Some Private Practice Pet Peeves

[whopper]

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1) Patient is clearly dangerous and the police refuse to take the patient to the hospital saying it's not their job even when I show them where in the state statutes it is their job, and they still refuse.

2) Patient changes their phone number (and/or address) doesn't tell us they changed it, then when we can't get in contact with them, and they show up to my office they complain at us. Even after telling them what happened some of these idiots pull a "well you should've known I changed my phone number even though I didn't tell you" line.

3) Patient lies to family about what I'm doing (e.g. that it's fine to take large dosages of Alprazolam), family calls my office complaining, and I can't tell them what's really going on because of HIPAA.

4) Patient's family calls my office repeatedly, I tell the family I can't talk to them because of HIPAA and they do a grandstand display of telling me how much I don't care about the patient because I won't break the law to tell them the patient's personal information. Then a few days later repeat the same exact thing despite that they know I can't tell them anything because of HIPAA, then they do it again a few days later, then again a few days later.

5) Insurance doesn't tell me what meds they'll pay for ahead of time, so I give the patient a script, insurance won't pay for it, and I send them another, and they won't pay for that one either, rinse and repeat.

6) Patient needs a lab but it's not extremely important (e.g. Vitamin D levels), and I'd like for them to have the lab done but not if it's going to be expensive for the patient and I can't tell how much of it will be covered by insurance. So then I warn the patient I can't tell how much it'll cost them and that if it does cost them anything more than say $30 they should just walk out of the lab. Then the lab tells the patient they won't "have to pay anything today," and so they get the lab done and it turns out the lab sends the patient a bill in the mail charging them a few hundred dollars.

Then the patient calls my office screaming at me despite that I have no control over what insurance pays for, that I didn't make 1 cent off of that lab, told the patient not to get the lab if they felt it was too expensive because it wasn't a very important lab, and that I found what the lab did reprehensible.

7) Patient comes to my office with bed bugs, so now hundreds of not thousands of dollars worth of furniture need to be destroyed.

8) Patient or their family complains that I'm doing a bad job when in fact I know I'm doing everything up or above the standard of care. E.g. 4th antidepressant is still not helping the patient. Not my fault the patient has treatment-resistance, I already explained what that was and gave them references to read up on it. So they make a scene in the office of how terrible I am and storm out. We send the patient a termination letter ending the doctor-patient relationship. Then it's like 6 months later, the patient saw other doctors, realized I actually was doing a good job cause the next two doctors they saw only spend 30 seconds with them never returned their phone calls, and now the patient's actually much worse, and they actually read up on treatment resistance (despite that I told them to do so while they were my patient but they didn't listen). So then the patient calls my receptionist screaming at her demanding I take them back as a patient instead of being polite.

 

[wolfvgang22]

I experience most of these things regularly and I work at the VA. Insurance is a bit less of a problem, but our formulary is restrictive.

 

[whopper]

These same things too happen outside of private practice but in big institutions you can have others such as the social worker or nurse deflect a lot of the above away from you.

And if some patient comes in with bed bugs and furniture needs to be destroyed, the VA pays for it. In private practice you pay for it out of your own pocket or you have to get the patient to pay for it.

 

[wolfvgang22]

These same things too happen outside of private practice but in big institutions you can have others such as the social worker or nurse deflect a lot of the above away from you.

And if some patient comes in with bed bugs and furniture needs to be destroyed, the VA pays for it. In private practice you pay for it out of your own pocket or you have to get the patient to pay for it.

It is true nurses and social workers help a lot. At the same time, the acuity and volume I see is generally higher than my friends in private practice down the street from me in my city. I know that can vary a lot. We have at times crushing bureaucracy and red tape here in the VA, so I envy them that they don't have that issue. True, I don't have to worry about furniture, and definitely do not talk to insurance nearly as much! I keep scrubs in the clinic to change into if necessary because of the bed bug epidemic, after one of our staff took bed bugs home 7 times. Yes, seven! She quit after that.

There are pros and cons to every setting, for sure. I don't mean to minimize your experience at all, instead I mean to empathize with you! I don't envy the pressures that come with running a business! Fear of that and worrying about having a steady income is what keeps me from private practice. I hope you have a great day.

 

[whopper]

Oh I totally agree. When in private practice you don't have to worry about the departmental BS. Each type of practice has it's own pros and cons.

