Inheriting patients on not the greatest meds..........

[TexasPhysician]

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I am a nurse practitioner and also a patient who has been on Xanax

the benzo's are making them happy and that is all that matters.

I had no time for CBT. So far I take 4 mg a day and have no adverse side effects.

It is the laziness of the prescribers.

Huh? Must be satire?

 

[WisNeuro]

Huh? Must be satire?

Either that or this person must have zero experience in gero psych.

 

[Attending1985]

Huh? Must be satire?

I was wondering the same thing but I don’t think so

 

[clinicalpresentations]

If find in a situation where a patient is really attached to a particular drug you need to stop pushing your agenda for a minute, park your feelings about their path of care, and really dig into the relationship end of the problem, and learn to think about recommending drugs as being a bit like selling cars.

Patients can get to feel about their meds the way Linus felt about his blankie. I know, as someone with ADHD, if you tried to pull my stimulants I'd bite your arm off at just shy of your jugular. I have a whole life that depends on me getting out of bed each day and sticking to my rituals so that the impact of my disorder stays in the background of my life, but meds changes bring that impairment right into the forefront. Suddenly what was just an annoying sniffle becomes the metaphorical bronchitis of neurological phenomena and my whole life grinds to a halt until I fix the problem.

For you to get buy in on the changes, you need them to really trust you.

Start off by accepting that a major change in drugs is not going to be something you can pull off in one session. I'd say about three sessions should work for most people.

You have to start out by doing some fishing into history. Try to dig into what they were like BEFORE they stabilised, preferably before they even touched meds the first time. Just get a feeling for what that was like. Talking to them about a time where they felt really bad and totally helpless will help them feel you actually know enough about their struggle to respect why the current equilibrium of possibly bad meds matters so much to them.

Next start digging into the symptoms that don't respond. There's going to be some. Most patients that end up on a plethora of bad meds get that way because they were treatment resistant - nothing seemed to stick. Even really good doctors get to a point where they become scared of messing with a complicated cocktail when a patient has been coming back year after year barely responding, and suddenly you hit on something that gives you just a tiny win.

Thankfully modern improvements in psychopharmacology means we often can do much better now with those issues. As recently qualified physicians you actually have an edge here. As a patient and a provider, it's been my experience that while older doctors have a better eye for diagnostics and patient interactions, younger ones tend to be more innovative with pharmacology because they have the most up to date info at their fingertips fresh off the research presses.

Exploring those issues, and explaining to your patient that you think that this or that drug just developed recently (well compared to what they are on anyway) might offer better coverage on these intractable symptoms may just give you the leverage you need. I promise you, as someone with a diagnosis myself, if a doctor could suggest a drug that gave me all the joys of my current medications, but with a little extra spin off my anxiety or sleep problems as a side dish, I'd jump at the opportunity to try it out. Selling new meds is like selling a car, really. You're selling a means for a patient to get where they need to go in their lives. Speak to the lifestyle aspirations 🙂

Next up is family. If a spouse, child or parent is involved, bring them in. Sit with them and talk. Talk to them privately. Get the full skinny on both their gripes and their joys. They will often drop valuable little hints on things the patient themselves may overlook or forget about that clue you into unexpressed needs or problems that, if brought up in the context of trying new meds, might go well for you. My partner actually did this at one session where she pointed out her observations of how my focus dipped at certain times of the day. This led to a better idea of how rapidly I was metabolising my stimulant meds, and how to choose which drug was best, and dosing to get better coverage. Without her keen observance I'd never have known. But your patients aren't trained to think of such things or ask them of their family. You are.

People like to feel like they still have agency. When a patient gets a mix of meds that give them back some of that agency (ie. if I am a good little girl and drink my pills every day, I won't end up in the psych ward again and I get a cookie!) they will wrestled you to death for that little bit of control they feel they have. Mental illness is disempowering and soul crushing. Remember that when working with them. You're dealing with a subtle lifetrauma over and above whatever originally brought them in - the experience of losing control of your mind - that permeates every reaction they will have to you and all aspects of their lives. How well that issue is handled by each patient (and you, their physician) determines their relationship to you and their treatment protocol. So try to frame these changes in a manner that allows them to have a measure of control. Present them with options between different drugs you're thinking of trying. Give them information on the drugs in question and encourage a discussion about these options at home, away from you so they can engage with their support network about the wisdom of the decision.

Have a frank discussion about side effects, and ask them questions about their other health problems - for example, one patient I had that was reluctant to abandon lithium. I wasn't sure it was helping her as much as something like Lamotrigine might do, but she was very insistent that she didn't want to change. Turns out she'd been having some issues with interstitial cystitis that turned out to be related to the lithium. Her kidney function was ok, and everything looked fine on the surface, but apparently shortly after starting lithium she'd begun having these "bladder infections" that wouldn't go away. She'd been to urology repeatedly and nothing cultured, and was really unhappy because she'd started to need incontinence products. When I explained that Lithium might be contributing to the issue due to it's renal effects, she suddenly got a lot more enthusiastic about trying something else - because wetting our knickers in public as an adult is pretty strong motivating stuff.

 

[WisNeuro]

Next start digging into the symptoms that don't respond. There's going to be some. Most patients that end up on a plethora of bad meds get that way because they were treatment resistant - nothing seemed to stick. Even really good doctors get to a point where they become scared of messing with a complicated cocktail when a patient has been coming back year after year barely responding, and suddenly you hit on something that gives you just a tiny win.

