This is Why You Remain Professional and Respectful Even with Malingerers

[whopper]

Doctor suspended for berating basketball player suffering from anxiety attack

If you've read several of my posts you've likely read a few where I mentioned I've kicked out malingerers out of the ER and the psych unit on several occasions.

If you do so, you do it respectfully and in a manner suggestive they continue to get the help they need. E.g. if someone is malingering cause they want a roof over their head, you refer them to the homeless shelter and politely tell them the hospital is to treat severe illness and their homelessness understandably could make someone stressed but there's better avenues to approach it.

Further, don't peg the patient as malingering unless you got real real solid evidence and reasoning. First time visits you never can be very sure unless something way extreme happens like you hear him call up someone and admit their malingering scheme is working (and yes I've seen that!)

In the case above, apparently the ER doctor only saw the guy once, his father was with him, and while we don't have the kid's medical records, even if the kid was drug seeking and/or malingering there's much better ways the doctor could've handled it. Also in California (where it happened) she could've accessed a PDMP to see if the kid was using benzos responsibly.

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[NontradCA]

It seems that doctor was having a bad day, week, month, year whatever and it culminated in that encounter. She’s prolly burned out. That sucks.

 

[whopper]

Yeah, and I've seen a lot of people do what she does. I don't say this as an excuse because it's not excusable. Further several physicians get an attitude that if the issue is psych it's BS. The doctor in this above seems to fit this based on her responses.

 

[Attending1985]

I feel for the doctor in the video. Maybe she lost her cool but the situation was obviously difficult. She’s probably burned out not a bad person or doctor.

 

[birchswing]

I've had encounters as a patient similar to that. The reason I never recorded is that I assumed there would be blowback from the facility and you would get blackballed. You could bring video to the hospital to complain, and they'd ask why were you recording. I guess it depends on how egregious it is and whether the media picks it up; at that point I guess the facility has the public against them. With the police, it's now been established that recording is legal. In a hospital, since it's their property it's probably a bit more of a grey area, especially if they have to consider other patient confidentiality. But given the power differential, I'm not against the ability of the patient to record a bad encounter.

 

[whopper]

Recording-the laws vary per state. In some states it's illegal to record a conversation unless all parties involved know it's going on, in other states as long as 1 party knows, that's all that's required.

 

[675015]

Recording-the laws vary per state. In some states it's illegal to record a conversation unless all parties involved know it's going on, in other states as long as 1 party knows, that's all that's required.

Our ERs have official policies against it because of other patients’ privacy protection. I don’t know where that stands legally but it seems logical in a crowded busy ER with no private rooms.

 

[birchswing]

Recording-the laws vary per state. In some states it's illegal to record a conversation unless all parties involved know it's going on, in other states as long as 1 party knows, that's all that's required.

Yeah, I'm familiar with the 1 vs 2 party, but I would think private businesses can put restrictions up and beyond that.

 

[Nasrudin]

This was a clear example of self-victimization with anti-social intent at ambush. The patient is looking for klonipin. He is young and healthy. And the parent child dyad is pathologically conspiratorial in their own victimization. Which is about as dishonorable a thing a father can do in my opinion. What he is teaching his son is far more repugnant than the physician’s poor behavior.

That said. The physician WAS gruff. And unnecessarily emotionally invested in the enactment of helplessness and externalization.

Which makes it a great post and thread topic whopper. And I heed your advice. Thank you.

 

[WisNeuro]

Having anywhere between 30-55% of my VA patient load, depending on the clinic, clearly malingering on neuropsych tests definitely helped with maintaining a professional demeanor when dealing with said patients. It's definitely something that students/trainees/interns should get training and supervision in.

 

[Nasrudin]

Having anywhere between 30-55% of my VA patient load, depending on the clinic, clearly malingering on neuropsych tests definitely helped with maintaining a professional demeanor when dealing with said patients. It's definitely something that students/trainees/interns should get training and supervision in.

While that's good, and no doubt true. I don't think we're looking at a shrink here. This is an ED doc. They're busy learning medicine. Although maybe for their own mental health teaching them how to manage these situations with stoicism and distance would be a great idea.

If you've managed to graduate psychiatric residency without the skills to manage this type of situation then you were asleep at the wheel.

 

[WisNeuro]

While that's good, and no doubt true. I don't think we're looking at a shrink here. This is an ED doc. They're busy learning medicine. Although maybe for their own mental health teaching them how to manage these situations with stoicism and distance would be a great idea.