I call it emotional carpal tunnel. Repeated exposure in a tender spot makes you that much more vulnerable. If I was just doing inpatient, a lot of the above wouldn't tick me off anywhere near as much but then I'd have to deal with an idiot IM consultant who refuses to show up or do a halfway decent job, possibly work with at least a few inept colleagues, etc, and I am way way way more happy doing private practice vs my last job at an institution where all the computers for the doctors minus 1 in the inpatient unit were broken and they never fixed them despite over 100 work orders. (Being totally serious. One of those computers was broken the first day at work, and even on my last day on the job 1.5 years later it was still broken with no attempts by IT to fix it).

I'd love to do mornings inpatient, afternoons outpatient but I'd still have to pay the same amount of rent, malpractice, etc so it's more cost-effective just to do private practice all day the entire week --> hence the emotional carpal tunnel.

 

[Sushirolls]

1) Patient is clearly dangerous and the police refuse to take the patient to the hospital saying it's not their job even when I show them where in the state statutes it is their job, and they still refuse.
There is nothing more you can do, serenity prayer, let it go.
2) Patient changes their phone number (and/or address) doesn't tell us they changed it, then when we can't get in contact with them, and they show up to my office they complain at us. Even after telling them what happened some of these idiots pull a "well you should've known I changed my phone number even though I didn't tell you" line.
I use Luminello and require electronic intakes from the start, skip the phones, and use the luminello messages. Very small volume of things I call patients for. Provides greater buffer for incorrect phones or addresses.
3) Patient lies to family about what I'm doing (e.g. that it's fine to take large dosages of Alprazolam), family calls my office complaining, and I can't tell them what's really going on because of HIPAA.
There is nothing more you can do, serenity prayer, let it go. Or request the patient to sign an ROI so you can talk with the family.
4) Patient's family calls my office repeatedly, I tell the family I can't talk to them because of HIPAA and they do a grandstand display of telling me how much I don't care about the patient because I won't break the law to tell them the patient's personal information. Then a few days later repeat the same exact thing despite that they know I can't tell them anything because of HIPAA, then they do it again a few days later, then again a few days later.
There is nothing more you can do, serenity prayer, let it go. Or request the patient to sign an ROI so you can talk with the family.
5) Insurance doesn't tell me what meds they'll pay for ahead of time, so I give the patient a script, insurance won't pay for it, and I send them another, and they won't pay for that one either, rinse and repeat.
Good Rx, refer to that website, or point to a Costco, they typically have the lowest out of pocket costs. I'm not really running into this problem, maybe prescribing habits or just one bad insurance? Consider dropping that insurance?
6) Patient needs a lab but it's not extremely important (e.g. Vitamin D levels), and I'd like for them to have the lab done but not if it's going to be expensive for the patient and I can't tell how much of it will be covered by insurance. So then I warn the patient I can't tell how much it'll cost them and that if it does cost them anything more than say $30 they should just walk out of the lab. Then the lab tells the patient they won't "have to pay anything today," and so they get the lab done and it turns out the lab sends the patient a bill in the mail charging them a few hundred dollars.

Then the patient calls my office screaming at me despite that I have no control over what insurance pays for, that I didn't make 1 cent off of that lab, told the patient not to get the lab if they felt it was too expensive because it wasn't a very important lab, and that I found what the lab did reprehensible.
I rarely order Vit D because of these coverage issues, easier to simply say take D3 1000iu daily.
7) Patient comes to my office with bed bugs, so now hundreds of not thousands of dollars worth of furniture need to be destroyed.
I didn't even think about that with the population I have been working with. I get tobacco smoke plumes or perfume plumes, but oye, I hope not bed bugs. I wonder if wood non-cushion chairs might be solution...
8) Patient or their family complains that I'm doing a bad job when in fact I know I'm doing everything up or above the standard of care. E.g. 4th antidepressant is still not helping the patient. Not my fault the patient has treatment-resistance, I already explained what that was and gave them references to read up on it. So they make a scene in the office of how terrible I am and storm out. We send the patient a termination letter ending the doctor-patient relationship. Then it's like 6 months later, the patient saw other doctors, realized I actually was doing a good job cause the next two doctors they saw only spend 30 seconds with them never returned their phone calls, and now the patient's actually much worse, and they actually read up on treatment resistance (despite that I told them to do so while they were my patient but they didn't listen). So then the patient calls my receptionist screaming at her demanding I take them back as a patient instead of being polite.
No. Being mean to your office staff is uncalled for (some specific mental health conditions of exception, Axis II is not one of them).