I don't know where you practice, but I have never seen this to be the case. I can see the med histories. Most patients are on a plethora of bad medications due to lazy/incompetent prescribing habits. And, in the case of anxiety, there was zero discussion about therapy or behavioral interventions before being given a benzo. There are always a handful of prescribers in any system who generally hand out Xannies like tic tacs. Luckily it's usually s small number of individuals, but they can still do a ton of damage. I mean, I get the whole, let's be holistic attitude, but we also have to look at base rates and where people are practicing. I deal with a primarily gero population, and I see the damage caused by bad prescribing on an almost daily basis. We need to look at both sides of the issue, but at least in my clinic, bad prescribing habits are the much bigger slice of the pie.

 

[clinicalpresentations]

I don't know where you practice, but I have never seen this to be the case. I can see the med histories. Most patients are on a plethora of bad medications due to lazy/incompetent prescribing habits. And, in the case of anxiety, there was zero discussion about therapy or behavioral interventions before being given a benzo. There are always a handful of prescribers in any system who generally hand out Xannies like tic tacs. Luckily it's usually s small number of individuals, but they can still do a ton of damage. I mean, I get the whole, let's be holistic attitude, but we also have to look at base rates and where people are practicing. I deal with a primarily gero population, and I see the damage caused by bad prescribing on an almost daily basis. We need to look at both sides of the issue, but at least in my clinic, bad prescribing habits are the much bigger slice of the pie.

I'm working in a state run clinic in Capetown South Africa, so your mileage may vary. Still, you have to ask yourself: If I distrust the prescribing doctor who took these notes, how much credence do I give them? For me, that's the moment I go back to the source and rethink this from scratch before wading in with new meds.

I hear you on the benzos. If they aren't looking at things like mindfulness practices and handling any possible root traumas in therapy, tossing pills at the problem isn't good medicine.

Thing is, if you need to get them on your side to fix this, you have to realise your patients don't know that what they got was bad medicine. All they know is the lady they liked said take two of these day and night to feel better, and they did. You know they could feel MORE benefit with a different intervention because you've seen the research, you've seen the effects first hand. All they have however is your say so. You have to win their trust in your judgment. You're asking them to toss out a known good thing for an unknown allegedly better thing.

Say you have a nice mobile phone, but the screen is cracked a bit. Still works, but it's a good phone. All you want is a new screen. But while you're at the shop the guy behind the counter has been watching you with your phone for fifteen minutes. He's a phone salesman. He knows phones. And he thinks he has just the upgrade for you.

Now remember, you're not here for a new phone. You're here to get your old phone as quickly as possible and get home so you can go feed your kids. But he's REALLY insistent about this phone.

What makes you decide to take his advice?

THAT is the No. 1 quality you need to cultivate with these patients.

 

[WisNeuro]

I don't care about phones, I care about mortality, fall risk, and increased cognitive difficulties in my patients.

 

[erg923]

Say you have a nice mobile phone, but the screen is cracked a bit. Still works, but it's a good phone. All you want is a new screen. But while you're at the shop the guy behind the counter has been watching you with your phone for fifteen minutes. He's a phone salesman. He knows phones. And he thinks he has just the upgrade for you.

Now remember, you're not here for a new phone. You're here to get your old phone as quickly as possible and get home so you can go feed your kids. But he's REALLY insistent about this phone.

Are you serious with this?

 

[clinicalpresentations]

Are you serious with this?

Utterly. Why?

 

[erg923]

Utterly. Why?

Well, does a phone sales man provide healthcare services, take the Hippocratic oath, or have any degree of the responsibility of a prescribing physician?

Patient centered care does not meant patient directed care.

 

[clinicalpresentations]

Does a patient not have the right to direct care? Did I miss out on some aspect of the ethics of informed consent?

A cellphone salesmen is the suitable expert in advising on the purchase of cellphones. A medical provider is the suitable expert on the topic of choosing healthcare interventions. But just like cellphone shops, there are millions of them and not all of them are equally competent. What do you call a physician that finished at the bottom of their class?

Doctor.

If you find that you believe that your title negates the patient's right to choose you have a problem with your ethics.

We are fallible. We miss things. We are not gods. And at the end of the day the only person who will have to live with our mistakes for the rest of their lives are the patients. For the most part unless we get sued or they die we won't ever have to live with any inkling of exactly how our screw ups screw them up.

Not really. We may go through a lot of emotional stress when we lose a patient, or we see someone suffer for our mistakes, but we are still on the outside of that suffering, not inside of that loss of life or quality of life.

I think it's natural for patients to have no more fait in our judgment than in the judgment of any other person unless they know us, as a person.

I certainly hope that the fact that I wasted most of my drinking years in the library and not in the pub would count in my favour, but what do they know of our institutions, or the promises we make and why we make them? Do they have our education? Do they know what the hippocratic oath even means to us when we take it? Do they even know whether we meant it? Who could know the inside of another man's mind, after all?

But you can tell a lot by their character. By the way they talk to you, and the respect they give your feelings and opinions on things that concern your health and your life.

Waving around our credentials feels too much like a dominance display to me. There should be a limit on how paternalistic our attitudes can be towards our patients. They are autonomous individuals with an adult's right to free choice. I would guard against getting too comfortable in this bubble of unquestioned authority we inhabit that is so rarely challenged by the average patient while they dutifully perform the sick role and we the role of priest of healing.