If you've managed to graduate psychiatric residency without the skills to manage this type of situation then you were asleep at the wheel.

My comment was aimed at healthcare in general, not just those of us in the MH arena. Malingerers/exaggerators/etc are not unique to MH. Dealing with such people is a skill everyone the patient comes into contact with needs to learn. Also, while I agree that MH providers should have the skills to deal with this, many don't. I see way too much on both ends of the spectrum, either like this ER doc, and the other side, MH providers who will take just about anything the patient says at face value, in spite of the evidence and common sense suggesting otherwise. Way too many asleep at the wheel, it seems.

 

[whopper]

The patient is looking for klonipin. He is young and healthy. And the parent child dyad is pathologically conspiratorial in their own victimization.

All are possible-in a bad sense. Also possible is he was on a low-dosage of Clonazepam, using it responsibly, and/or his outpatient doctor directed him to use it without giving other options such as SSRIs that I see quite often.

Also possible-the father was just trying to protect his son.

We will likely never know if the patient had any hidden agenda but we do know that doctors aren't supposed to presume patients are guilty without a significant amount of information.

Further, while many people in the ER are trying to take advantage of services, only based on what's been presented in the media it's a 50-50. The kid could've been abusing it. HE also could've been using it the way he was supposed to do as directed by his doctor. It's too much of a leap to treat to assume the patient has bad intent when it's a 50-50 like this.

Again, even if it known he was trying to manipulate the doctor, the doctor should've kept a better demeanor.

 

[whopper]

Also, while I agree that MH providers should have the skills to deal with this, many don't.

Given that malingering is quite common in ER settings I find it shocking how little is taught on this in residency, well at least the residency I was trained in, where we had malingerers everyday and no one putting their foot down and creating a policy based on evidence to deal with them.

I later got that training in forensic psychiatry but how many forensic psychiatrists do you see running inpatient or ER?

 

[thoffen]

This was a clear example of self-victimization with anti-social intent at ambush. The patient is looking for klonipin. He is young and healthy. And the parent child dyad is pathologically conspiratorial in their own victimization. Which is about as dishonorable a thing a father can do in my opinion. What he is teaching his son is far more repugnant than the physician’s poor behavior.

That said. The physician WAS gruff. And unnecessarily emotionally invested in the enactment of helplessness and externalization.

Which makes it a great post and thread topic whopper. And I heed your advice. Thank you.

I'm not sure how you can peg conscious intent based on this video, although that is definitely a possibility. But interactions like this are what drove me to psychiatry. If they weren't aggressive they were likely passive-aggressive. Not that psych somehow avoids those kinds of provider reactions -- hence the reason for the thread -- but rather we have the tools to examine them and consider their meanings. Here is where I would depart. If definite and complete malingering, the physician's behavior is still bad, but there are a lot of other possibilities. And considering those possibilities does not mean provision of benzos. The fact that it seems so split between needing requested treatment and full of s--- hopefully elucidates that some therapeutic communication is being provided but not appreciated.

 

[wolfvgang22]

Always take the high road, always treat others with respect, whether they deserve it or not.

Burnout and fatigue have occasionally caused me to forget my own advice. I hope both the patient and doctor in this story are able to move on to better days with neither experiencing too much trauma along the way.

 

[Nasrudin]

Good points.

Keep in mind. I’m not saying they were malingering. In fact, my guess is that, they were looking for a simple, ineffective method of not experiencing negative emotions. And most likely the son had a panic attack.

What I’m talking about is the style of interaction. How the video was shot. On the sly. What was done with it. And about it.

I’m simply saying I’m not as simple minded as to say... awwwww poor oppressed patients. Like a patronizing liberal who always looks for the infant in the other.

 

[clausewitz2]

Good points.

Keep in mind. I’m not saying they were malingering. In fact, my guess is that, they were looking for a simple, ineffective method of not experiencing negative emotions. And most likely the son had a panic attack.

What I’m talking about is the style of interaction. How the video was shot. On the sly. What was done with it. And about it.

I’m simply saying I’m not as simple minded as to say... awwwww poor oppressed patients. Like a patronizing liberal who always looks for the infant in the other.

