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The ethical dilemmas in daily family practice


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I am in a tiny solo practice family practice in a mid size city with lots of specialist availability and 4 hospitals.

 

I joined a year ago when an older doc retired and took his panel of somewhere around 3000 people - some come in regularly, some hardly at all and some haven't been back in years.

 

Sorting out all of their maladies has been a challenge.

 

We cannot force patients to comply but the question keeps coming up as to what to do with the ones who won't comply, ignoring huge medical issues, risking health, safety and even life.

 

Liability is an issue, frustration, anger, bad outcomes - it all adds up. Basically all of us involved in this profession want our patients to get better, stay better, not have complications of diseases. 

 

Do we fire them if they refuse to deal with something? Do we just document the snot out of all of our attempts to convey the seriousness of the situation? Do we call adult protective services on the elderly with no support who aren't taking care of issues?

 

What is enough? When is enough? 

 

40ish guy comes in to my PA partner just not feeling right. Well, glucosuria, HTN, A1c comes back at 13.

He calls from Florida for lab results and says he is too busy to come in - just send in a med.

We say no - you need insulin and more workup.

He refuses. Says he is too busy, copays too high and he doesn't feel THAT bad for all this fuss.

We sent him a certified letter outlining his lab results, their meaning and the consequences and list death, dysfunction, stroke, MI, renal failure, yada yada yada as consequences.

He begrudgingly sees an endocrine colleague and then never follows up with either of us.

BUT - he calls in for refills but won't come in for monitoring.

I say - the boot - firmly in the gluteal cleft and BYE BYE. 

 

76 year female with dementia, uncontrolled DM (A1c 11) and frank protein in her urine - think a filet mignon - creatinine somehow still below 3. Husband hearing loss and nearly as demented. When he brings her in - she stinks of urine and BO. She won't let home health in to the house anymore and now husband doesn't want to take her to the kidney doctor because it means driving 11 miles downtown. I called one adult child, said screw HIPAA and explained the issue. Turns out the couple is SUING their own kids for some issue about providing care to this woman and then wanting state pay for being a caregiver (the kids sound legit). The other kid is in their favor but completely useless and probably a tad mentally ill. I called Adult Protective Services. They did not see imminent danger and say they have no case. She is going to die a miserable death and probably find her husband along side her.

What to do? They can't take care of themselves and I can't find anyone else who will.

 

Mid 50s female with suboptimal type II DM control. A1c over 8. WILL ONLY COME IN ONCE A YEAR. Says she won't come in more often due to her insurance "only paying for one visit a year" and high deductible. Wants refills for one year at a time. I said NO. Told her the standard of care does not change based on patients' insurance or coverage. Her DM is not controlled and I have no recent kidney, liver labs or A1c. Office Manager (I know - GROAN) wants us to "take care of her" while medically I am peeved and want the patient to grasp reality and the fact that I did not pick her insurance. Doc is wishy washy on this one. 

 

The list goes on. One in three Americans is diabetic...... chronic disease is rampant.

There are truly troubled sick folks in the world who won't care for themselves or can't and the resources are slim.

 

Besides the fact that I care and wouldn't want my family like this - how far do you let this go? When do you excuse the patient from your practice for failure to follow recommended treatment plans? How long do you let them slide and not come in or do you even refill their meds with no follow up? Risk managers are just not helpful on this. DO NOT ASK ADMINS because they want happy "customers".

 

What have all of you guys experienced?

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pt #1, I would've done the same

 

pt #2, I honestly don't know what you can do.  Psych? Social services?  

 

pt #3, That's annoying, but you can bargain with labs = refill.  Document that you explained all the risks.  Try to get all her diagnostics done on that once a year f/u, document noncompliance, and bill a 99215 for all the DM sequalae you are going to deal with.

 

You can't help people who don't want to help themselves.