 

[WisNeuro]

If you find that you believe that your title negates the patient's right to choose you have a problem with your ethics.

The title means that we do not offer treatments that we know are overwhelmingly harmful to the patient, even if that's what they want. We are not a supermarket. Patients can't pick whatever they want off the shelf. We give them the best options available according to the science at the time. We do not give them our advice and let them pick whatever they want anyway. They're free to go find an incompetent doctor that will do so, but we do not need to be complicit in causing harm and incompetence.

 

[erg923]

Does a patient not have the right to direct care?

No.

 

[clinicalpresentations]

I don't care about phones, I care about mortality, fall risk, and increased cognitive difficulties in my patients.

They care about their mortality and cognitive difficulties too, but there's a very serious communication problem here and that's what I'm trying to highlight to you.

My ex was an IT guy. He was all about network switches and servers and the shell. I got to be pretty good at this stuff from having his work lying around in untidy piles all over the house for fifteen years. I'm trying to illustrate to you one of the reasons why we have such a hard time getting patients to work with us and not against us when it seems so obvious to us that they are being self defeating.

One of the standing jokes in IT is the on about the problem existing between Screen and Keyboard. That's you by the way, the User. They also call it the ID10T error. That's when an IT guy thinks you're too ignorant to understand why your computer won't work any better if you keep clicking the mouse over and over while the program loads. Whenever we crack jokes about the stupid things patients try to get past us I see parallels with those geek conversations where a bunch of fellows with messy haircuts and pasty skin tones crack jokes about the user that forgot to turn it off and on again before calling support.

Likewise, those around IT geeks joke about how socially inept they generally are as a professional group. How utterly incapable they are of translating their advice into user friendly terms at times, or how they somehow seem to think everyone speeks in Geek.

We're like that too. We also forget that not everyone knows what we know, sees what we see.

We get sarcastic and snippy with people who are obviously ignorant even though that's none of their fault for the most part. We also forget that to them we're like foreigners. We use words they've never heard of to explain concepts they can't even begin to grasp right before we give them instructions that to them are just as terrifying as the words "You'll need wipe the harddisk, you have a virus." or "Your dissertation is corrupted, do you have a backup?"

Years of watching this in action made me realise that I could be a better carer if I stopped and considered exactly how what I was doing was going to be perceived by my patient - from THEIR frame of reference.

 

[erg923]

We get sarcastic and snippy with people who are obviously ignorant even though that's none of their fault for the most part. We also forget that to them we're like foreigners. We use words they've never heard of to explain concepts they can't even begin to grasp right before we give them instructions that to them are just as terrifying as the words "You'll need wipe the harddisk, you have a virus." or "Your dissertation is corrupted, do you have a backup?"

Infantilizing your patients is bad.

 

[WisNeuro]

I don't think it's more a problem that you are arguing for something distinctly different than the point of this thread. The majority of this thread is about bad prescribing habits. How this bad prescribing is harmful to patients. In very clear, measurable ways. I would say most here are not "blaming" the patient. They blame bad providers who started the mess. Yes, the patient eventually becomes part of the problem when they become addicted to their poorly prescribed medications and resist a change. But, most here would agree that it's a problem at the front end, that drags patients along and entrenches them into the problem too.

Trying to empathize with patients from their point of view is one thing. Acquiescing and contributing to harmful outcomes and gross incompetence is another matter altogether.

 

[clinicalpresentations]

The title means that we do not offer treatments that we know are overwhelmingly harmful to the patient, even if that's what they want. We are not a supermarket. Patients can't pick whatever they want off the shelf. We give them the best options available according to the science at the time. We do not give them our advice and let them pick whatever they want anyway. They're free to go find an incompetent doctor that will do so, but we do not need to be complicit in causing harm and incompetence.

Agreed. We have a higher responsibility, precisely because we did take that oath. But at what point does our perception of what they have begin to have more weight than their actual lived experience? When did we begin to read their minds?

The effort MUST be collaborative. The patient's own subjective experience of reality remains subjective. We cannot displace it with our perception of their reality. Reality will assert itself. And sometimes that is expressed by patients asserting that we are wrong, that they know better. Sometimes they really do. The discernment we must learn most in our profession is telling WHEN they do.

And to me that can only happen when we know that we are pulling our weight in terms of bringing excellent people skills and communication to the table, and really maintaining a high level of respect for patient autonomy.

Increasingly we are being challenged by patients who walk into our office not as a source of first information on a complaint, but as a source of confirmation or secondary opinion - the first opinion now being usurped by the internet.

This is obviously a big problem, because the internet takes no oaths.

But likewise, the internet speaks their language, and sometimes there are people who did take oaths who are actually listening to them when we aren't. There's a fair bit of research now into the reasons behind why people are flocking towards alternative health practitioners in such droves and so far as I can tell, we have a PR problem.

They think our bedside manner sucks.

 

[WisNeuro]

We are talking about different things here. I do not need to be able to read my patient's mind to know that 4 mg/day of Xanax is an extremely inappropriate way to deal with mild anxiety in a 72 year old. The bulk of this problem is not communication skills, or empathy with the patient, it is about bad prescribing.

 

[WisNeuro]

Or, let's use an example from just this morning. 70 year old woman, family describing progressive memory problems, confusion, no insight. Also having sleep problems, doctor told her to take 1-3 Tylenol PMs every night for sleep. This is also in addition to high strength tylenol that she takes in the morning and afternoon, and some other drugs with mild to moderate anticholinergic properties. Any problems with that?

