PAMANZ Posted October 13, 2015 Share Posted October 13, 2015 Please share experiences. Feeling kinda upset from a long time patient of mine. Im now in ER so I get lied to daily from DSB patients. I know we are to leave work at work. But tonight I'm feeling a certain type of way. Only a human, I am.... Link to comment Share on other sites More sharing options...
sk732 Posted October 13, 2015 Share Posted October 13, 2015 It sucks getting lied to all the time...however when you catch them at it, it's fun to listen to the back pedalling and makes telling them "No", followed shortly thereafter by that look of surprise on their face, then an argument and finally that cathartic "Get the (add your own expletive) out of my ER" makes it worth the crap. The down side of course is you assume everyone is a liar... My last job, I had two complaints in my first week because I wouldn't give narcotics to folks. I don't take that crap personally - I was told it's a badge of honour actually, since it means I'm doing my job. My more memorable one was when this patient was late for an appointment and my SP left (I can't write for certain meds here) and this person was definitely abusing their meds. His rules were basically "tough tiddly winks" if you missed the appointment. Patient shows up just as I was about to close up, starts freaking out, saying if they can't have X then I'd "have to" give them Y...I said "No, your options are simple - a script for indomethacin or leave". This turned into a loud argument, followed by the usual pile of sob stories that they thought excused them, culminating in me just snapping "What part of NO do you not f&^king understand? If you're really in the pain you claim, you'll take what I'm giving you. Either way, you're leaving now." SK Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted October 13, 2015 Administrator Share Posted October 13, 2015 I'd absolutely try to avoid pejorative or cursing words, and keeping it as honest as possible: "Look, you told me you were clean, but your drug screen was positive for meth and consistent with heroin or a large quantity of morphine. Neither of those are consistent with a trace of "something" on the paper of a friend's joint that you didn't know about. I don't see how we can have a productive provider-patient relationship if your opening story to me is so objectively false" Remember, they are human beings whom we are dedicated to serve--just because they're so broken that they can't even tell us the truth doesn't make them valueless, just that much more broken. Link to comment Share on other sites More sharing options...
jdenning Posted October 13, 2015 Share Posted October 13, 2015 I think we've all learned some form of this lesson the hard way or otherwise. Be kind but firm, and fine tune your BS detector. In my world I ALWAYS check blood levels before telling any patient taking an anticonvulsant that they can drive. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted October 13, 2015 Share Posted October 13, 2015 I have always tried to have my patients understand this is a partnership - Only they can follow the advice I give them. Kind of like having your car worked on. If I tell you the brakes are bad and you might crash - you should do something about it. The relationship is also about trust. I trust them to answer my questions and tell me the truth - ugly or not - and they trust me to not harm them and give them advice I would give my own sister or family. When they break that trust - it hurts - no doubt. There is no benefit to persistent anger or profanity. I tell the patient - "You broke my trust. Now I will not know what to believe or not. That puts me in a position that is unfair and hazardous. You need to find someone else to take care of you." It has taken a long time but when I say that to the patient and sign the certified dismissal letter - I am done. I can't let it eat at me or go home with me. That person is no longer in my care and I hope the best for them. But - I AM DONE with them. They can't take up anymore space in my psyche or daily thoughts because that is dangerous and destructive. They chose to lie and cheat the system and mostly themselves. It takes a lot of work to get to that point because I care about my patients and they worry me at night or I dread their test results because I found something ominous. I care, so it hurts. But, I have to put what energy I have into those who tend to take care of themselves and are honest with me. They deserve my best attention. So, folks will continue to lie and cheat and scam and be general knuckleheads sometimes - Karma will get them - not me. My very old 2 cents...... Link to comment Share on other sites More sharing options...
lightbearer06 Posted October 27, 2015 Share Posted October 27, 2015 When I find out a drug seeker lied to me, I make it about them, not about me not giving them narcotics. "You didn't tell me that your PCP was prescribing you narcotics" or "It looks like you have gotten a lot of prescriptions for narcotics recently" and "10s of thousands of Americans die every year from narcotic overdoses. I am afraid you might have a problem. If you don't, that's okay, but I am going to include a brochure for a substance abuse treatment program in your discharge paperwork. If you ever want help for narcotic abuse, just make sure to followup with them." Link to comment Share on other sites More sharing options...
winterallsummer Posted October 28, 2015 Share Posted October 28, 2015 I am very frank with them. "I have assessed your situation. At this point I feel narcotics are not the right thing for you. The risks of them including sedation and dependency outweigh the benefit. I recommend over the counter pain medication such as Motrin and Tylenol. Exercising, eating right and addressing your emotional issues with a counseled or at a church also will help. I have given you he medical care you're entitled to and will not change my plan." Then walk out even if they're upset. If they refuse to leave I have staff call security. Maintaining your composure, giving an appropriate medico legal response and avoiding conflict are paramount. I have under stress gotten to the point of yelling at a patient once in my career. Next room over was a pt from jail there for heroin withdrawal. When I went into the room he told me he heard me and didn't give me any drama at all and was promptly discharged along with the prior patient. Link to comment Share on other sites More sharing options...
