Patient filed medical board complaint after 1st visit

[the5thelement]

Patient was aggressive/rude/ demanding multiple controlled substances during initial evaluation. When
she was told that she was not going to be accepted as a patient, she filed a complaint immediately
alleging patient abandonment. Patient had medicare.
If someone was not accepted into the practice after initial visit, what is the usual course
of action. Do we still need to give a 30 day letter even when they were told they would not be accepted
into the private practice?

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[TexasPhysician]

What does your initial paperwork say? Most patients will associate you seeing them in a session as establishing a physician-patient relationship unless the paperwork they signed says otherwise.

 

[Sushirolls]

All my intake stuff says consultation. Website and intake paper work, and reflects may or may not be taken on as a patient.

People who aren't taken on as a patient from the consult receive no prescriptions and are pointed in direction of where they can get help since not with me.

I had one patient on 2 benzos, opioid, Z drug, and stimulant from previous docs. Discussed won't be prescribed here, and current dosing levels and patient behaviors warrant inpatient. Discussed where inpatient level options were, documented not in an acute withdrawal state. Left open the option to call back for another consultation if got off these drugs and thought might still need services.

 

[shahseh22]

All my intake stuff says consultation. Website and intake paper work, and reflects may or may not be taken on as a patient.

People who aren't taken on as a patient from the consult receive no prescriptions and are pointed in direction of where they can get help since not with me.

I had one patient on 2 benzos, opioid, Z drug, and stimulant from previous docs. Discussed won't be prescribed here, and current dosing levels and patient behaviors warrant inpatient. Discussed where inpatient level options were, documented not in an acute withdrawal state. Left open the option to call back for another consultation if got off these drugs and thought might still need services.

You're fortunate you have places you can send them for inpatient detox. If they have Medical, the options are limited and the beds are limited where I'm at.

 

[splik]

I put “this was a one time consultation and does not constitute the formation of a doctor patient relationship” at the bottom of my notes if I’m not seeing them again. Patients can complain about anything and make vexatious complaints to the board or file spurious lawsuits. It is stressful and It sucks. But it is also the cost of doin business as a physician today. It is best to make clear at the outset your initial consultation will determine whether you can provide appropriate care and if not you must refer them on or provide information on how to seek care elsewhere. It is always better to frame it as “I’m not equipped or qualified to help you” than to narcissistically injure the patient by implying you are rejecting them. Carefully document the appropriate level and kind of care (eg do they need DBT or specialized substance use treatment like IOP that is beyond what you provide). Have you referred them on or given them info (even a psychology today link or link to you the local APA district branch Psychiatrist directory etc will suffice). You should also provide or offer copies of notes to their next doctor. That is usually sufficient.

for a pt like this if they don’t have a supplemental plan I would waive the portion of their visit Medicare does not cover. It will save you a lot of additional headache.

 

[VA Hopeful Dr]

I put “this was a one time consultation and does not constitute the formation of a doctor patient relationship” at the bottom of my notes if I’m not seeing them again. Patients can complain about anything and make vexatious complaints to the board or file spurious lawsuits. It is stressful and It sucks. But it is also the cost of doin business as a physician today. It is best to make clear at the outset your initial consultation will determine whether you can provide appropriate care and if not you must refer them on or provide information on how to seek care elsewhere. It is always better to frame it as “I’m not equipped or qualified to help you” than to narcissistically injure the patient by implying you are rejecting them. Carefully document the appropriate level and kind of care (eg do they need DBT or specialized substance use treatment like IOP that is beyond what you provide). Have you referred them on or given them info (even a psychology today link or link to you the local APA district branch Psychiatrist directory etc will suffice). You should also provide or offer copies of notes to their next doctor. That is usually sufficient.

for a pt like this if they don’t have a supplemental plan I would waive the portion of their visit Medicare does not cover. It will save you a lot of additional headache.

The key is to make sure the patient is told, directly and multiple times (prior to the appointment and at check-in) that this is a one time visit and not the establishment of a doctor-patient relationship and that you document both saying that and their consent to it. Putting just that it wasn't in your note often isn't enough. Medical boards often go based on the patient's perception for this so discussing and documenting specifically that they were told and agreed is the important part.

You also can't waive their Medicare copay but still bill Medicare for the visit.

 

[nexus73]

Having patient sign something acknowledging the fact of a potential one time visit as part of the initial paperwork process is a good idea. That way not only is the patient told verbally, and it's in your note, there's form the patient signed. It'd be pretty hard for a reasonable person to argue with that.