 

[erg923]

Agreed. We have a higher responsibility, precisely because we did take that oath. But at what point does our perception of what they have begin to have more weight than their actual lived experience? When did we begin to read their minds?

The effort MUST be collaborative. The patient's own subjective experience of reality remains subjective. We cannot displace it with our perception of their reality. Reality will assert itself. And sometimes that is expressed by patients asserting that we are wrong, that they know better. Sometimes they really do. The discernment we must learn most in our profession is telling WHEN they do.

And to me that can only happen when we know that we are pulling our weight in terms of bringing excellent people skills and communication to the table, and really maintaining a high level of respect for patient autonomy.

Increasingly we are being challenged by patients who walk into our office not as a source of first information on a complaint, but as a source of confirmation or secondary opinion - the first opinion now being usurped by the internet.

This is obviously a big problem, because the internet takes no oaths.

But likewise, the internet speaks their language, and sometimes there are people who did take oaths who are actually listening to them when we aren't. There's a fair bit of research now into the reasons behind why people are flocking towards alternative health practitioners in such droves and so far as I can tell, we have a PR problem.

They think our bedside manner sucks.

Our job is to use various clinical methods to discern proper diagnosis and render treatment. Not to just empathize with subjective complaints and prescribe as the patient wishes.

 

[Attending1985]

I think it’s absolutely right that patients become victims of bad prescribing and then our frustration is turned on them. It’s important to remember that they were given these meds by a trusted doctor and now are in a bad spot and to show some empathy . That being said I don’t think you have a responsibility to continue these meds indefinitely just because the patient wants to. The fact is that some medications are dangerous and causing more problems than they’re solving. Patients often aren’t aware of this because they’re not trained to be or their judgement is impaired by the influence of powerful, reinforcing effects of medications. I think we’ve all had experiences where a patient is initially resistant but thanks you in the long term. It’s not paternalistic to say that we know more than patients about treatment it’s just a fact. Collaboration will always be the best way to go but sometimes it’s just not possible no matter how skilled we think we are and we still have to do the right thing.

 

[clinicalpresentations]

Infantilizing your patients is bad.

And yet everywhere I go in our community I see that we still do.

I don't think it's more a problem that you are arguing for something distinctly different than the point of this thread. The majority of this thread is about bad prescribing habits. How this bad prescribing is harmful to patients. In very clear, measurable ways. I would say most here are not "blaming" the patient. They blame bad providers who started the mess. Yes, the patient eventually becomes part of the problem when they become addicted to their poorly prescribed medications and resist a change. But, most here would agree that it's a problem at the front end, that drags patients along and entrenches them into the problem too.

Trying to empathize with patients from their point of view is one thing. Acquiescing and contributing to harmful outcomes and gross incompetence is another matter altogether.

How is it ok to blame a patient for resisting a change when they are addicted? Is that not the definition of addiction? The inability to cease using the substance because it creates dependency? They are still not part of the problem other than in the sense that they ARE now the embodiment of it. But they are a sentient and autonomous embodiment, and we cannot pretend that the solution doesn't involve engaging that sentient mind in it's own healing. That's a relational activity.

There's a massive discrepancy in the degree of power we have versus the degree of power of the patient. What are you afraid of? They are always in the position of supplicant in relation to us. We control that prescription pad. They would have to commit a literal crime to gain control of it by any other means than persuasion. That to me is a big deal. That means I really need to remember to allow myself, on occasion, to be persuaded.

And that's an issue for my ego, even if it isn't for yours. Persuasion involves admitting wrong, or ignorance, or conceding a point. It involves ceding to them, for a moment, the high office of being the most informed person in the exchange.

I know we work really hard on keeping our egos out of it, but we are still human. We have feelings. And its unpleasant when you're really trying to look out for someone and they go "Nope, no thanks. I'll be over here puffing on cancer sticks and missing my meds thanks." It's hard in that moment to suck it up and go "Why? Why won't you listen to me? What is it that you feel I'm missing? I'm really asking, and I'm really listening. Give me your perspective." because usually the response is going to come out of a place of irrational thinking or needless hostility which is, again, unpleasant to deal with.

But I argue that that's the job. We're handling people with a MENTAL illness here. Just because they are being generally irrational or hostile doesn't mean they don't have a valid point in there that's really important for us to consider. And it's part of our chosen vocation to help unearth the reasons they struggle - regardless of where that answer lies.

 

[WisNeuro]

No one said to blame the patient. Your words, not ours. They are saying that we now have to work with the patient to change the bad prescribing. If they are unwilling to make a slow change, they are free to find care elsewhere. If you want to be the "most empathic you can be" and continue to harm your patients, as other bad prescribers have, go right ahead and join the herd. I'll continue to care about the well-being of my patients and making recommendations aimed at maximizing their quality of life and physical safety.

 

[clausewitz2]

No one said to blame the patient. Your words, not ours. They are saying that we now have to work with the patient to change the bad prescribing. If they are unwilling to make a slow change, they are free to find care elsewhere. If you want to be the "most empathic you can be" and continue to harm your patients, as other bad prescribers have, go right ahead and join the herd. I'll continue to care about the well-being of my patients and making recommendations aimed at maximizing their quality of life and physical safety.

