PAC1720 Posted October 17, 2016 Share Posted October 17, 2016 I graduated in August and recently started at a family medicine practice. I interviewed during the summer and everything seemed to line up as a solid first job. i would be seeing mainly same day appointments or sick visits at first until I developed my own panel of patients. everything seemed to line up and I relocated. My first week was last week. Out of the 40 something patients I saw (by myself), 2 visits were for non chronic pain management. Everything else was oxycodone + bzd + soma +/- ambien or trazodone refills. I was also told on my second day that one of the doctors had his DEA suspended in September after a year long investigation for mismanagement of pain medications. Needless to say my first week was overwhelming and it was not what I was expecting this job to be. If I wanted to go into pain management there were plenty of opportunities where I am from. My question is am I being naive about the "real world" of family medicine or is this a bad situation? Link to comment Share on other sites More sharing options...
marktheshark89 Posted October 17, 2016 Share Posted October 17, 2016 Bad situation. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 17, 2016 Share Posted October 17, 2016 That is not family medicine. That is BAD medicine. Sorry it is your first job. I inherited about 3000 patients from a retiring doc a year ago and have spent an overwhelming amount of time weaning people off of asinine combinations as you describe. I have stuck to the literature and told patients we aren't mixing these meds and they aren't going to take ambien anymore and we have to do more about their musculoskeletal complaints. University of Washington has a pain mgmt guide and it is about 100 pages. The visits can be painful for me as the provider and the patients are confounded, angry, flat out mean and mostly stoned. It is a bad situation. Choices ---- Either embrace it - wean everyone off or make it clear that "these meds don't mix", hand out literature and stick to your guns. Muddle through while not harming anyone and get the hell out. I feel you Link to comment Share on other sites More sharing options...
BruceBanner Posted October 17, 2016 Share Posted October 17, 2016 Bad situation. Agree with the above---if at all possible I would leave; but if not, try to refer them all to a pain practice so your license doesn't draw any scrutiny due to continuation of someone else's bad prescribing. The reason I say that is it is VERY hard as a new grad to have the stones and bedside countenance to tell a bunch of drug addicts "no, we are weaning you off". I still have trouble sometimes and I've been a PA for 4.5 years. Very dishonest on their part. Again, if it wont wreck you financially, just politely leave and find a new job. Link to comment Share on other sites More sharing options...
jwells78 Posted October 17, 2016 Share Posted October 17, 2016 We had a local doc just go down for s$$t like this. Guess who went down with him? The PA. If it were me, I would get out. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 17, 2016 Share Posted October 17, 2016 http://depts.washington.edu/anesth/education/pain/ http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm http://www.aarp.org/health/drugs-supplements/info-06-2012/xanax-ambien-side-effects-armon-neel.html http://articles.mercola.com/sites/articles/archive/2014/09/25/long-term-use-benzodiazepines.aspx Just thought these might help you with documentation and support info. Not sure about Mercola from a credibility stance but the others are solid. Link to comment Share on other sites More sharing options...
cbrsmurf Posted October 17, 2016 Share Posted October 17, 2016 It's a GREAT situation. ...To taper down or refer out. You need to talk to your SP or management, gets contracts and urine drug tests started. That's the only way to salvage this, which is tough as a new grad. Otherwise you need to get out ASAP. Link to comment Share on other sites More sharing options...
sk732 Posted October 18, 2016 Share Posted October 18, 2016 I know some docs here that refuse to get triplicate prescriptions, which is what we use here for certain scheduled narcotics...they can legally say "I can't and won't Rx those drugs". SK Link to comment Share on other sites More sharing options...
PAC1720 Posted October 18, 2016 Author Share Posted October 18, 2016 Thank you for all the responses and advice. It is unfortunate that this is my first job out of school. I put my big girl pants on and talked to my SP laying out my concerns. I told him that this is not the job description I was sold in my interview. I understand circumstances change (it sounded good). If pain management is now a major part of his practice then my plan for care is to 1. follow CDC guidelines 2. Taper (i asked for additional training in how to do this safely) and 3. refer patient to pain management/psychiatry. I made it clear that I do not feel comfortable/qualified to manage complex pain cases without input from psychiatry and pain specialists or to refill medication combinations that I feel are unsafe for the patient. My SP interpreted my plan as not seeing pain management. He politely explained that this is the "real world" and pain management is a part of it. No response to my additional training request. We are at a crossroads now. Any suggestions for a contract lawyer? Link to comment Share on other sites More sharing options...