 

[Merovinge]

Patient was aggressive/rude/ demanding multiple controlled substances during initial evaluation. When
she was told that she was not going to be accepted as a patient, she filed a complaint immediately
alleging patient abandonment. Patient had medicare.
If someone was not accepted into the practice after initial visit, what is the usual course
of action. Do we still need to give a 30 day letter even when they were told they would not be accepted
into the private practice?

If you wouldn't mind updating this thread once this gets cleared up. I think it would be helpful to hear how the course of this complaint went, as it's about as concretely spurious as possible.

 

[Sushirolls]

I suspect 0 of the state nursing boards would even look into this.

 

[Candidate2017]

It addition to the "we do not have a Dr-pt" discussion and documentation above, I tell patients they are free to seek a better psychiatrist who fits their needs, or come back if they want to discuss again. Invariably, they never come back, which negates any abandonment claim if they are even able to get past the lack of Dr-pt relationship hurdle. They later get an official letter to the effect of, "Thanks, sorry we didn't see eye to eye on the tx plan, recall we don't have a Dr-pt relationship, goodbye, god speed."

I also thoroughly document their MSE, especially behavior and thought content (angry, loud and threatening when demanding controlled subs, focused on controlled subs).

 

[Candidate2017]

You're fortunate you have places you can send them for inpatient detox. If they have Medical, the options are limited and the beds are limited where I'm at.

Limited resources is not your problem. Provide a list of referrals, educate on signs and symptoms of life threatening withdrawal, recommend go to ED.

 

[shahseh22]

Limited resources is not your problem. Provide a list of referrals, educate on signs and symptoms of life threatening withdrawal, recommend go to ED.

Whenever they go to the ED, they usually stay there for a couple of hours, usually without any treatment and are told to just follow up outpatient. Our ED is horrible when it comes to this stuff and usually laughs at us when we send people in for Alcohol withdrawal. FYI, the PCP's usually detox outpatient with Valium or Librium.

I would love to provide a list of referrals but reality is we are so limited.

 

[Sushirolls]

Send the patients to a different ED.

Some AUD warrants Internal Medicine floor admission if no specific Psych/Addiction units to manage or available. Typically, I've only seen these admissions once people are showing moderate/severe AUD withdrawal. Mild or no withdrawal, ED punts back to outpatient due to lack of acuity.

 

[nexus73]

Send the patients to a different ED.

Some AUD warrants Internal Medicine floor admission if no specific Psych/Addiction units to manage or available. Typically, I've only seen these admissions once people are showing moderate/severe AUD withdrawal. Mild or no withdrawal, ED punts back to outpatient due to lack of acuity.

Summer places the next ED is 1 hour away or more.

 

[Sushirolls]

Summer places the next ED is 1 hour away or more.

That's not a barrier. Traffic in medium/large cities can be more than an hour. Much of the mountain west, west, and midwest rural have lengthy driving time requirements to get to specialized care.

I've even used public transportation in a medium sized city in the midwest before, and it took 1 hour to go from one side of the city to the other side of the city.

Two hours for travel to receive any medical care is within reason, in my opinion.

 

[PistolPete]

Man, what a nightmare. Sorry you're going through this OP!

 

[TexasPhysician]

Summer places the next ED is 1 hour away or more.

I used to commute 1 hr each way to a job, and I never left the city.

 

[whopper]

Having been on the receiving end of bogus complaints but also in the areas of defending, evaluating, and judging other health care providers to see if they should continue to practice or not. (I had to sit in meetings and had to make a decision determining if a medical student, a resident, an attending was to be let go. I've done forensic evaluations for health organizations for providers found to be violating rules, etc).

The bigger issue is usually...is there a pattern of bad practice?

A one time complaint is only a big deal if the offense was egregious and there's a lot of evidence showing it really happened. Almost everyone, even the best providers will have a bogus complaint against them sooner or later. I had a male inmate accuse me of trying to seduce him after I refused him benzos and Quetiapine even though I'm heterosexual and the entire meeting was witnessed by a correctional officer who reported he was there the entire time and the inmate was lying.

A forensic psychotic patient complained to the state board accusing me of being part of a big sex conspiracy where I had supermodels and billionaires in on it and I was the worldwide mastermind pimp. Colleagues would joke that I wished the delusion was true.