First, it is of course the case that most of the threads on here about ADHD and stimulants, for example, contain an awful lot of venting of negative feelings and frankly mocking patients as drug-seekers. I definitely get the frustration and even the need to vent about it, but pretending we are entirely beneficent and not at all hostile in our attitudes expressed here is prima facie ridiculous and not credible.

There is a harm reduction case to be made of trying to get buy-in from these sorts of hard cases (especially when the fault lies with a previous prescriber) by not immediately ripping away something they have come to depend on, however harmful. If they do not perceive you as being on their side, they are simply never going to listen to your treatment recommendations, no matter how virtuous they are. I wonder if this is more immediately obvious as a compelling rationale to those of us from the medical side because we have all had the experience of seeing people dying because they were surprisingly not motivated to address their health issues by hectoring lectures or prim insistence on 100% adherence v. the door. Regardless, I know I am not super well-trained in therapy, but it seems to me like even if you thought a client presenting to you was in a very toxic and frankly dangerous relationship, you would not in fact end your first evaluation session with "you need to leave your husband immediately" if the client did not seem interested in or ready to go down that road.

Of course this needs to not become an excuse to actively and in the long term perpetuate things that are extremely harmful just because we cannot tolerate some negative affect, but who exactly is helped by us acting as Paragons of Evidence-Based Virtue if all it means is that our patients disappear and find the local Xan-dyman?

 

[WisNeuro]

First, it is of course the case that most of the threads on here about ADHD and stimulants, for example, contain an awful lot of venting of negative feelings and frankly mocking patients as drug-seekers. I definitely get the frustration and even the need to vent about it, but pretending we are entirely beneficent and not at all hostile in our attitudes expressed here is prima facie ridiculous and not credible.

There is a harm reduction case to be made of trying to get buy-in from these sorts of hard cases (especially when the fault lies with a previous prescriber) by not immediately ripping away something they have come to depend on, however harmful.

Of course this needs to not become an excuse to actively and in the long term perpetuate things that are extremely harmful just because we cannot tolerate some negative affect, but who exactly is helped by us acting as Paragons of Evidence-Based Virtue if all it means is that our patients disappear and find the local Xan-dyman?

I would say that many on here have already stated that they advocate a tapering down, and that's what I see from the good prescribers I work with. I don't think anyone is against forming an alliance with the patient to advocate for their collaboration in the matter. I think most of us are a little alarmed by a supposed notion that some are seeming to take that the patient can stay on whatever they want, for as long as they want, because empathy reasons. Additionally, you will find patients that no matter how empathic you are, will refuse to give up their xannies/otherbenzos/unnecessary stimulants, no matter what kind of tapering plan you try to work with them on. In such cases, I see no problems with prescribers not wanting to continue the bad prescribing habits. Heck, if even for liability purposes alone. If my mother were on the med regimens that I see many of my patients on and she had a negative reaction/adverse outcome that was predictable given the regimen, you can bet your ass I am pursuing legal action and doing my best to make that prescriber regret their decision to practice incompetently. Perhaps we should stop shielding the Xandyman from negative consequences and hold them accountable for their actions.

 

[clinicalpresentations]

Infantilizing your patients is bad.

How is assuming they cannot be useful in selecting their own treatment plan not a form of infantilization? Just because we are better informed doesn not mean we have better organs of thought. Our patients, if allowed to engage with our knowledge via our careful and thorough explanation of the ideas involved, can sometimes provide extremely useful insights into their case.

Again, I call on the example of my ex the IT guy. Sometimes he was struggling to troubleshoot some of the issues on a device. Because I'd picked up a few things watching him work over the years we found that now and then I could actually make remarkably astute observations despite my lack of a degree in information science. So from time to time he'd take the time to explain the issue he was having trouble pinning down, and I'd apply my very different way of thinking about problems to his problem, and it often proved extremely helpful. This was doubly true if the system in question was my own laptop, a device I know well and had much experience with. I could, if prompted correctly, provide valuable observations on it that would have taken an eternity to obtain in any other way.

The knowledge and insight of a patient into their own experience is a resource and I think to dismiss it so readily is deeply problematic.

 

[erg923]

How is assuming they cannot be useful in selecting their own treatment plan not a form of infantilization? Just because we are better informed doesn not mean we have better organs of thought.

No one said any such thing. To the second sentence: Actually, yes it does. What the hell do you think all the education is for if that statement is false?!

If my assessment and clinical/diagnostic judgment is discrepant from their wants, I have duty to treat them appropriately. Not simply as they want/see fit. I'm not sure why anyone in a prescribing position would let a patient dictate their prescribing if it's against their clinical judgement. We aren't selling phones here, right? We are prescribing a medical treatment that poses undue risk if it is not truly clinically appropriate.

IT analogies are really not applicable to the doctor-patient relationship and the responsibility put on the attending healthcare provider.

 

[randomdoc1]

First do no harm...

 

[clinicalpresentations]

I would say that many on here have already stated that they advocate a tapering down, and that's what I see from the good prescribers I work with. I don't think anyone is against forming an alliance with the patient to advocate for their collaboration in the matter. I think most of us are a little alarmed by a supposed notion that some are seeming to take that the patient can stay on whatever they want, for as long as they want, because empathy reasons. Additionally, you will find patients that no matter how empathic you are, will refuse to give up their xannies/otherbenzos/unnecessary stimulants, no matter what kind of tapering plan you try to work with them on. In such cases, I see no problems with prescribers not wanting to continue the bad prescribing habits. Heck, if even for liability purposes alone. If my mother were on the med regimens that I see many of my patients on and she had a negative reaction/adverse outcome that was predictable given the regimen, you can bet your ass I am pursuing legal action and doing my best to make that prescriber regret their decision to practice incompetently. Perhaps we should stop shielding the Xandyman from negative consequences and hold them accountable for their actions.