marktheshark89 Posted October 18, 2016 Share Posted October 18, 2016 Time to find a new job. In the mean time refer all patients you are uncomfortable with out to pain management or have your SP see them and prescribe for them and document your concerns in the medical record. Check a PMP on all of them. Link to comment Share on other sites More sharing options...
tunafish Posted October 18, 2016 Share Posted October 18, 2016 I do not think you can avoid this issue in any field unless you deal with specific narrow field like work physicals. There is a ton of drug addicts there thanks for MDs writing narcs like candy 20-30 years ago. I am in ED and it is beyond frustrating when those people try to get you to write narcs with ANY issue. I think you need to build a personality and your style and stick to it. I do not know how are old are you, but it can be tough to deal with those people. At the end of the day you can either try to make the world better or not and keep writing them their crap and make your life easier mentally. I am a strong believer that there is a reason why you do not abuse heroin and someone does. You can not reason with vast majority of those people, its like trying to reason a sugar level in type 1 DM. Link to comment Share on other sites More sharing options...
jwells78 Posted October 18, 2016 Share Posted October 18, 2016 this is the "real world" Wow. And its gonna be a REAL MESS when those people mob the local ER in a year or two... Link to comment Share on other sites More sharing options...
PAC1720 Posted October 18, 2016 Author Share Posted October 18, 2016 Well I was just called out this morning by my SP for working up an adult patient with "concentration issues at work" by checking labs and a TSH. I should have made the diagnosis of ADHD and given her the stimulant. Oops my bad.... In other news, I read the investigation report for the other doc in the office last night. They nailed him for prescribing stimulants for no reason in addition to prescribing long term bzds, narcotics, and muscle relaxers without taking proper h/p or imaging. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 18, 2016 Administrator Share Posted October 18, 2016 Yeah, you don't have a supportive SP there. Leave as quickly as possible. Your call on whether you want to bring up your disagreement with controlled substance prescribing practices to the state medical board, but you absolutely need to document it in every appropriate note you write. Link to comment Share on other sites More sharing options...
EMSGuy1982 Posted October 18, 2016 Share Posted October 18, 2016 Well I was just called out this morning by my SP for working up an adult patient with "concentration issues at work" by checking labs and a TSH. I should have made the diagnosis of ADHD and given her the stimulant. Oops my bad.... In other news, I read the investigation report for the other doc in the office last night. They nailed him for prescribing stimulants for no reason in addition to prescribing long term bzds, narcotics, and muscle relaxers without taking proper h/p or imaging. Really think it's time you make an exit plan! Sooner rather than later. Sounds like a toxic situation and not a place to start out your career. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 18, 2016 Share Posted October 18, 2016 My doc is doing similar things and I won't do like he does. Dang, what is wrong with these folks? Another vote for FP independence................................. Link to comment Share on other sites More sharing options...
sk732 Posted October 18, 2016 Share Posted October 18, 2016 I have problems concentrating at work...doesn't mean I need Adderall...means I need to deal with some of my SP/CP's and or a new job. I suppose I could jus tcome and see your doc an get the speed though :-D. Sounds like someone is very customer oriented vs patient oriented. SK Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 18, 2016 Administrator Share Posted October 18, 2016 Sounds like someone is very customer oriented vs patient oriented. I honestly think this is one of the hidden costs of high medical education. I happen to have made a lot of money in IT before switching, so all my student loans are paid off already and I have more flexibility. On the other hand, one of the things an ACO like Group Health really does well is NOT do things like that. They have good practice guidelines and stick to them. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 18, 2016 Share Posted October 18, 2016 Just re-read the posts. Sounds like the docs hired a PA JUST to do refills and see these folks but did not actually make that clear to the new hire. Sneaky.... and wrong. Recent (yesterday) turn of events in my office makes me feel like my boss doc is feeling like I HAVE TO do anything and everything he says and do it just like him. Even if it flies in the face of medical logic and ethics. I am not supposed to question or disagree with his medical judgment and sign controlled rx's in his absence because I "am HIS PA". Never mind I have done this 4 times longer than he has. Again, the title Assistant has hindered us by allowing others to think we are drones who do the bidding of someone else and have no individual thought process or medical knowledge base to think with. So, is this what we are relegated to? Do we HAVE to do what our docs expect or tell us to do? Where is the line in the sand about individual medical thought? Do we have to just keep finding jobs over and over and hope we find one where we can function? Frustrated.......................... Link to comment Share on other sites More sharing options...