Given the history of how poorly most people of color have historically been treated by the medical establishment in particular and hierarchies of authority in this country generally, I don't think their initial reaction is at all pathological. It seems much more like people trying to use whatever tools they have to feel less radically disempowered, in addition to the vigilance for the point at which this white doctor is going to show her *ss (figuratively) and let the veil drop to reveal her true racist self.

Think very hard if this situation would have gone this way if a young white man had just come from basketball practice with these complaints, and imagine he does not have neck tattoos. I think things go differently.

 

[st2205]

Given the history of how poorly most people of color have historically been treated by the medical establishment in particular and hierarchies of authority in this country generally, I don't think their initial reaction is at all pathological. It seems much more like people trying to use whatever tools they have to feel less radically disempowered, in addition to the vigilance for the point at which this white doctor is going to show her *ss (figuratively) and let the veil drop to reveal her true racist self.

Think very hard if this situation would have gone this way if a young white man had just come from basketball practice with these complaints, and imagine he does not have neck tattoos. I think things go differently.

Or two men in a patriarchal society struggling with a female given direction and authority over them.

But whatever angle floats your boat.

 

[st2205]

Always take the high road, always treat others with respect, whether they deserve it or not.

Burnout and fatigue have occasionally caused me to forget my own advice. I hope both the patient and doctor in this story are able to move on to better days with neither experiencing too much trauma along the way.

These interactions are the crux of life. It’s all about how to learn from, address, and handle such issues. If we view this as a trauma, from either side, then we’re patronizing their adult capabilities while encouraging their own feelings of helplessness.

 

[clausewitz2]

Or two men in a patriarchal society struggling with a female given direction and authority over them.

But whatever angle floats your boat.

Mmkay. If we want to ignore the highly specific and relevant historical context here, that's your choice, but I think you're missing a critical piece to understanding.

Rational not to care enough to think about it very hard from an effort-reward standpoint based on your priorities and valurs I suppose.

I think there is a very clear direct line from recordings of police a la Fernando Castile to this incident.

I do agree with you that this is about how people try to take back some power in a hostile interaction with authority, though. There is an interview in which the young man asserts he wanted to start filming when he saw the ED doc come back with security so I think he was afraid things would go very badly.

 

[Nasrudin]

Given the history of how poorly most people of color have historically been treated by the medical establishment in particular and hierarchies of authority in this country generally, I don't think their initial reaction is at all pathological. It seems much more like people trying to use whatever tools they have to feel less radically disempowered, in addition to the vigilance for the point at which this white doctor is going to show her *ss (figuratively) and let the veil drop to reveal her true racist self.

Think very hard if this situation would have gone this way if a young white man had just come from basketball practice with these complaints, and imagine he does not have neck tattoos. I think things go differently.

This is exactly the type of grandiose moral narcissism that the vulnerable victimized narcissism of these 2 depends on. Congratulations on being a moral savior of the downtrodden. You get to have that feeling. They get to feel sympathy and unaccountability for their actions. And no one wins. A doctor, unskilled in the management of a psychiatric complaint with poor care seeking behavior who behaved poorly gets a public flogging at the hands of the morally superior and self-victimized.

The patients learn nothing. Are reinforced in their maladaptive behaviors and poor care seeking strategies. The doctor suffers grave consequences. And everyone who chooses to can lecture about the moral depravity of one of the few places on earth that has deliberately tried to make itself accountable to it's amazing founding principles. Congratulations. If you want that. You can have it from me too. Just not for the reasons you dictate.

 

[WisNeuro]

Is this the psychiatry forum, or the SPF?

 

[NontradCA]

This is exactly the type of grandiose moral narcissism that the vulnerable victimized narcissism of these 2 depends on. Congratulations on being a moral savior of the downtrodden. You get to have that feeling. They get to feel sympathy and unaccountability for their actions. And no one wins. A doctor, unskilled in the management of a psychiatric complaint with poor care seeking behavior who behaved poorly gets a public flogging at the hands of the morally superior and self-victimized.

The patients learn nothing. Are reinforced in their maladaptive behaviors and poor care seeking strategies. The doctor suffers grave consequences. And everyone who chooses to can lecture about the moral depravity of one of the few places on earth that has deliberately tried to make itself accountable to it's amazing founding principles. Congratulations. If you want that. You can have it from me too. Just not for the reasons you dictate.