Anyone with a singular complaint against them I'd pretty much not even consider it an issue unless the matter in hand is egregious and/or there's real verifiable evidence something bad happened such as the doctor giving out dangerously large amounts of controlled substances

We know that there are angry and vindictive patients out there who will complain about anything. ESPECIALLY IN AN ER.

Also when such a patient makes a complaint I will gather evidence if the patient has a history of making similar complaints that could be false or otherwise other questionable behavior such as having multiple controlled substances from several providers.

Note to all of you who will make a practice, whenever you take new patients you're rolling the dice. Many of them will be vindictive and trouble-makers outside of their Axis I diagnosis. Of course it's a minority but let's say it's only 5%, and you see 15 patients a day that's going to come out to at least 1 headache every other day. My first year of practice I was terminating people at least monthly if not weekly and even had days where it was happening a few times in a row. After you've been in practice for several months the number of stabilized patients go up and the number of troublemakers (people causing disruptions outside of an Axis I illness) go down.

(e.g. of troublemaker patient: "I need Dr. Whopper to get me more Adderall." Receptionist tells her I just filled it out 5 days ago. "But I like it a lot so I gave some to my dad and he likes it too!" I called up the patient, told her that I already explained to her multiple times this is a controlled substance and she needed to follow the rules that I explained to her and gave to her in writing and terminated her.

My 5th year in private practice and now the overwhelming majority of patients are just refills, easy going, and they and I have a strong relationship. I'm typing this letter at 11 AM in between patients and as I look down my schedule every single patient is just an easy refill.

And this is also a strong reason why even when denying a patient's request for whatever (e.g. the pt could be malingering, wanting something inappropriate such as a large amount of Alprazolam for a minor issue, etc), do it in a respectful manner. To tell them to go eff themselves upon discharge you're just upping the ante there'll be a complaint. Don't give in and do something inappropriate either by cussing them out or enabling their problem.

 

[WisNeuro]

I used to commute 1 hr each way to a job, and I never left the city.

Sounds like Houston

 

[namethatsmell]

ER doc here. I learn a lot from your forum and wanted to chip in an EM perspective...

For the OP, I'm sorry you've got to deal with this. It sounds like things will be fine but if you haven't already you should lawyer-up (or talk with risk if you're hospital-employed) to ensure things go smoothly.

Limited resources is not your problem. Provide a list of referrals, educate on signs and symptoms of life threatening withdrawal, recommend go to ED.

The vast majority of EDs also have very limited resources for all things psych/SUD-related (which mirrors our overall "system"). It sucks, but it's the reality in most places. Outside of some select academic/tertiary systems, pretty much the only things I can routinely admit are: pts with active SI/HI, pts with acute psychosis or other acute MH process where the pt really poses an acute risk to themselves/others, or pts actively withdrawing from alcohols/benzos with unstable vitals and/or seizures. Expect pretty much everybody else to be discharged from your local ER as there are no upstairs docs we can find to admit MH patients to that fall outside of these catagories. Occasionally you'll find a community ED with connections to private inpatient detox units that will send somebody to pick up the patient from the ED and admit them to their facility. That's a great thing. But those connections are fickle and can change day to day.

Whenever they go to the ED, they usually stay there for a couple of hours, usually without any treatment and are told to just follow up outpatient. Our ED is horrible when it comes to this stuff and usually laughs at us when we send people in for Alcohol withdrawal. FYI, the PCP's usually detox outpatient with Valium or Librium.

If you're sending in somebody into the ED who's in legit alcohol withdrawal (unstable vitals, disoriented, seizures, decent CIWA etc) and they're actually being discharged home without any treatment as you describe...well that's insane and you need to talk with the head of that ED. No normal EM-trained doc would ever a) not medicate that patient and b) elect to d/c them home. What often happens however is we get patients who are in some level of withdrawal, we stabilize them, and then they refuse admission and leave ama to go drink again.

We'll also get alcoholics who want to detox but are medically stable. As an EM doc there's nothing for me to stabilize/treat and there's usually no doc I can find to admit a stable patient to for inpatient detox.

Send the patients to a different ED.

Some AUD warrants Internal Medicine floor admission if no specific Psych/Addiction units to manage or available. Typically, I've only seen these admissions once people are showing moderate/severe AUD withdrawal. Mild or no withdrawal, ED punts back to outpatient due to lack of acuity.

This is all spot-on.