 

[whopper]

Yeah I know about the "letting it go" thing, the GoodRx thing, you did however teach me something with the Luminello.

 

[wolfvgang22]

Hard wood chairs sounds like a brilliant way to limit appointments running over time, also!

I have some patients that I learn are coming to attend their appointment due to the haze and odor of marijuana and the distinct second hand high we experience when they are still a block away. I gently advise them caution as they pass by the police on the way here, among other health recommendations.

 

[Mass Effect]

Not to discount your experiences, but you know you don't have to destroy all your furniture due to bed bugs, right? That was the old thinking. Bed bugs can be treated. The problem is, it takes weeks of the furniture being isolated to effectively treat, so your waiting room furniture you may have to get rid of, but if you have another personal office you can use, you can isolate the office the patient was in for a few weeks to get rid of them.

 

[whopper]

Oh yeah I'm aware but safer to destroy. Some can survive pesticides.

 

[the5thelement]

We must not allow the ignoble to injure the noble, or the smaller to injure the greater. Those who nourish the smaller parts will become small men. Those who nourish the greater parts will become great men. (Meng Tzu)

 

[dl2dp2]

People in your practice seem quite ill. I hope they are paying you enough to justify being in your practice. I've never had a problem using EMS to take to patient to the hospital. Not sure what is going on there.

 

[wolfvgang22]

We must not allow the ignoble to injure the noble, or the smaller to injure the greater. Those who nourish the smaller parts will become small men. Those who nourish the greater parts will become great men. (Meng Tzu)

I nourish my great parts a lot. It's great!

 

[Merely]

People in your practice seem quite ill. I hope they are paying you enough to justify being in your practice. I've never had a problem using EMS to take to patient to the hospital. Not sure what is going on there.

Doubtful as the sicker you are the less you are probably paying

 

[wolfvgang22]

Doubtful as the sicker you are the less you are probably paying

🤣

 

[whopper]

I've never had a problem using EMS to take to patient to the hospital. Not sure what is going on there.

Every outpatient clinic I've seen has a patient, rarely, but a few times a year need to have someone taken to the hospital.

 

[wolfvgang22]

Every outpatient clinic I've seen has a patient, rarely, but a few times a year need to have someone taken to the hospital.

I sent 5 patients to the ER down the hall to be admitted this week. Not for psychiatric reasons, though.
Fractured humerus after a drunken fall 2 days prior, hyponatremic delirium, atrial fibrillation, paralytic ileus, severe gout attack. I should get another raise.
At least clinic ain't boring.

 

[TexasPhysician]

The adult tantrums are the worst.

 

[Jules A]

People complain that many psychiatrists no longer accept insurance and yet 3 of 8 (5,6,7) would be a non issue if an out of network private practice.

 

[calvnandhobbs68]

People complain that many psychiatrists no longer accept insurance and yet 3 of 8 (5,6,7) would be a non issue if an out of network private practice.

How would being in or out of network affect a patient coming in with bedbugs...

 

[splik]

How would being in or out of network affect a patient coming in with bedbugs...

you bill it as group therapy and each bed bug has to pay $500 a session. that usually keeps them out. 😉

 

[calvnandhobbs68]

I would disagree with the just accept the police won’t take the patient to the ER thing. I personally would be letting the police officers refusing to do this know that you’ll be contacting the chief of police, the mayor of whatever locality you’re in and the state attorney general to let them know why Officer X thought it was not his/her responsibility to transport a patient who was a harm to themselves or others to the emergency room for emergency psychiatric treatment.

If they continue to refuse, I would also let them know that you do not have police powers and so cannot physically transport a patient against their will to the ER safely. If they are refusing to do so, you’ll be documenting the name person you are talking to in the EMR so when the family sues after the patient kills herself or when the victims family sues when the patient kills someone else, the lawyers will see you did all you could reasonably do and will know the appropriate entity to sue (the police department).

 

[birchswing]

I would disagree with the just accept the police won’t take the patient to the ER thing. I personally would be letting the police officers refusing to do this know that you’ll be contacting the chief of police, the mayor of whatever locality you’re in and the state attorney general to let them know why Officer X thought it was not his/her responsibility to transport a patient who was a harm to themselves or others to the emergency room for emergency psychiatric treatment.