This is exactly the type of grandiose moral narcissism that the vulnerable victimized narcissism of these 2 depends on. Congratulations on being a moral savior of the downtrodden. You get to have that feeling. They get to feel sympathy and unaccountability for their actions. And no one wins. A doctor, unskilled in the management of a psychiatric complaint with poor care seeking behavior who behaved poorly gets a public flogging at the hands of the morally superior and self-victimized.

The patients learn nothing. Are reinforced in their maladaptive behaviors and poor care seeking strategies. The doctor suffers grave consequences. And everyone who chooses to can lecture about the moral depravity of one of the few places on earth that has deliberately tried to make itself accountable to it's amazing founding principles. Congratulations. If you want that. You can have it from me too. Just not for the reasons you dictate.

You’re going a little too far. What poor care seeking behavior was the patient exhibiting exactly? Just the facts sir. This is a 6’9 20 year old with witnessed syncopal episode following basketball practice. From what I can tell in the video the patient seems to be responding appropriately to a very aggressive and abusive physician. Let’s be clear: It’s unsettling the father would record this encounter but the vast majority of physicians would never act like this towards a patient.

 

[WingedOx]

My comment was aimed at healthcare in general, not just those of us in the MH arena. Malingerers/exaggerators/etc are not unique to MH. Dealing with such people is a skill everyone the patient comes into contact with needs to learn. Also, while I agree that MH providers should have the skills to deal with this, many don't. I see way too much on both ends of the spectrum, either like this ER doc, and the other side, MH providers who will take just about anything the patient says at face value, in spite of the evidence and common sense suggesting otherwise. Way too many asleep at the wheel, it seems.

While that's good, and no doubt true. I don't think we're looking at a shrink here. This is an ED doc. They're busy learning medicine. Although maybe for their own mental health teaching them how to manage these situations with stoicism and distance would be a great idea.

If you've managed to graduate psychiatric residency without the skills to manage this type of situation then you were asleep at the wheel.

Let's not act like we don't get floor consults from IM et al. for "I can't talk to this difficult patient myself."

 

[Nasrudin]

You’re going a little too far. What poor care seeking behavior was the patient exhibiting exactly? Just the facts sir. This is a 6’9 20 year old with witnessed syncopal episode following basketball practice. From what I can tell in the video the patient seems to be responding appropriately to a very aggressive and abusive physician. Let’s be clear: It’s unsettling the father would record this encounter but the vast majority of physicians would never act like this towards a patient.

He’s participating in his own poor management of anxiety and panic by demanding to not feel this way with a pharmaceutical. That would’ve never bothered me in the least. But having a poor idea of good care being enforced and entrenched in the overemphasis on a bad interaction is just concretizing the notion that good doctor = pill that makes me feel good, and, bad doctor = those that don’t give me this.

I didn’t know about the syncope. If that’s the case he needs a full cardiac work up. And if his medical medical care has not been adequate then that’s a whole separate issue that was not in the information in the OP.

I think we probably agree essentially. Although you haven’t been in the psych game to see what I see: the use of cultural narratives of oppression to absolutely ensure that no personal porgress is made and no accountability for oneself is instilled.

This might be region dependent. But here in liberal Hoity-toityVille this is a culturally prominent codependent phenomenon.

I’m interested in this kid being his most awesome self. And if he had presented to me. He would’ve left with the best plan for addressing his psychiatric complaints that I could muster. Which would’ve included patient education to both of them as to why BDZ therapy is not ideal for long term management. If anxiety is the problem. If it was syncope then they would’ve gotten my best effort at getting the patient’s cardiac status worked up properly.

 

[NontradCA]

He’s participating in his own poor management of anxiety and panic by demanding to not feel this way with a pharmaceutical. That would’ve never bothered me in the least. But having a poor idea of good care being enforced and entrenched in the overemphasis on a bad interaction is just concretizing the notion that good doctor = pill that makes me feel good, and, bad doctor = those that don’t give me this.

I didn’t know about the syncope. If that’s the case he needs a full cardiac work up. And if his medical medical care has not been adequate then that’s a whole separate issue that was not in the information in the OP.

I think we probably agree essentially. Although you haven’t been in the psych game to see what I see, the use of cultural narratives of oppression to absolutely ensure that no personal porgress is made and no accountability for oneself is instilled.

This might be region dependent. But here in liberal Hoity-toityVille this is a culturally prominent codependent phenomenon.