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Can you IVC #2? I don't know what the IVC laws are like where you are, but in NC they're pretty liberal. While that can certainly be abused (and frequently is), in some instances it's for the best. Maybe this is one of those situations? I'm not a PA (yet) but work in psych and I see a lot of geriatric patients with similar situations who truly benefit from being in a hospital and having their care taken out of their hands, if only for a brief period of time. It's also an opportunity for social workers to examine the family situation for a while and make an informed decision about stepping in. 

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I forgot to mention, regarding pt #3, in a 'healthy' 50's pt w/ an A1C of 8 doesn't bother me too much.  Yes, there risk of MI, renal dysfuction/degredation, retinopathy, etc etc goes up, but it's not that much more (only a few % increase in relative risk) than someone with an A1C of 6.5.  At this 'mid-range' A1C, if they don't want to help themselves with a healthier lifestyle, the medications/check-ups/interventions that a clinician can give doesn't make much of a difference.

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I forgot to mention, regarding pt #3, in a 'healthy' 50's pt w/ an A1C of 8 doesn't bother me too much.  Yes, there risk of MI, renal dysfuction/degredation, retinopathy, etc etc goes up, but it's not that much more (only a few % increase in relative risk) than someone with an A1C of 6.5.  At this 'mid-range' A1C, if they don't want to help themselves with a healthier lifestyle, the medications/check-ups/interventions that a clinician can give doesn't make much of a difference.

 

I think what bothered me more was her attitude about follow up and compliance. She was very defiant with my MA on the phone and dictatorial about how things would be done. She has her own battles to fight but if I am going to Rx meds - they aren't going to be for a year and I need to monitor potential toxicities of drugs and make sure there is no harm. She was more bothered because I felt some responsibility and wouldn't just prescribe blindly.

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No relevant labs, "no" refills.

No visit in 1, 3, or 6 months (depending on condition severity and stability), "no" refills.

By "no" what I really mean is they get a note that they need to come in before next refill (3 months for stable DM/HTN/etc.), and if they don't, they get one more month and another reminder.  I'll throw another couple of weeks in if they make an appointment that is beyond the horizon... you get the picture.

 

Chronic conditions need monitoring.  That is standard of care.  Your clinic administrator should be backing you up on this, because patients don't generate revenue without visits.  If everyone actually came in WHEN they were supposed to, we'd make decent money, see an appropriate amount of patients, and we'd keep them healthy and tuned-up nicely.  Not to mention they'd actually have a provider *relationship* rather than a semi-stranger across the exam table.

 

Explain it well and often, have it in writing, and trim your panel appropriately.  You have nothing to lose: they aren't getting care anyways, and your name won't be on their death certificate.  If they want to come back and work within the system, follow preventative medicine guidelines, etc., then by all means take them back.  Wouldn't even hurt to send letters out periodically "We were sorry to have to let you go because you were not taking care of your health. We remain ready and willing to assist you if you've changed your mind."

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I don't think we should subscribe to the idea that every customer is a customer worth having. We want the customers who are right for our firm. Saying goodbye to the wrong customer for your firm is good business. It only means you'll be better equipped to serve the customers who are right for your firm. No business can be all things to all customers. I think you should expect and anticipate a certain number of dismissals every month. The perturbations in the panel will stabilize in time.

 

Remember, we work too hard and have invested too much to have our advice dismissed by those who are ill informed. If the patient doesn't trust your judgment and wants to argue, let them find another practice. They will be a financial drain on another firm's practice. 

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I don't think we should subscribe to the idea that every customer is a customer worth having. We want the customers who are right for our firm. Saying goodbye to the wrong customer for your firm is good business. It only means you'll be better equipped to serve the customers who are right for your firm. No business can be all things to all customers. I think you should expect and anticipate a certain number of dismissals every month.

We run a walk-in clinic ~30 hours per week, in which we see all valid patients (not medicaid, nor a few others...), but I am pretty adamant that if I just met a patient, they do not get any controlled substances.  I will occasionally do refills for established patients, but I want the word on the street to be clear: even if you're paying cash, have a good story, and have an ID that doesn't get any hits on the PMP database... you're still not getting any narcotics, benzos, or even ambien from me as a walk-in patient.  I want my patients to be NOT-targets for parking-lot mugging for scripts.