Katera Posted October 18, 2016 Share Posted October 18, 2016 One of the main reasons I don't do Family Practice, those big Narc refills. Yuck. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 18, 2016 Share Posted October 18, 2016 One of the main reasons I don't do Family Practice, those big Narc refills. Yuck. A lot of family practices simply will not do pain mgmt anymore. The very old practice I joined has folks who have been on them way too long and before legislation and guidelines, monitoring, etc. I am trying to wean all these people off or find out exactly WHY they got on them in the first place. One of the TENETS of pain mgmt that is completely ignored is EXIT STRATEGY. No one wants to talk about ever being off the drugs and then time goes by and it never gets brought up and it is just easier to keep filling the meds. In my community one is hard pressed to find a PCP who will actually do pain mgmt or prescribe long term narcotics. Now, if we could only realize how bad benzos are and stop mixing them with narcs and actually expect folks to do something proactive about their situations instead of being dazed and confused............................. Link to comment Share on other sites More sharing options...
overthehorizen Posted October 18, 2016 Share Posted October 18, 2016 I know that much of this is simply about making money for the practice. Happy (high) customers keep coming back and the practice keeps billing revenues up. The other part that nobody mentions is that these supervisors are frequently impaired providers. I believe we would understand the situation and motivation of SPs and managers if we were able to get a drug screen on the bosses. The SP is thinking to himself "Hey, I can't get through my day without a benzo or some opioids or stimulants, why should I deny my patients the same pleasure." I will cite two very curious examples from two different jobs I had and one friendship. Job one. I inherited the panel of a physician who left after eight years at the clinic. One of his patients was a medical student (MS1) at the time the physician was taking care of him. the medical student had chronic pain. Medical student took more than was prescribed. Physician declined to provide early refill. Medical student stole a prescription pad from another medical practice and forged the Physician's name. Pharmacist reported to the physician that the signature wasn't right. Physician confronts medical student who then confesses. Physician tells medical student "Just don't do it again." I learn of this through notes. Medical student now a practicing physician. Job two. Community psychiatrist comes to see me for benzo refill. I'm not his regular provider but cover for someone who ordinarily sees him. I ask the reason for chronic benzo use. He states "insomnia." I ask what else he has tried besides benzos. Nothing. Oddly they are prescribed bid. He only has two pills left and his provider won't be back for a week. I tell him I'll discuss this with a Psychiatrist in the practice. He tells me who I shouldn't talk to for "privacy reasons." I go to a Psychiatrist he allows me to speak to and the Psychiatrist declines. I don't write it. Never saw him again. Third situation was not a job but just a personal experience. Friend from college was destined for medical school from day one as an undergraduate. He worked hard and did very well as an undergrad. Accepted to Hopkins. Of course, he spent every weekend as an undergrad doing cocaine, mj and etoh. I have had no further contact with him since but he is a very successful cardiologist now. Link to comment Share on other sites More sharing options...
Houstonian Posted October 18, 2016 Share Posted October 18, 2016 PAC1720 you need to simply leave this job. Don't even put it on your resume. If it comes up in an interview, tactfully explain that things didn't work out, and if necessary, explain why. You shouldn't be accepting a salary from these corrupt doctors. If you stay, you can easily get in legal trouble. Whether you report what is going on is another matter. Your own career prospects will be better if you don't report. Of course you will have to deal with pain management issues to some extent in any setting (in a legitimate manner), but this practice sounds like a narcotic mill. Link to comment Share on other sites More sharing options...
PAC1720 Posted October 19, 2016 Author Share Posted October 19, 2016 Thanks for all the advice! It sucks that I relocated to a new state for this job. You win some and you lose some. Time to hit the job boards again. Link to comment Share on other sites More sharing options...
sk732 Posted October 19, 2016 Share Posted October 19, 2016 I suppose you could look for a silver lining in this - maybe they hired you to see if you had the testicular/ovarian fortitude to stand up to patients and not renew drugs, unlike the colleague that was fired. But I think we've already passed that when someone gave you crap for actually checking to make sure someone didn't actually need speed... SK Link to comment Share on other sites More sharing options...
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