That's the thing though. I got this really hostile reaction to the idea of just edging a little more towards free choice for our patients - and the reaction I got was like I suggested we start photocopying scripts for benzos and leaving them in the waiting room with a stamp for our signatures.

I've been on benzos at times for my own anxiety. I've had a xandyman who was happy to write me up one a day for a month even though I'd never needed more than a handful for really hectic stress situations. I know this is a real issue, and I know we end up having to clean up the mess when the addict eventually begins to escalate and things get hairy, or even later on when they wash up in ward after an overdose because they fell off the slippery slope into the loving arms of the black market while nobody was looking.

But I've been on the other side of that prescription pad. Some doctors really don't even engage with you. And I've talked to a a lot of fellow patients in my capacity a peer, not as a provider. There's this feeling of disempowerment and fear that runs as a deep undercurrent in the support communities. We are both revered...and feared.

I see them having little caucuses on how to talk to us in the most productive way. The content is disturbing. It's the kind of level of distress you see in people who are applying for parole. They are self censoring real experience to conform whatever narrative they can find that works because they are terrified we'll pull drugs that allow them to keep their kids out of foster care. By not speaking to this fear, by not acknowledging the very real and very dangerous power dynamic, we create exactly the kind of ripe breeding ground where xandyman's get to write up whatever they want to so long as it keeps patient's quiet.

If we educate a patient about drugs of abuse, and then engage with them, and they turn out to be one of the good apples, that's one more peer in the community - that back end world we never really get to see where patients find some of their most hairbrained ideas - that might JUST influence a patient to actually heed our warnings.

I'm rambling on here, but I just cannot seem to convey the seriousness that I feel about this issue with patient autonomy. We're getting it wrong, not just as individual prescribing doctors, but as a discipline, and until we get it right I think we are quietly contributing to an environment where bad prescribing practices is the norm rather than the exception.

 

[erg923]

That's the thing though. I got this really hostile reaction to the idea of just edging a little more towards free choice for our patients - and the reaction I got was like I suggested we start photocopying scripts for benzos and leaving them in the waiting room with a stamp for our signatures.

I've been on benzos at times for my own anxiety. I've had a xandyman who was happy to write me up one a day for a month even though I'd never needed more than a handful for really hectic stress situations. I know this is a real issue, and I know we end up having to clean up the mess when the addict eventually begins to escalate and things get hairy, or even later on when they wash up in ward after an overdose because they fell off the slippery slope into the loving arms of the black market while nobody was looking.

But I've been on the other side of that prescription pad. Some doctors really don't even engage with you. And I've talked to a a lot of fellow patients in my capacity a peer, not as a provider. There's this feeling of disempowerment and fear that runs as a deep undercurrent in the support communities. We are both revered...and feared.

I see them having little caucuses on how to talk to us in the most productive way. The content is disturbing. It's the kind of level of distress you see in people who are applying for parole. They are self censoring real experience to conform whatever narrative they can find that works because they are terrified we'll pull drugs that allow them to keep their kids out of foster care. By not speaking to this fear, by not acknowledging the very real and very dangerous power dynamic, we create exactly the kind of ripe breeding ground where xandyman's get to write up whatever they want to so long as it keeps patient's quiet.

If we educate a patient about drugs of abuse, and then engage with them, and they turn out to be one of the good apples, that's one more peer in the community - that back end world we never really get to see where patients find some of their most hairbrained ideas - that might JUST influence a patient to actually heed our warnings.

I'm rambling on here, but I just cannot seem to convey the seriousness that I feel about this issue with patient autonomy. We're getting it wrong, not just as individual prescribing doctors, but as a discipline, and until we get it right I think we are quietly contributing to an environment where bad prescribing practices is the norm rather than the exception.

Patient comes to your first appt demanding admission for residential treatment of a substance use disorder Do you just appease them and refer? Or do you use some actual clinical judgment about their requested level of care and speak to them (therapeutically) about this?

The former is attending to the patient's choice but is an abrogation of your ethical duties to triage to appropriate levels of medical care. This can be viewed as a UR issue, as well as clinical and ethical one.

Think of it this way: Patient presents with CC of shoulder pain. His suggestion is to kick him square in the nards so that his shoulder pain isn't so prominent. Would this work? Yes. Is this clinically appropriate? No. You wouldn't appease the patient in this situation, right?

 

[WisNeuro]

Think of it this way: Patient presents with CC of shoulder pain. His suggestion is to kick him square in the nards so that his shoulder pain isn't so prominent. Would this work? Yes. Is this clinically appropriate? No. You wouldn't appease the patient in this situation, right?

But what if another doctor did this for the patient in the past and the patient insists that it's pretty much the only thing that works. I mean, we have to be empathic to their needs and experiences.

 

[thoffen]

I think you are a fool if you don't recognize that medications become objects that are used by both patients and doctors within therapeutic relationships. But you can't really make generalizations from that realization.

 

[clinicalpresentations]

Patient comes to your first appt demanding admission for residential treatment of a substance use disorder Do you just appease them and refer? Or do you use some actual clinical judgment about their requested level of care and speak to them (therapeutically) about this?