I’m interested in this kid being his most awesome self. And if he had presented to me. He would’ve left with the best plan for addressing his psychiatric complaints that I could muster. Which would’ve included patient education to bog of them as to why BDZ therapy is not ideal for long term management. If anxiety is the problem. If at syncope then they would’ve gotten my best effort at getting he patient’s cardiac status worked up.

I would guess that he had a cardiac workup if that was his complaint and he was in the ER. Maybe that’s why the ER doc is unimpressed. Aside from that, how can you blame the 20 year old patient who, was prescribed the BZD by a physician for panic attacks in the first place, to ask for more when he has a debilitating one? I would think the doctor that prescribed them to him doesn’t agree with your assessment of poor treatment seeking behavior.

 

[WingedOx]

I would guess that he had a cardiac workup if that was his complaint and he was in the ER. Maybe that’s why the ER doc is unimpressed. Aside from that, how can you blame the 20 year old patient who, was prescribed the BZD by a physician for panic attacks in the first place, to ask for more when he has a debilitating one? I would think the doctor that prescribed them to him doesn’t agree with your assessment of poor treatment seeking behavior.

I mean, he was given the benzo which is a (probably, we don't really know the backstory) questionable tx decision by what we assume is a licensed physician. Not like the kid is going to know any better.

 

[deleted736562]

I thought that the patient dealt with the doctor pretty well actually, even if little manipulative. It's one of those situations where you're not sure who's who.

 

[clausewitz2]

I mean, he was given the benzo which is a (probably, we don't really know the backstory) questionable tx decision by what we assume is a licensed physician. Not like the kid is going to know any better.

This. It isn't malingering if you are genuinely seeking what you think is appropriate care.

 

[clausewitz2]

This is exactly the type of grandiose moral narcissism that the vulnerable victimized narcissism of these 2 depends on. Congratulations on being a moral savior of the downtrodden. You get to have that feeling. They get to feel sympathy and unaccountability for their actions. And no one wins. A doctor, unskilled in the management of a psychiatric complaint with poor care seeking behavior who behaved poorly gets a public flogging at the hands of the morally superior and self-victimized.

The patients learn nothing. Are reinforced in their maladaptive behaviors and poor care seeking strategies. The doctor suffers grave consequences. And everyone who chooses to can lecture about the moral depravity of one of the few places on earth that has deliberately tried to make itself accountable to it's amazing founding principles. Congratulations. If you want that. You can have it from me too. Just not for the reasons you dictate.

I think you're reading way more into what I said than is there. Some of your factual assertions I find risible but this is not the time or place. Mostly I try to be sensitive to these issues in a professional context for purely pragmatic reasons. I found that working with people with certain experiences very different from mine that rapport sometimes evaporated without warning or never got established at all. That's happened a lot less as I've been more thoughtful about this.

I guarantee that you will walk into 100% of the hidden landmines and tripwires out there if you pretend they don't exist.

 

[PsyDr]

Los Gatos: Doctor removed from El Camino Hospital after video shows her mocking a patient

More information.

The father stated that the patient was prescribed benzos for ptsd. He stated that benzos cause seizures. He stated that his son ran out of medication for 2 days because he couldn't get to the pharmacy before it closed. The recorded event took place on a Monday. The father stated that the son and father felt as if they were treated as drug seeking. The father, in the same interview, stated that all medical staff needed to do was to give his son one or two pills (of klonopin).

 

[Nasrudin]

I would guess that he had a cardiac workup if that was his complaint and he was in the ER. Maybe that’s why the ER doc is unimpressed. Aside from that, how can you blame the 20 year old patient who, was prescribed the BZD by a physician for panic attacks in the first place, to ask for more when he has a debilitating one? I would think the doctor that prescribed them to him doesn’t agree with your assessment of poor treatment seeking behavior.

I make an observation and describe it: ie the baby is sucking on a pacifier and will not get any milk from it. And you say “how can you blame him” for sucking on the pacifier.

I don’t care who gave him the medication. You will deal routinely with perscribers who have started opiates and BDZ’s for which you are dealing with the consequences of. For this reason I acculturate radical personal responsibility and personal stewardship, so that no random a-hole with a script pad will easily persuade any patient I’ve seen to take a medication without critical thought. Or at least that’s what I aim for. For their sake.