If they continue to refuse, I would also let them know that you do not have police powers and so cannot physically transport a patient against their will to the ER safely. If they are refusing to do so, you’ll be documenting the name person you are talking to in the EMR so when the family sues after the patient kills herself or when the victims family sues when the patient kills someone else, the lawyers will see you did all you could reasonably do and will know the appropriate entity to sue (the police department).

Too meek.

I'd be making a citizen's arrest of those police officers for failure to ensure public safety.

I'd bet you'd be seeing the chief of police in no time. And if he wouldn't listen to reason, I'd take them all to court.

As long as it takes, and as high up as I'd need to go. I'd citizen arrest Ruth Bader Ginsburg if it came down to it.

 

[Jules A]

private pay psychiatrists still have to navigate insurance as the overwhelming majority of patients use insurance to pay for their meds and labs even if they are paying out of pocket for their psychiatrist visits. And though hopefully unlikely, cash paying patients have bed bugs too!

Just asked a friend to ensure I wasn't way off base as I work in a practice that sounds like the OP.
n=1 but they said there are some prior auths, which their secretary handles, on rare occasion labs the patient either elects to pay out of pocket or won't get drawn and zero incidents of bedbugs in 8 years of practice.

 

[Sushirolls]

I would disagree with the just accept the police won’t take the patient to the ER thing. I personally would be letting the police officers refusing to do this know that you’ll be contacting the chief of police, the mayor of whatever locality you’re in and the state attorney general to let them know why Officer X thought it was not his/her responsibility to transport a patient who was a harm to themselves or others to the emergency room for emergency psychiatric treatment.

If they continue to refuse, I would also let them know that you do not have police powers and so cannot physically transport a patient against their will to the ER safely. If they are refusing to do so, you’ll be documenting the name person you are talking to in the EMR so when the family sues after the patient kills herself or when the victims family sues when the patient kills someone else, the lawyers will see you did all you could reasonably do and will know the appropriate entity to sue (the police department).

I know of one sheriff's department that won't respond to SI calls. They simply stated that due to limited resources they have to triage and unless there is mention of a weapon they won't go. I believe they defer to other county crisis resources to go investigate. I believe they will detain if there is a legal document equivalent to the usual 3 day holds most states have, but simply calling the police because of SI concerns, they won't bother.

 

[wolfvgang22]

I know of one sheriff's department that won't respond to SI calls. They simply stated that due to limited resources they have to triage and unless there is mention of a weapon they won't go. I believe they defer to other county crisis resources to go investigate. I believe they will detain if there is a legal document equivalent to the usual 3 day holds most states have, but simply calling the police because of SI concerns, they won't bother.

Wow. This is the height of shirking duty to protect.

Back in the day when I was a case manager, a colleague of mine was shot and killed responding to a suicidal patient with psychosis, even with a police escort.

 

[whopper]

I personally would be letting the police officers refusing to do this know that you’ll be contacting the chief of police, the mayor of whatever locality you’re in and the state attorney general to let them know why Officer X thought it was not his/her responsibility to transport a patient who was a harm to themselves or others to the emergency room for emergency psychiatric treatment.

I did. Nothing substantive happened. They offer me to teach the officers some classes, and I made some lectures and taught them for free, but they controlled the content and they didn't give me an opportunity to mention that they need to take patients to the hospital.

The bottom line is in most localities the police officer is not some uber-trained individual, and if the locality is not densely packed this type of thing is so rarely seen the police officer is not familiar with it, and the community has no or few local resources for mental health treatment. Kind of like having to make a new password for an account you only access once every 2 years. You're not going to remember how to do it right.

And as bad as this is I've seen doctors doing similar things. E.g. the doctor that gives out Ambien to all for years at a time. They ought to know better, and usually do know better but don't care nor act on it.

The above was going on in a small town outside of Cincinnati. In the actual city the cops knew what to do cause they would see this type of thing enough to have the schema in their heads plus there were enough city resources pushing the police force into being on top of stuff like this.

I've mentioned this before. In training they often teach you what to do in perfect-world scenarios. E.g. if your patient is suicidal you call 911 and have them brought to the hospital unless someone else such as a family member is present and can safely do it. They don't tell you what to do when the police officer is refusing to do their job even as specified under law. They don't tell you what to do when the IM consultant shows up and is a total ass and won't do his job right.

I don't have to worry about that problem now. In the office I'm currently in the police and I have a good relationship and they know what to do in this type of situation, but back in that small town in Ohio? No.