The former is attending to the patient's choice but is an abrogation of your ethical duties to triage care to appropriate levels of medical care. This can be viewed as a UR issue, as well as clinical and ethical one.

Think of it this way: Patient present with CC of shoulder pain. His suggestion is to kick him square in the nards so that his shoulder pain isn't so prominent. Would this work? Yes. Is this clinically appropriate? No. You wouldn't appease the patient in this situation, right?

Patient comes to me on first appt demanding anything I establish the fact that whatever it is they want I cannot just open my arms and give it to them. I explain exactly what we have all said here. I can't just go with the flow - I swore to put your best interest above anything else, and I cannot in good conscience say that I know what your best interest is until I know more about who you are, what you want from your life, and what it is that brought you to be here in front of me now. Please help me understand. Explain yourself.

It's my call, and I'm not making it until I'm satisfied. That's how it's got to be, so work with me.

But it's how I get to that moment of deciding if I like the story or not that is important to me in this conversation. During my residency I found myself repeatedly feeling like there were missed opportunities for understanding that could have been prevented if there was just a little more respect for the intelligence of the patient, or a little more patience with the fact that althought they don't have a lot of education like we do, sometimes they have enough for it to matter.

Because I started seeing this problem. We have these patients at the teaching hospital outpatient clinic. They are supposed to leave the system. We're an acute care facility. We're supposed to devolve to a day hospital in their hometowns. Instead, I see them and sometimes their family members come in month after month, weary and disheartened by lack of progress. They are our paradoxical longtimers in an institution that isn't supposed to have any.

Used to be I couldn't do a thing. I sat in those sessions as a student, biting my tongue. I'd see opportunities to slip past as I see them try, as politely as possible, to present their little idea or paper printout, and watch them deflate as the person behind the prescription pad doesn't even read through the first paragraph. Or the ones that came in swinging only to get shot down for being too hostile but the content of that little rant was surprisingly cogent. Sometimes I've dug those printouts out of the trash, and read them all the way through...and felt like maybe the patient had a point. Over the years I would fill in here and there for a busy clinic or someone taking leave, and I'd run into these patients - now jaded and laconic and obviously distrustful of me on sight. That's not what they were like before.

And this wasn't just the patients of doctors I was working under who obviously were just bad apples (ther's always one...at the least). There were situations where this happened that I was actually shocked because I didn't expect that kind of reaction from my teacher given what I'd been taught. They did not practice what they preached - or at least it didn't seem that way to me. Or it was a friend or someone who's clinical judgment I admired. There are these moments where I wonder whether we listen to the things we say before we say them.

I've seen the jerk patients too. I know why we have to be careful. You give an inch and they they take a mile. The ones that look at your prescription pad like it's a cookie they want to steal out of the jar (which they might if they think they can forge your signature...).

But there's an issue with us not realising how often we end up behaving like jerks ourselves because WE have a problem and can't take no for an answer, or because we cut someone short who takes a while to warm up to their explanation, or we decide to cut to the chase because the clinic is really full and we can't get into this right now but don't put a clear "check this later" note in the file and the next person who is filling in at the clinic never knows to ask. And I don't know but it's like there's not an awareness that this missed opportunity to listen can literally cost lives.

There were some of these patients where I ended up taking over care later on when I graduated. I read their files, right through to that session I sat in on...and it was a shock. It looked above board. Nothing in that was out of place or suspicious. The notes they wrote down, the script written up... it looks all above board. But I was there. I saw those patients get smacked into submission. And they never left the clinic year after year after year. Many of them got branded as unresponsive to treatment and drifted into the arms of some nutter that put them on a cocktail so heavy it's a wonder their kidneys didn't conk out, or paradoxically they got blacklisted as "problem patients" and were put on such minimal regimes that they may as well have been drinking m&m's because the script wasn't a serious attempt to help them, it was just this vestigial perpetual rewrite that had been decreed by the senior registrar and nobody gave enough of a damn to fight for a change because this patient was tiresome and difficult.

And getting into it with them I obviously can't admit how I feel about this, but as I give them room to speak I watch them defrost in front of me out of these tense, hostile, defensive, laconic blocks into chatty cathies who are forthright and cooperative and compliant or wake up from these stupors of drugged hazes or depressions.

I want to know what we are doing about THOSE issues. I want to know how we are making sure WE don't inadvertently leave behind a wake of mismanaged, ignored patients who only needed a bit or room to explain themselves and be heard.

 

[smalltownpsych]

I think you are missing the distinction between venting frustration about how difficult it is to try to help patients with bad information with actual clinical practice. I was venting to a colleague about what are we expected to do with a patient with 75 IQ due to fetal alcohol effects, maternal abandonment, childhood and adult sexual abuse, out of control polysunstance use, psychosis, poverty, stigmatized and traumatized culture. She said, “take ‘em out behind the barn and shoot ‘em.” We laughed and I went ahead and did what I could to help this kid no matter how hopeless it appears. If a clinician in mental health hasn’t become frustrated by the enormity of what we deal with, then they are either a novice, a saint, or in denial. The last is the worst because eventually it leads to harm to the patient.