Eastcoast PA-C Posted October 29, 2015 Share Posted October 29, 2015 I think the "walk out" part is the most important. You can have the most articulate and effective response in the world, but if you hang around and give them the chance to argue/plead/threaten/sob story, they will just wear you down. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted November 10, 2015 Moderator Share Posted November 10, 2015 I think the "walk out" part is the most important. You can have the most articulate and effective response in the world, but if you hang around and give them the chance to argue/plead/threaten/sob story, they will just wear you down. Sent from my iPhone using Tapatalk This is solid advice. Many people who are addicted are almost masters of psychological warfare designed to coerce you into doing what you don't want to do- they see providers of all different types, and they can likely read you as well as you read them. I had an attending who had an interesting term for it- "chislers"- i.e., they chisel away at your good nature until you admit defeat and give them what they ask for. Link to comment Share on other sites More sharing options...
delco714 Posted November 10, 2015 Share Posted November 10, 2015 What about the older-ish lady on chronic opiates who tests negative for opiates and their daughter comes in furious because you say they breached contract and won't get any more meds. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 10, 2015 Administrator Share Posted November 10, 2015 What about the older-ish lady on chronic opiates who tests negative for opiates and their daughter comes in furious because you say they breached contract and won't get any more meds. What about them? Patient safety issue, societal safety issue. If they're on prn medications, I'll refill once and put them on a medication use diary, which I get to see before I do any more fills. If they're on daily chronic opiates such that they cannot have been following the maximum sig AND have run out 3+ days ago, they're done. Link to comment Share on other sites More sharing options...
delco714 Posted November 10, 2015 Share Posted November 10, 2015 Exactly. So daughter who is selling or taking herself raises fell in the office :) Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 10, 2015 Administrator Share Posted November 10, 2015 Exactly. So daughter who is selling or taking herself raises fell in the office :) Then call CPS for elder abuse, or 911 for drug diversion. Dispensing controlled medications without a license to do so is a crime, even to another family member. If you are going to do narcotics in your practice, then you (collective you, not accusing you personally of not...) need to have the tools to detect abuse, the willingness to use them, and the intestinal fortitude to act on them. I throw out a patient every few weeks, and most of them *just* *leave*. Link to comment Share on other sites More sharing options...
dchampigny Posted November 10, 2015 Share Posted November 10, 2015 http://emergencymedicinecases.com/opiate-misuse-physician-compassion/ I'll just leave this right here. Link to comment Share on other sites More sharing options...
jen0508 Posted November 19, 2015 Share Posted November 19, 2015 Honestly after working in the ER for a few years I'm more suprised by patients who are actually telling the truth. I look all patients (who are in the ED for pain related complaint) up on the narcotic registry (love that thing!). I always ask patients what meds they are on and if they have been prescribed narcotics/pain medication. If they are lying/malingering I prescribe an NSAID or put "tylenol prn" on dischage instructions. My nurses know I don't negotiate so if they "want something stronger", they are told by nurse it's not an option, end of story - Bye. New nurses get chewed out if they come to me with the "room 8 said the only thing that works is percocet". I typically avoid the confrontation all together but if its necessary, I keep it short and sweet and tell them "I see you were prescribes xx percocet last week you can use that if needed". Or - "Opiates were noted in your urine, I cannot prescribe any because I don't want to prescibe anything that will interfere with what you have been taking". I agree with leaving the room asap. The longer the convo goes on, the messier it gets. Link to comment Share on other sites More sharing options...
moestown1016 Posted April 12, 2016 Share Posted April 12, 2016 I try to always keep my cool and not let them see me upset. I typically look people up in the narcotic database prior to seeing them if it's a pain related complaint or if they've had multiple visits. I give them the opportunity to tell me and keep a "kill them with kindness" approach until I feel strongly they are trying to manipulate me. If they aren't forthcoming I ask "who's taking care of your pain these days" and sometimes they will tell me once they suspect I know. If they don't I tell them the computer won't let me write the RX because they recently got 120 percocets or something OR I blame it on our "narcotics policy" that won't let me write it for them. If that doesn't work and they get ugly and I'm sure it's the right patient right address right date of birth right room etc (learned the hard way once haha) I will be more confrontational. Sometimes I just have to say I'm sorry I'm not going to argue I could get in trouble with my job if I write these medications for you and walk out. I used to be a lot more angry but finally calmed down about it. Reminded myself they can't be living a happy life etc and go on about my day. Mentally and emotionally it's easier on me and I don't carry it home. If someone really really pisses me off I type of the chart print it out and fax to their pcp or pain management provider. Our legal team said it was ok to do as long as I have documentation that proved they are consistently involved in the patients cafe. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
jmj11 Posted April 12, 2016 Share Posted April 12, 2016 Injury-related Headache. I ask: "Are you here to just document your suffering for your lawyer or are you here to get better." They, seeming offended, "Oh, I'm here to get better . . . of course, to get better!" I do a detailed note (knowing that it will end up in court) and I also come up with a comprehensive treatment plan. I think and work hard to create this plan. Then, virtually always, within a couple of days a lawyer's office calls and wants all the notes. Then, the patient no-shows their follow up appointment. I call the pharmacy and they never picked up their prescriptions. Happens almost every time I see a post-traumatic headache patient, whose injury is within the window of suing someone. If the injury was 10 years ago, it is a different story. Link to comment Share on other sites More sharing options...
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