 

[Liquid8]

Can't say I have too many issues with private practice at the moment. Have only had to organise emergency services to come over twice in the last 5 years, with one guy being obviously catatonic and the other one having a vasovagal but not wanting to take any risks.

A couple of years ago a patient brought in their dog which had a bout of diarrhoea in the reception area 😵

 

[whopper]

3) Patient lies to family about what I'm doing (e.g. that it's fine to take large dosages of Alprazolam), family calls my office complaining, and I can't tell them what's really going on because of HIPAA.
There is nothing more you can do, serenity prayer, let it go. Or request the patient to sign an ROI so you can talk with the family.

Forgot to mention, in this situation and I am reasonable confident the patient is lying to others about their treatment with me alleging I've done things I haven't, and there's enough drama being caused by this, I will request an ROI to clear things up and if they refuse I will likely terminate the patient-doctor relationship. IMHO it's completely warranted cause they lied about their treatment and I will not enable this type of toxic relationship.

In situations where the friends/family are causing the drama, and the patient him/herself didn't cause the problem I won't terminate because that'd be punishing the patient for something outside their control.

 

[Orgone]

Maybe I've just been lucky so far, or am in a better location, but over 1 year in private practice taking a couple of the better insurances, and out of whopper's 1-8 I've had exactly none of those things happen.

Fingers crossed it stays that way.

 

[wolfvgang22]

Maybe I've just been lucky so far, or am in a better location, but over 1 year in private practice taking a couple of the better insurances, and out of whopper's 1-8 I've had exactly none of those things happen.

Fingers crossed it stays that way.

Sooo...where is this magical location...

 

[Orgone]

 

[Monocles]

Whopper you are scaring me away from private practice...

 

[Sushirolls]

Whopper you are scaring me away from private practice...

8 months into my private practice, it hasn't been anything like Whopper's experience.

My biggest headaches:
-figuring out payroll for first employee. Finally did it, got it done, no longer an issue.
-prior auths for CT or MRI heads, I've done two...
-trying to get patients into Sleep Medicine at big box shops. I solved that problem, stopped sending to them and refer to an independent doctor now.
-thinking about how high my office lease is. That's my own fault, and I can move in a few years if need be.
-I prevent benzo headaches up from by making clear on website and possible inquires I don't prescribe them, I will taper but I don't prescribe.

8 months into my practice, I am loving it, feel so much happier and won't go back to other employed group jobs, never again. This is this closest thing to 'the promised land.'

It will be your practice, and you can control a lot of it.

 

[whopper]

I am enjoying private practice far more than working in the university or hospital. It pays more and I have more control over BS. Lots of the same things I'm complaining about do happen in other types of practice. As I mentioned, while I worked at the last university, a computer was broken there the first day, up until the last day I worked there over 1 year and each time I called IT they would just say to put in a work order and nothing got fixed. In private practice if a computer's broken you or your secretary have the IT guy you pay or send it to a computer place and and it's fixed the same day.

What I miss in hospitals and universities are being with great colleagues and teaching students/residents, but it's mixed with also being exposed to a lot of bad ones.

The main drawback with private practice, and it's related to the complaints above is that you keep onto the same patients indefinitely. So if they (or their families/friends) are ticking you off it keeps hitting the same sore spot. E.g. a patient's father called me on my emergency line for the 5th time in about 3 weeks, asking me to violate HIPAA every single time, the situation was not an emergency, and I raised my voice at him, and in a very terse, stand-my-ground tone because this was now the 5th time I told him I would not break the law and that he was a physician, that he was abusing the emergency line, and that if he continued to do so I would likely take legal action against him.

Each time I talked to the guy until the last I was diplomatic, calm, patient, even spent about 45 minutes on him the first call, telling him that although I understood his concerns I couldn't break HIPAA and was trying to be the nice guy. Well now it's the 5th damned call from him where now I've wasted about 2 hours, there was never an emergency, and he just keeps calling me despite that I told him not to do so. I even told him I was considering reporting him to the state medical board because he was asking me to break the law, knowingly violating several boundaries, and I knew he was aware of the law cause he was a physician. I even had a lawyer get involved because I never encountered this type of thing before and there was no clear-cut textbook way in psych training to handle this, and I didn't want to terminate the patient because of his father's bad-behavior.