Clausewitz can laugh all he or she wants. This phenomenon illustrated above. And the temperamental/political proclivities of psychiatric clinicians that are illustrated in the different ways you and I perceive the world around us. Have huge implications for how psychiatric care is delivered. Having done the research on this. And having been an increasingly libertarian leaning person amidst intensely liberal enclaves for training has given me the experience to understand how the liberal—hyperagreeable—mind operates in the clinical sphere.

And this the perfect place for this.

Because this case. Like all the hot political-viral issues of the day display how humans of different temperaments and political persuasions think.

With the information provided above, I think it would be a question of institutional culture and policy whether or not short term BDZ rx’s could be provided from the ED.

Making it then a question of individual clinician coping and communication failure. Not a question of racism or oppression or discrimination. At least from he available evidence. To assume otherwise says more about the sayer than the observed. And this from a libertarian who have demonstrably better ability to represent the liberal thought process than the other way around—for which there is good evidence to say.

 

[WingedOx]

Samuel’s Bardwell’s father, Donald Bardwell, said his son previously had been diagnosed with anxiety and post-traumatic stress disorder and was prescribed Klonopin, which can cause seizures.

[sigh...]

 

[birchswing]

I think these prescriptions for children are more common than you might think. The person who started me on Ativan at 14 was a child and adolescent-certified psychiatrist. I had no idea what I was taking. It was the "a diabetic takes insulin" explanation.

And do they cause seizures . . . well that's an interesting way of putting it, but in the sense that the body potentially loses the ability not to seize in the absence of the medication, yes, you could word it that way. It's not a way I would have considered/worded it, but with most medicines you expect to be able to stop them and not have a problem you didn't have before you started it. So in that sense, I can see why someone would say benzodiazepines cause seizures.

When I went to college, the psychiatrist told me that Klonopin is not a benzodiazepine. I didn't want to be on one as I started to become aware of what Ativan trul was. He said it wasn't. He said it was anti-convulsant and mood stabilizer. I didn't know.

These are still some of the most prescribed psych meds and are getting new approvals in recent years (Xanax XR and new nasal forms of Ativan, etc.).

 

[lyla]

If he has severe panic attacks, he could have made time to pick up his Klonopin Rx. I don't buy this bull**** when someone claims to have a severe mental health condition but can't be bothered to pick up their meds. Your goddamn bad.

 

[whopper]

Here's what I do in ERs when I get patients requesting benzos.
1) Check the state PDMP (and guess what? I'm in Missouri the only idiot state in the country to not have a PDMP.
2) Contact (or have staff contact) the benzo provider's office.
3) Tell the patient that it's better to try alternatives to benzos such as an SSRI, SNRI, Buspirone, B-Blocker, etc.
4) If the patient still wants the benzo, I'd either say no based on the whole picture we can get at the time or give an amount that will last just a few days if everything checks out okay.

If the patient freaks out in anger cause you didn't do what they wanted you remain calm, stick to your guns, and if need be get security involved (but only if you got good reason to think they're going to get violent).

But again, do not do what the doctor did in the video.

 

[WingedOx]

1) Check the state PDMP (and guess what? I'm in Missouri the only idiot state in the country to not have a PDMP.

I thought I'd read that they finally rectified this. Is their system just not up and running yet?

 

[Armadillos]

I feel like the PMP databases have changed everything and many doctors who have super strict and inflexible personal “rules” related to prescribing controlled substances need to adapt.

For example, you have a patient with ADHD you’ve been seeing for awhile lose their adderall XR script (shocking that someone with ADHD would lose something). I check the database and they haven’t filled it and aren’t filling any other controlled substances. I write a new Rx and at followup I can check database again and confirm they didn’t fill both prescriptions. The worst case scenario is a patient could scam me for 1 extra prescription before I discharge them.

Or patient seeing someone else in one of our clinics is on long term benzos and couldn’t get a refill for whatever reason to cover a holiday/weekend/travel/whatever. If I confirm the story checked out with the database I can feel completely fine calling in someone 4 klonopins to prevent a ridiculous ER visit.

 

[Candidate2017]

No way that's an ED doc. She spoke to a "psych" patient for more than 2 minutes!

 

[Candidate2017]

The patient and his father may have their own issues but the doc is 100% in the wrong. Sarcastically mocking a patient is NEVER ok. Cursing at a patient is only ok if they've taken a swing at you or something.

