the first time, they're dismissed the second time. They don't need me to help them take crappy care of themselves.

Are you serious BD? I didn't know you could do that in that situation. I dismissed my first one for seeking behavior recently but I never actually considered dismissing a patient for non-adherence in the sense of the "homecoming" described by the OP. While I obviously couldn't do that at Parkland during residency (would have to fire over half of the patient panel), but I've had a few in private practice that have pulled those shenanigans. Usually, I'll restart medications and try to pick up where I left off.

I have heard in our practice, some of the partners discussing that certain physicians in the area will fire patients for non-adherence if the patient's numbers make the docs look bad but no one has ever mentioned dismissing a patient for a "homecoming" type of behavior. I wonder if that would work here --

Again, I've never thought of that case ---

 

[VA Hopeful Dr]

Are you serious BD? I didn't know you could do that in that situation. I dismissed my first one for seeking behavior recently but I never actually considered dismissing a patient for non-adherence in the sense of the "homecoming" described by the OP. While I obviously couldn't do that at Parkland during residency (would have to fire over half of the patient panel), but I've had a few in private practice that have pulled those shenanigans. Usually, I'll restart medications and try to pick up where I left off.

I have heard in our practice, some of the partners discussing that certain physicians in the area will fire patients for non-adherence if the patient's numbers make the docs look bad but no one has ever mentioned dismissing a patient for a "homecoming" type of behavior. I wonder if that would work here --

Again, I've never thought of that case ---

I've done it a few times as well. They're wasting my time and theirs by not treating their chronic issues (and it will somehow be my fault when things go bad) so its easier to just boot them.

 

[deleted87716]

Are you serious BD? I didn't know you could do that in that situation.

You can dismiss a patient for pretty much any reason, as long as you do it properly. In my practice, the main reasons I dismiss patients are: 1) Multiple no-shows (usually 3 or more); 2) Violating pain contract; 3) Recurrent noncompliance re: a serious health problem; 4) Failure to pay their bill (hard cases excepted, of course); 5) Egregious behavior (e.g., being repeatedly rude to staff, threatening, etc.)

That being said, I don't dismiss people very often (a handful per year).

I imagine that dismissal for noncompliance will become more commonplace in the era of pay-for-performance.

 

[JustPlainBill]

You can dismiss a patient for pretty much any reason, as long as you do it properly. In my practice, the main reasons I dismiss patients are: 1) Multiple no-shows (usually 3 or more); 2) Violating pain contract; 3) Recurrent noncompliance re: a serious health problem; 4) Failure to pay their bill (hard cases excepted, of course); 5) Egregious behavior (e.g., being repeatedly rude to staff, threatening, etc.)

That being said, I don't dismiss people very often (a handful per year).

I imagine that dismissal for noncompliance will become more commonplace in the era of pay-for-performance.

That's what I like about you BD -- a reasoned, adult response that's not colored by any sort of sanguine behavior -- unlike others *cough JustPlainBill *cough --- I was discussing a case with a colleague in our practice yesterday -- My colleague had a patient who had no-showed 16 times and then remonstrated with the MA that they had not no-showed 16 times, they had been more than 15 minutes late 5 times and were told they'd have to reschedule. My colleague told their staff that the patient would have to be seen before refills would be allowed.

I find it rather interesting that the consumerism mentality has been applied by the lay public to medicine. I recently had a conversation with a patient who was shocked, nay, aghast I tell you when I informed them that bipolar disorder did not mean that they had emotional swings between mania and depression -- that was not what the term "Bi-polar" was referring to despite a common misconception. Little Ms. KnowItAll questioned the veracity of my statement and requested proof to which I replied that for $250K and 11 years of her life, she could obtain the proof but for now, not to confuse her Google search with my medical degree.

However, I do want to thank @Blue Dog and @cabinbuilder for helping me learn to firmly establish boundaries without fear. It's a lot easier to practice that way ----

 

[cabinbuilder]

Yw, of course, @JustPlainBill, always glad to spew forth words of wisdom (or not so much) but I try. 🙂

I have "unofficially fired" a family from urgent care (admin won't allow it). However, when the wife who is an obvious addict has been seen in urgent care 29 times in 6 weeks for the same sinus/allergy, etc but never seems to get the meds or "forgets", I have a problem with that. The husband threatened to physically hurt me and have me fired screaming in the lobby - that is a deal breaker for me, and I will not allow them nor will I ever be in a room with them again. Have had too much violence in the past against me and I absolutely will not put myself in potential danger ever and not in a closed room with a man 2-3 times my size.

Today I had a 15 year old girl, runaway, brought in by dad who was very sick. She tells me "I don't do shots, but you can draw my blood for mono". Now a needle is a needle in my book and I don't let some teen dictate the care. It's all or nothing. She got nothing but oral meds. Whatever, no need to waste my time and I never, never beg or plead with a patient. It is what it is. Take what I offer or you can go to your PCP.