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I am also trying to outlive the legacy of the retired doc who I think just got tired and complacent and became a "friend" rather than a provider.

 

I am tired of hearing "Well, Dr. C would never have put me through this. He made sure I had what I needed."

 

"Well, he's not here. I am and current literature says................................" 

 

I have stories and fables and make sure they know I won't Rx for them what I wouldn't let my sister or aunt or dad take due to dangers, etc. I really do try to get them to know I have their best interest at heart. 

 

My doc is in his first year of owning the clinic without the shadow of his dad and the other partner. He seems a bit afraid to stand up to some folks for fear of bad word of mouth. Being a doc does not mean one knows how to own a business.

 

I am more in line with - this might not be a good fit for some patients and they are welcome to go elsewhere...................

 

Some days are way more painful than others. Today is one of them.

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We work in a deeply flawed system. There is only so much you can accomplish within the constraints of such a system, especially when you are more interested in a patient's health than they are.

 

One of the best things about the death of paternalistic medicine is that the patients now need to assume primary responsibility for their own well being. The best we can do is provide the best, current, evidence-based recommendations we can come up with. It is up to the patient to determine whether to follow the recommendations. Many people will unfortunately make poor decisions.

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Sit down

 

Burn brain cells and come up with a plan of care for common Dx

 

Ie DM on insulin, q 3m office visits with labs in order to get meds - if miss q 3m visit, single refill for 30 days for them to get in

Do this for all common Dx which get ignored

 

Make this a nice letter to the entire panel, explaining that if the patient is not able to follow through with their end of the bargain - coming in and accessing care at appropriate time intervals - then they will be D/C from the practice with 3 months refills of meds.

 

Define the expectation - hold patients to it very consistently

 

The writing is on the wall - 3000 patients for a single provider is about 1500 to many if you have sickly panel.....

 

 

 

It is nothing more then helping people - define the expectations - get your office staff to realize it is your decision and only you can override it, and then stick to it except for extreme situations (you will know them when you see them)

 

 

Don't feel bad about it - the non-compliant patient will not feel any remorse when they sue you for malpractice!

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Half the problem is the patient mentality of being a "customer" or "Client"...a patient is neither, they're a patient.  Once they become a customer, you're nothing but a kid at the McDonald's drive through to them and they all of a sudden are telling you what to do.  The only thing they should be telling us is "Help me get better"...but more often than not, it's "Just give me what I tell you to, that's what I'm paying you for".  Even up here people feel that way.  Goes back to that sign I wanted to put up in the ER of "This isn't a fast food restaurant..."

 

With the elderly couple, I likely would have tried to have them brought in to hospital under the Mental Health Act...I used to do housecalls for some of my elderly folks that were teetering on full dementia and actually driven a couple to hospital myself for admission (don't get me going about the local coppers not doing their f*&king jobs under th MHA).  If they came voluntarily, great.  If not, went to the judge and had them issue an arrest warrant based on my statement.  Easy after the first time.  (Local laws applying of course)

 

Other ones - fire them IMHO.  That's another one that's easy once you've done it the first time :-D.  Wish I could fire one of my SP's...that'll be a harder one.

 

SK

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A group of local inmates petitioned to STOP being called inmates and be called clients or residents because INMATE is so derogatory.

 

NOT KIDDING.

 

I came up with SEVERAL other appropriate names for them but none would pass muster with admin.

 

A shovel is sometimes a shovel and no other title is appropriate.

 

A medical patient is not a client or customer.

 

My doc and I don't see eye to eye 100% on tolerance for manipulative patients. He is worried about pissing people off and getting bad word of mouth.

 

I am setting boundaries and expectations of patient behavior and responsibilities while clearly calling out BS and bad behavior. THAT is what I want MY reputation to be in the community.