I also alerted the patient to the above behavior asking him if he wanted to sign a release so I could talk to his father (patient refused) and if there was something I needed to know or do to somehow fix the situation. The patient said he didn't know other than that the father was being a helicopter parent and that the father himself needed a psychiatrist but wasn't getting one.

That's the type of thing where unlike inpatient you discharge the patient and they're out of your hair or the social worker handles this BS for you. In outpatient you keep the patient and if they have this type of repeat-bothersome behavior they can get under your skin and start ticking you off. Of course I don't mind if a patient is sick and calls me and it turned out the reason for them calling me was valid (e.g. a side effect to a medication, a question about their treatment, etc).

(The specific case mentioned above ended up solving itself at least on my end, although not the patient's. A few days later the patient himself asked me to do something inappropriate so I was able to terminate him guilt-free, but even better when I refused to do the inappropriate act the patient fired me as his doctor --> YAY! I even went home that day and made a drink, sat down, enjoyed it, and felt free and I don't drink).

But bear in mind this type of case is a very small minority and the ones that tick you off you usually can very easily ethically terminate them because it's the patient (not their father or other family member) causing the behavior warranting termination. E.g. if a patient screams at me or my secretary for not somehow knowing they got a new phone number despite that they never told me I got no problems terminating them and won't lose a wink of sleep over it.

 

[Merely]

8 months into my private practice, it hasn't been anything like Whopper's experience.

My biggest headaches:
-figuring out payroll for first employee. Finally did it, got it done, no longer an issue.
-prior auths for CT or MRI heads, I've done two...
-trying to get patients into Sleep Medicine at big box shops. I solved that problem, stopped sending to them and refer to an independent doctor now.
-thinking about how high my office lease is. That's my own fault, and I can move in a few years if need be.
-I prevent benzo headaches up from by making clear on website and possible inquires I don't prescribe them, I will taper but I don't prescribe.

8 months into my practice, I am loving it, feel so much happier and won't go back to other employed group jobs, never again. This is this closest thing to 'the promised land.'

It will be your practice, and you can control a lot of it.

You don’t prescribe benzos? Even when indicated you just wont prescribe? That doesn’t seem reasonable lol

 

[Candidate2017]

Bed bugs, patients angry about not reporting address changes. Seems like a lot of this is due to patient population.

Family calls/issues, insurance, lab fees... those are responsibilities of the patient. Perhaps you are working harder than the patient? As well as being pulled into a triangulated, 3-way relationship. I feel the doctor should not be a go-between because the patient needs to be an adult and do adult things like deal with family, figure out labs/insurance/$. Otherwise we are stunting their therapeutic process. If they are incapable of acting as aduIts, they are inappropriate for a private clinic and need a higher level of wraparound services. We also aren't paid to deal with family neuroses. Rarely do families call for medical information. They call to displace anger and frustration, but we aren't their therapists or psychiatrists. I avoid calling families, and never more than a few minutes and tell them they and the patient need to work out effective communication. So boundaries and putting responsibility back where it belongs.

Maybe this is a function of spending lots of time in academics (or bureaucracy like the VA), where boundaries are not respected (hey, let’s use residents/employee docs to do all this crap!) there is a pervasive god-like assumption that we can and should solve all of the patient’s problems and are given lots of time to play all-powerful social worker and nanny to patients, which does not work well in the real world.

 

[Candidate2017]

You don’t prescribe benzos? Even when indicated you just wont prescribe? That doesn’t seem reasonable lol

If the goal is to screen out bzd headaches, it's much more effective to state they don't prescribe bzds than make it known on their website that, “I will only prescribe bzds if indicated”. I imagine they'd have no problem starting bzds if properly indicated.

 

[NITRAS]

Oh yeah I'm aware but safer to destroy. Some can survive pesticides.

Heat kills bed bugs. Only need like 125 degrees. Cover in bag...leave in the sun in this heat (in Texas) Done.

Diatomaceous earth works too. A bag at Home Depot is like $8.

 

[whopper]

Family calls/issues, insurance, lab fees... those are responsibilities of the patient.

Simplistically said...yes. (And BTW I agree wholeheartedly with your post).

Play mental chess. Think 4 moves ahead. Patient or their family is known to be litigious. Even if they aren't if they are ticked off at you they can become so.

Still the above is not worth much concern unless the patient is high risk. E.g. a schizophrenic or bipolar disordered patient who frequently is noncompliant or abusing drugs.