 

[birchswing]

Patient comes to me on first appt demanding anything I establish the fact that whatever it is they want I cannot just open my arms and give it to them. I explain exactly what we have all said here. I can't just go with the flow - I swore to put your best interest above anything else, and I cannot in good conscience say that I know what your best interest is until I know more about who you are, what you want from your life, and what it is that brought you to be here in front of me now. Please help me understand. Explain yourself.

It's my call, and I'm not making it until I'm satisfied. That's how it's got to be, so work with me.

But it's how I get to that moment of deciding if I like the story or not that is important to me in this conversation. During my residency I found myself repeatedly feeling like there were missed opportunities for understanding that could have been prevented if there was just a little more respect for the intelligence of the patient, or a little more patience with the fact that althought they don't have a lot of education like we do, sometimes they have enough for it to matter.

Because I started seeing this problem. We have these patients at the teaching hospital outpatient clinic. They are supposed to leave the system. We're an acute care facility. We're supposed to devolve to a day hospital in their hometowns. Instead, I see them and sometimes their family members come in month after month, weary and disheartened by lack of progress. They are our paradoxical longtimers in an institution that isn't supposed to have any.

Used to be I couldn't do a thing. I sat in those sessions as a student, biting my tongue. I'd see opportunities to slip past as I see them try, as politely as possible, to present their little idea or paper printout, and watch them deflate as the person behind the prescription pad doesn't even read through the first paragraph. Or the ones that came in swinging only to get shot down for being too hostile but the content of that little rant was surprisingly cogent. Sometimes I've dug those printouts out of the trash, and read them all the way through...and felt like maybe the patient had a point. Over the years I would fill in here and there for a busy clinic or someone taking leave, and I'd run into these patients - now jaded and laconic and obviously distrustful of me on sight. That's not what they were like before.

And this wasn't just the patients of doctors I was working under who obviously were just bad apples (ther's always one...at the least). There were situations where this happened that I was actually shocked because I didn't expect that kind of reaction from my teacher given what I'd been taught. They did not practice what they preached - or at least it didn't seem that way to me. Or it was a friend or someone who's clinical judgment I admired. There are these moments where I wonder whether we listen to the things we say before we say them.

I've seen the jerk patients too. I know why we have to be careful. You give an inch and they they take a mile. The ones that look at your prescription pad like it's a cookie they want to steal out of the jar (which they might if they think they can forge your signature...).

But there's an issue with us not realising how often we end up behaving like jerks ourselves because WE have a problem and can't take no for an answer, or because we cut someone short who takes a while to warm up to their explanation, or we decide to cut to the chase because the clinic is really full and we can't get into this right now but don't put a clear "check this later" note in the file and the next person who is filling in at the clinic never knows to ask. And I don't know but it's like there's not an awareness that this missed opportunity to listen can literally cost lives.

There were some of these patients where I ended up taking over care later on when I graduated. I read their files, right through to that session I sat in on...and it was a shock. It looked above board. Nothing in that was out of place or suspicious. The notes they wrote down, the script written up... it looks all above board. But I was there. I saw those patients get smacked into submission. And they never left the clinic year after year after year. Many of them got branded as unresponsive to treatment and drifted into the arms of some nutter that put them on a cocktail so heavy it's a wonder their kidneys didn't conk out, or paradoxically they got blacklisted as "problem patients" and were put on such minimal regimes that they may as well have been drinking m&m's because the script wasn't a serious attempt to help them, it was just this vestigial perpetual rewrite that had been decreed by the senior registrar and nobody gave enough of a damn to fight for a change because this patient was tiresome and difficult.

And getting into it with them I obviously can't admit how I feel about this, but as I give them room to speak I watch them defrost in front of me out of these tense, hostile, defensive, laconic blocks into chatty cathies who are forthright and cooperative and compliant or wake up from these stupors of drugged hazes or depressions.

I want to know what we are doing about THOSE issues. I want to know how we are making sure WE don't inadvertently leave behind a wake of mismanaged, ignored patients who only needed a bit or room to explain themselves and be heard.

As a patient, I have experienced what you describe, and of course as a human you try to make sense of it. And two conclusions I have:

1) The nature of the practice of medicine is such that when applied to the soul (the psyche in psychiatry) or the mind, it will appear crude and uncaring. I have had to come to accept for lack of better options, that the psychiatrists I see are as interested in my life and thoughts as much as a gastroenterologist is interested in what food I eat—which is to say some, but not a lot and not with detail.

2) With regard to the part you said about patients' insights being dismissed, I think that falls into the first point I made about the nature of medicine. Doctors see the same thing over and over, and in their experience they know what works for the majority of people. I also have found that if you come to a doctor with an idea, you are essentially saying your idea is better than the one the doctor would otherwise like to implement. I can't know what they feel, but I perceive the need to protect the value they have built in becoming the expert. It was actually in my very first encounter with a psychiatrist that I didn't just perceive it but it was spoken, "Do you tell the pilot how to fly the plane? I'm the pilot of this plane." It's an ego hit. And it raises the questions that have been posed here in not so many words, "What is our role if the patients decide?" Although, it's clear to me you're not saying decide but rather collaborate, but you can see where the ego takes it.

 

[thoffen]

I have mixed feelings about patients being here because this place absolutely has providers expressing things that would never come out in clinical practice and are only part of what they feel anyway. Clinicians are people too, and we are tasked with containing a whole lot of junk on behalf of our patients. When it comes out here, it doesn't mean that someone lacks compassion for their patients or that they cross boundaries in the treatment relationships. It might, but as a lot I think we're some pretty conscientious folks.