 

I have twice the years in practice as the doc and he sees me as tainted and somewhat harsh instead of "customer service". Not sure how long it will take him to get badly burned and toughen up a touch. He is getting a reputation as a pushover for benzos and crap. Me, not so much.

 

Not going to cave..... You don't have to adore me to know I gave you the right medical advice

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A group of local inmates petitioned to STOP being called inmates and be called clients or residents because INMATE is so derogatory.

 

NOT KIDDING.

 

I came up with SEVERAL other appropriate names for them but none would pass muster with admin.

 

A shovel is sometimes a shovel and no other title is appropriate.

 

A medical patient is not a client or customer.

 

My doc and I don't see eye to eye 100% on tolerance for manipulative patients. He is worried about pissing people off and getting bad word of mouth.

 

I am setting boundaries and expectations of patient behavior and responsibilities while clearly calling out BS and bad behavior. THAT is what I want MY reputation to be in the community.

 

I have twice the years in practice as the doc and he sees me as tainted and somewhat harsh instead of "customer service". Not sure how long it will take him to get badly burned and toughen up a touch. He is getting a reputation as a pushover for benzos and crap. Me, not so much.

 

Not going to cave..... You don't have to adore me to know I gave you the right medical advice

 

 

I'd love to be able to do the above but since we're a "trial" clinic (my words, not theirs) one doesn't wish to cut-off the hand that feeds you (piss off patient, tells everyone else, and now no one comes, thus no job).  It pains me to say this but this is why I give everyone a door prize of an abx. for cold sx. WITH explicit instructions both verbally and in writing that they are to fill the abx. ONLY under the circumstances described (ST >7 days w/o obvious source such as snot drainage, cough >3 weeks w/o improvement, current rhino sinusitis guidelines).  F/U calls show a <50% subjective fill rate.  I justify it in my mind based on the fact that we're supposed to have only one visit per complaint and that any follow up goes to their PCP.  I'm trying to be proactive since they'll complain about then having to pay a co-pay which for some of the folks is prohibitive (again, their problem, not mine).

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Nope. We answer to our employing entity. No one refers to us since we're a closed clientele population. We only refer out if there is a concern regarding whatever and we either have them see their PCP, and if not available, we send to our SP clinic for evaluation (several clinics to send to depending on preferred location of pt.). I actually spend the time explaining that they don't need it now and when/if they would be indicated.

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Not-clinically-indicated abx are so far down the list, compared to other potentially abusable or harmful medications, I do not really spend much time on that problem. I've got to pick my battles.

Benzos, ambien, narcotics, NOT taking BP meds, smoking.....

 

YES, antibiotics are used too often and resistance is huge.

 

Medicine as Burger King IS MY BIGGEST resPROBLEM.

 

A copay does not ensure an RX or getting "what you want" versus what is needed and being judged by patient "happiness" is a load of crap.

 

Personal responsibility should be a written prescription and required contract of any patient

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Reality Check - best line I ever heard from my favorite doctor when a patient was trying to "bargain" with him to get antibiotics and a bunch of other ridiculous stuff -

 

"This is not Burger King - you cannot have it your way!"

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I feel your pain- that's primary care for you...

Those that are able to fire patients like these are lucky- usually frowned upon- my question is what to do in cases where it is frowned upon to dismiss patients!

 

My advice: be up front and DOCUMENT everything

 

Have a 50 yo Spanish speaking female with hx of CVA, right sided paralysis who has made repeated visits to the ED for pain medication

Since 1/16 has made at least 10 visits- always complaining of headaches- since she has had a CVA every time an extensive workup is done

So she gets the medication, attention that she wants for a few days.

So many ED visits to different hospitals that her med list is a mess- has only been in the office a few times since January.

Daughter has been kicked out of the practice for threatening staff

Cant get her to go to specialist appts- neurology, pain clinic appts.