The doc in the video is just verbalizing the, "You can breathe and aren't crashing? Get the F out my ED!" that many ED docs have towards patients, malingerers or otherwise. It's a field that refers to patient care as "moving the meat." Many ED docs mock "psych" patients behind closed doors or express hostility at having to see such patients. Did they go through med school and residency and not realize that a third or more of ED patients would be "psych" patients?

Different fields attract different personalities. People in EM are attracted to it because high hourly rate, days off, lack of continuity, short encounters, clock in-clock out work, adrenaline moments. Such personalities don't deal with interpersonal conflict or handle self-monitoring well.

 

[FlowRate]

Given that malingering is quite common in ER settings I find it shocking how little is taught on this in residency, well at least the residency I was trained in, where we had malingerers everyday and no one putting their foot down and creating a policy based on evidence to deal with them.

I later got that training in forensic psychiatry but how many forensic psychiatrists do you see running inpatient or ER?

At what point do you decide they're malingering? We're taught how to deal with the super clear malingerers (every day in multiple ED's) but seem to give pretty wide leeway otherwise (supposedly this will change when we see our other site next year.)

 

[Jules A]

For example, you have a patient with ADHD you’ve been seeing for awhile lose their adderall XR script (shocking that someone with ADHD would lose something).

Whats really shocking is that its always a schedule 2 that got lost. 😀

 

[Armadillos]

Whats really shocking is that its always a schedule 2 that got lost. 😀

I haven’t handed someone a paper prescription for a non-controlled substance in years, so obviously I’m only getting called about lost controlled scripts. The quoted sort of thinking is I think a somewhat antiquated “pre-database” worry if you have a pt you have followed for a little while with a consistent database hx.

 

[Liquid8]

Seems like the doctor involved has run into boundary issues before.

https://bmp.hlb.state.mn.us/corr/KEEGSTRA, Beth R (PY56186)/Keegstra, Beth R (2-27-17).pdf

 

[Jules A]

I haven’t handed someone a paper prescription for a non-controlled substance in years, so obviously I’m only getting called about lost controlled scripts. The quoted sort of thinking is I think a somewhat antiquated “pre-database” worry if you have a pt you have followed for a little while with a consistent database hx.

I didn't realize anyone still wrote scripts. I am so far evolved from "pre-database" that my e-prescribe transmits stimulants electronically. The only calls I get about lost meds in this day and age have already been filled.

 

[whopper]

I thought I'd read that they finally rectified this. Is their system just not up and running yet?

St Louis County got one, mostly to make a statement to the rest of the state that we need one, but St. Louis County is only 1 county in this state.
It did have the effect of making those in Jefferson City (the state's capitol) to consider getting one, it was debated and ultimately defeated...again. Aside that this is really stupid from a clinical perspective, from an insurance perspective many of them won't pay for the patient's meds unless we tell them we verified via the PDMP they are getting the meds from one provider.

Well guess what? We tell them we don't have one in this state (yes I have plenty of patients outside the county cause of the midwest shortage of doctors) and then they tell us we're lying, that all 50 states have it. When we tell them Missouri doesn't have one many of them won't double check and get angry...then hang up on us.

Which in effect causes a mechanism that leads to the patient not getting the meds paid for. I can't do anything (or my secretary) other than call again, get a similar response, so we tell the patient we tried, failed, it's not our fault and they can complain to the state insurance board about the insurance company and maybe, just maybe, 9 months from now after the investigation is done they might get their meds paid for by the insurance company.

 

[whopper]

Nasrudin...

Personal recommendation-don't apply politics or the philosophical/social trends on an individual. Individuals have the right to get individualized care. Of course trends, things like that need to be considered, but they don't prove one person guilty. You got nothing to lose by still doing correct care while not disrespecting the patient, even if they are a malingerer.

 

[Nasrudin]

What are you talking about?

I'm applying both Big 5 personality trait analyses to us as clinicians and to their political correlates. For which their is an active and viable body of research to do.

And furthermore, I am the individualist in this conversation. I'm not applying collectivist theories to these interactions. I'm looking at what they contain. And giving people the utmost respect, in my view, by granting them individuality.

What do you imagine I'm saying?

Because I'd like use to have a conversation between the actual me and you.

 

[whopper]

It's not in general recommended, actually recommended against, to use diagnose personality until you've gotten to know the patient very very well. Not a one time meeting.

ER visits are only that. Often times one-time meetings. Sometimes in the ER you see frequent-flyers but that's a different situation.