Now factor in the high risk patient + litigious family members + the family members are really testing the boundaries. That's where this becomes on the forefront of my mind because now you are getting into an algorithm where you can see yourself getting into a future lawsuit.

Nitras--> Thanks for the info!

 

[Ironspy]

You don’t prescribe benzos? Even when indicated you just wont prescribe? That doesn’t seem reasonable lol

I don’t either. Very clear up front. I taper. I rarely prescribe a very limited supply for something like flying anxiety but don’t believe they are indicated for most patients. My patients agree and those who don’t go elsewhere. I currently have zero patients on benzos.

 

[whopper]

I have about 5-10% of my patients on benzos but everyone's either on a very low dosage (e.g. Clonazepam 0.5 mg) or on Alprazolam or Lorazepam only for panic attacks and take them about once a month.

For patients already on a large dosage (that I didn't start), I tell them we will proceed to lower them within 1 month of seeing me or they need to get another doctor and lower at a rate of about 10% of the dosage/month.

I'm also willing to give the patient benzos for something very acute. E.g. fear of flying and they are taking plane flights, or they are undergoing chemotherapy.

 

[Sushirolls]

You don’t prescribe benzos? Even when indicated you just wont prescribe? That doesn’t seem reasonable lol

Nope. I prescribe to taper people off. I have 0 patients on benzodiazapines at this time in my practice.

Exceptions may include:
1) REM sleep behavior disorder after Sleep Medicine has confirmed the diagnosis and I have their notes/consult recommending it (I may have one soon).
2) Catatonia (which my current practice I don't anticipate seeing much anymore, unless I get the ECT service line up and running)
3) Acute Stress Disorder, i.e. something substantially traumatic just took place and I'm trying to head off the PTSD transition, but this Rx is a 1 time only, and have only done this once/twice in past 5 years within an outpatient clinic.
4) Acute plane phobia with 1 pill per flight, no more, no refills
5) Alcohol/Benzo detox in inpatient settings
6) Possibly outpatient alcohol librium taper, but I've yet to see a low enough risk patient to do this, and thus far ever one has been pointed to inpatient detox.

 

[Merovinge]

Nope. I prescribe to taper people off. I have 0 patients on benzodiazapines at this time in my practice.

Exceptions may include:
1) REM sleep behavior disorder after Sleep Medicine has confirmed the diagnosis and I have their notes/consult recommending it (I may have one soon).
2) Catatonia (which my current practice I don't anticipate seeing much anymore, unless I get the ECT service line up and running)
3) Acute Stress Disorder, i.e. something substantially traumatic just took place and I'm trying to head off the PTSD transition, but this Rx is a 1 time only, and have only done this once/twice in past 5 years within an outpatient clinic.
4) Acute plane phobia with 1 pill per flight, no more, no refills
5) Alcohol/Benzo detox in inpatient settings
6) Possibly outpatient alcohol librium taper, but I've yet to see a low enough risk patient to do this, and thus far ever one has been pointed to inpatient detox.

Is there any evidence for ASD to PTSD conversion being lessened by BZDs? Seems like we have tried everything from an Rx standpoint and come up short but it's also been awhile since I've looked over this literature.

 

[Sushirolls]

Some. Been awhile for my self too for that literature review. I believe most of the pubs were acute use in ED, or within 2-3 days type of time frame. Lot of gray in this indication with no clear answers was my take home.

 

[WisNeuro]

Is there any evidence for ASD to PTSD conversion being lessened by BZDs? Seems like we have tried everything from an Rx standpoint and come up short but it's also been awhile since I've looked over this literature.

Haven't seen anything convincing or methodologically sound on the medication front. On the intervention front, most of what we have suggests that blanket interventions following a trauma can actually increase the chances of conversion to PTSD (e.g., CISD). Haven't delved into this area in the past couple of years, though.

 

[whopper]

Is there any evidence for ASD to PTSD conversion being lessened by BZDs? Seems like we have tried everything from an Rx standpoint and come up short but it's also been awhile since I've looked over this literature.

The problem here is there's data showing it does reduce, but also data saying it doesn't. The data saying it does had low sample sizes.
Later data came out showing corticosteroids could prevent ASD to PTSD with better numbers but this hasn't caught on yet it seems with treating PTSD. I've considered it but never had an ASD patient yet after I learned of this newer data to give it a try.

But given that many cases of ASD don't progress to PTSD it's IMHO worth considering giving a benzo for it with the full disclosure of of the risks and educating the patient not to take it unless needed.