Recently had been hospitalized for overdosing on her amitriptyline( which was an old script that we didn't have on her med list from an ED visit)

Had to be rushed to the hospital

Took away amitriptyline- however RN care manager had done home case visit and found she was hoarding more of the amitriptyline.

Took that away.

Finally complained LOUDER to SP about this whole situation and how this woman was going to hurt herself.

Nothing done.

So just documented the hell out of everything and got daughter on board.

Took all of her meds and gave her monthly doses ONLY.

Just got word today she is going to another practice!!

 

Its only myself and MD right now- long story- but I just don't see what else I could have done if MD isn't interested

Even when pointed out how this patient is dangerous and should be discharged.

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[...] my question is what to do in cases where it is frowned upon to dismiss patients!

 

My advice: be up front and DOCUMENT everything

Document everything, document agreements and disagreements with the patient, and encourage them to find a provider who better aligns with their desires while making it clear that your stances are based on medical consensus.  When I fail someone on a DOT physical, for instance, I print out a copy of the relevant regulation showing that they simply don't meet the requirements.  If I were going to have to keep a patient who, for example, declined to provide a same-day urine sample when directed to as part of a controlled substance monitoring program to which they had previously agreed, I would document that I would never be providing controlled substances of any kind in the future, and why.

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I also document that I have sent my notes to specialists or spoke with them on the phone outlining noncompliance, concerns, etc.

 

A colleague used to say "don't walk in the swamp alone...."

 

Not sharing any culpability but trying to make everyone aware that the patient has issues and what I am doing about it and why. 

 

A cardiologist called out one of my patients for not attending to blood glucose - kudos - he actually READ my note and backed me up. Win-win

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Update on the folks from my original post ---

 

The older couple who scare me to death - FINALLY found their daughter (the one they like) and found out that she herself has had an MI AND CVA recently (bad genetics) and can hardly take care of herself. She told me the story of her sibling getting sued by the parents and the perception that they got a power of attorney (not just medical) and tried to "steal everything". There isn't much to steal honestly. The daughter cried and felt horribly guilty and has tried to talk her parents into going to assisted living for months and months. So, we are all fighting the same battle and their poor daughter has her own health issues and what sounds like poor support. Sad sad case. I talked to the daughter for 30 minutes and she had NO IDEA of ½ of what had transpired. She didn't even know her Dad had MRSA and her mom was going into kidney failure. Tried to reassure her guilt and such was understood but not to beat herself up. The parents won't allow ANYONE a power of attorney after the issue with one child - so we are screwed and will end up in competency court of by court order of nursing home placement after the next inevitable hospitalization or ER trip. My doc reviewed everything and put a note in the chart that he felt we had done everything possible and couldn't force them to do anything but we sure had tried. Won't dismiss them - not the right thing to do - but will keep trying.

 

The woman who refuses to come in more than once a year is getting her pink slip from the practice. My doc was not sympathetic and not willing to allow her to be seen less than twice a year and preferably every 3 months until A1c less than 7. He agrees that we can't make folks do some stuff but we can sure hold our standards and tell folks they abide (because they CAN) or they can go elsewhere. Folks choices of insurance and choices of what to address are their choices but they may not be the right ones.

 

Same thing for my PA partner's guy who won't address an A1c of >10. Certified letter about consequences and bye-bye. He CAN do things but won't and has the resources but refuses to address things. We won't be giving him medications after 60 days and he has been notified that he needs to address his issues or possibly die. 

 

We have a waiting list for new patients and I know there are those out there who WANT to participate. 

 

My doc is supportive and I am thankful daily for that. 

 

I remember my Mom back in the 1970s having to put an ad in the paper stating that she was no longer responsible for the financial issues of my biological father (it was a legal requirement in Texas) as she filed the divorce papers. Somehow I think we should put ads out for those patients who we fire just stating that John Doe is no longer a patient of PA X and we are not responsible for their medical concerns or outcomes, however bad they may be........

 

Sometimes folks just have to be put on notice that self responsibility is real and we all have to wear big girl panties and deal with stuff.

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