I cannot think of a single EM doc I've worked with who sends home a patient (who actually wants to be admitted) presenting with significant signs of etoh withdrawal. I admit these patients to medicine all the time. If you're seeing this happen at your local ED you should arrange a call or meeting with the ED medical director to find out why. Perhaps there's a doc who needs some further education, perhaps the patient wasn't actually unstable or they left AMA, perhaps there's a hospital policy that blocks the ED from admitting some of these patients (yes stuff like this exists), or something else going on. If things are still unresolved after speaking with the EM leadership then you should definitely send your patients to another ED.

That's not a barrier. Traffic in medium/large cities can be more than an hour. Much of the mountain west, west, and midwest rural have lengthy driving time requirements to get to specialized care.

I've even used public transportation in a medium sized city in the midwest before, and it took 1 hour to go from one side of the city to the other side of the city.

Two hours for travel to receive any medical care is within reason, in my opinion.

Agreed. For better or worse patients will travel quite a distance for care. And that includes EDs.

We know that there are angry and vindictive patients out there who will complain about anything. ESPECIALLY IN AN ER.

Ha totally true. Much as you guys have to deal with this, so too do we in the ED. In fact, a mark of good ED leadership is them shielding you from 99% of the bogus complaints made against you (ie "there wasn't enough mayo for my ED turkey sandwich" or "the ED doc spent too much time with this patient I saw covered in blood and not enough with me"). Most of the time nothing comes from these but over time they do drain one's soul a bit.

 

[whopper]

I used to work in an ER for years. I worked in two hospitals with a PES where we directly took in patients from the ER, or in ERs where we were asked to do a consult.

I cannot think of a single EM doc I've worked with who sends home a patient (who actually wants to be admitted) presenting with significant signs of etoh withdrawal. I admit these patients to medicine all the time. If you're seeing this happen at your local ED you should arrange a call or meeting with the ED medical director to find out why.

PCP's usually detox outpatient with Valium or Librium.

The new ASAM guidelines say that Gabapentin can be given instead of a benzo. I always hated the idea of prescribing a benzo to an alcohol detox patient who wanted to do it at home cause they might drink while on the benzo. Gabapentin does have some abuse potential but the risks are far less than a benzo.

 

[kopftonmd]

The new ASAM guidelines say that Gabapentin can be given instead of a benzo. I always hated the idea of prescribing a benzo to an alcohol detox patient who wanted to do it at home cause they might drink while on the benzo. Gabapentin does have some abuse potential but the risks are far less than a benzo.

Woah I didn't know that! Can gabapentin be used for acute withdrawal or is it more of a long-term detox treatment?

 

[whopper]

Can be used for both. The ASAM guidelines don't say how much Gabapentin to give out but a published study I read said about 1200 mg.

The problem being that I nor anyone I know has actually done this yet in clinical practice for acute withdrawal. I'd prefer doing it in inpatient, figuring out the kinks, then finally allow it for outpatient but I no longer do inpatient. Anytime you try something new there's a learning curve. The benzos are the conventional method but I like most clinicians don't want to give an alcoholic a benzo except in inpatient cause they might mix the benzo with alcohol.

 

[the5thelement]

Response was written and finally case was dismissed by medical board 3 days ago! (this didnt happen to me, but a friend)

 

[Stagg737]

Woah I didn't know that! Can gabapentin be used for acute withdrawal or is it more of a long-term detox treatment?

Can be used for both. The ASAM guidelines don't say how much Gabapentin to give out but a published study I read said about 1200 mg.

The problem being that I nor anyone I know has actually done this yet in clinical practice for acute withdrawal. I'd prefer doing it in inpatient, figuring out the kinks, then finally allow it for outpatient but I no longer do inpatient. Anytime you try something new there's a learning curve. The benzos are the conventional method but I like most clinicians don't want to give an alcoholic a benzo except in inpatient cause they might mix the benzo with alcohol.

My academic program regularly implements the benzo-sparing protocol with Gabapentin + Clonidine for inpatient detox (medical and psych units). Protocol is based on recs below from an article with multiple studies on various benzo-sparing protocols (Gabapentin, valproic acid, oxcarb, etc).

Day 1-3: 800mg TID + initial 1200mg loading dose
Day 4-5: 600mg TID
Day 6-7: 300mg TID

Clonidine patch 0.1mg daily + PO available for HTN

Ativan available as back-up for severe w/drawal sxms not adequately managed with the above.

For patients with h/o of really severe withdrawal, I don't screw with the above and just stick to benzos, but there's some pretty good evidence for benzo-sparing, especially in those without a really severe history.