I'm not a "shot" guy

[Guest ral]

I work as an independent contractor at a couple of hospitals, in the ED. Started a little side job at a newly opened urgent care, at the request of a professional (non-practitioner) colleague. In discussing providing coverage for the urgent care clinic with the supervising physician, I made it very clear that I do not do what I call "puppy mill medicine", meaning that if they were looking strictly for numbers of patients being pushed through, I was not their man. She agreed that quality of care trumps quantity. Okay, good. Got that out of the way. The first day I showed up, some of the MA's were asking my preferences for certain tasks such as lac tray set up and other procedures, injections, etc. I announced to the group that I am not a "shot guy". There is a role for injections, and I rarely use the commonly ordered Rocephin, when I am about to discharge a patient with a written antibiotic Rx, and I definitely discourage the used of IM steroids for everything from simple rhinitis, to ingrown toenails, that seems to be the med du jour of many practitioners. Not saying I never order an injection; I am just very selective, and have to convince myself that it would be beneficial. I always give my patients my reasoning, often citing evidence based research.

So I have worked a total of five shifts, and on my last one, the SP who interviewed me to begin with, drops in to ask me how things are going. I tell her that business is fine, touch base on a few documentation problems with the EMR, and then she hits with some BS about me "refusing" to give shots, and asks if I am not comfortable with them. I have worked high acuity ERs for almost fifteen years. I am not afraid or uncomfortable with just about anything in acute care. I ask her to elaborate, and she tells me that she heard I refused to give a shot of toradol to a headache patient, and antibiotic and steroid shots to others. I explain that I haven't refused anyone anything. I have explained to patients my reasoning for not using certain meds/routes, the majority of which have been very receptive once they hear that steroids don't cure the common cold, and a Rocephin injection puts them no further ahead if they go to the pharmacy and fill their Rx in the next couple of hours.

She comes back with, "Well, if the patient is not satisfied with your explanation, then we need to make them happy." In other words, give them a shot if they really insist.

I will finish off the my scheduled shifts for the month, and tell them that I am no longer interested in providing care at that location.

[LKPAC]

You make good points, but I've seen a properly prescribed dose of Rocephin keep someone out of the hospital and speed their recovery.  I agree that "patient satisfaction" alone is not a good reason to prescibe, though

[ventana]

Their are the extremes in medicine that you never want to enter, that far right and far left

 

In between these poles are the "middle ground" and we all belong

 

 

The world of being "dependent" means that we need to practice as our "DOC" wants us to

 

(Gotta love the dependent role)

 

They get final say, you will not win the battle of clinical decision making, if the doc says do it, and it is reasonable (And honestly even if it is not) you had best do it.

 

On the flip side, you might try to learn why they are practing this way. Did they get burned? Is there good reason be giving so many shots?

 

Honestly if you like the position, and want to stay, do enough to appease them, try to learn from them, learn to function with in the dependent role (as we are all stuck with it....). If not, do a good job, and move on.... The good positions are out there where the doc's respect you and allow you to function as independently as your training allows.....

 

 

Now about the DMS --> independent practice thread.....

[Acebecker]

Agree that if someone won't take a full Rx of their oral ABx (because they're lazy) and they want the Rocephin - that's not a good reason to expose them to the risks of an IM injection.  Same for some steroids. 

 

I think your particular problem encounter with the doc is more related to the front you have put up about shots.  Where staff is concerned, they will take anything "abnormal" about the new guy and talk it up.  It's kind of like a game of "telephone."  By the time word gets back to your doc, it's blown out of proportion.  And now, if you leave, the interpretation will be, "I don't give a crap about patient satisfaction." 

[Guest JMPA]

this is not about shots, its an ego game with backstabbing staff. think outside the box

[GetMeOuttaThisMess]

I'll say it again, there is no therapeutic benefit of IM/IV steroids over oral dosing aside from the additional billing. Stand your ground if they cannot provide documented evidence for why Rocephin is indicated. It is YOUR liability and license. Odds are they need you worse than you need them. I despise turds like these. It's a benefit of being older and close to retirement.

[rev ronin]

I would much rather give IM toradol than PO narcotics for a headache...

[Reality Check 2]

In the ER in an urban area of low income and poor parenting - IM antibiotics for proven strep or tonsillitis gave us all a better nights' rest. It was not likely Mom would go fill the Rx - in Texas years ago where kids' state insurance is nonexistent and sucks - and the kid was miserable but not admit criteria. Medical benefits in Texas really stink and kids get the shaft. I would do more for them than anyone else to keep them safe.

 

If a kid comes to the office these days (in another state now) and has really nasty tonsils but no stridor or obstruction - they aren't going to swallow the first dose of meds - it HURTS and they will barf it back up. So, a single starting dose of an IM antibiotic goes a long way to bring them to a position of decreased pain to swallow the following course of orals.

 

I agree with Rev - Toradol has helped a lot. Yes, there is some placebo effect - "I got a shot. Must be powerful". But, Toradol is awesome and can bring a barfing kidney stone sufferer some relief or a "migraine" something to work on for a few hours. Throw in 100% O2 on a nonrebreather for 10 minutes with toradol and you actually get a migraine solution sometimes. 

 

Demerol is out of the picture in any ambulatory clinic I have been in for the past 15 yrs. Too risky to keep on hand. Urgent Cares usually don't keep IM Valium or benzos on hand either. I don't worry about those anymore.

 

Steroids are a hard call. Yep, they ALL take 4 hours to kick in. Some patients have crappy pharmacy benefits that limit their resources after hours or on weekends. Some HMOs are VERY restrictive on where a patient can go pharmacy-wise. Many patients cannot afford the full price at a 24 hr pharmacy when their insurance would cover all but $10 at the preferred. So, IM steroids DO have their role. 

 

I think patient selection, gut feeling and likelihood of complications should all factor in to a decision.

 

I would avoid the ALWAYS or NEVER approach and yet I have been guilty of it as well.

 

Sounds like you have more of a staff loyalty problem than a medical issue. The staff ratted you out to the doc and it seems the staff gets what it wants with the patients whether you want it or not. A backwards hierarchy and some power tripping.

 

Move on and don't look back. But, consider the opinions here as possibilities.

[GetMeOuttaThisMess]

Why are you supplementing IM abx with po for strep? If one is concerned about compliance only, then I could see the IM administration for the steroid.

[Reality Check 2]

Because I am not using Pen G. Only have Rocephin available and it is not listed as curative at one dose, just Pen G.

 

IM Steroids have their role - limited sometimes but at least available.

 

My point was to not throw out "shots" as a set in stone law. They can be useful.

[GetMeOuttaThisMess]

Gotcha, and concur.

[Guest Paula]

Is it possible that the urgent care has the reputation that a patient can go there and get their "shot"?  Is it a matter of billing and making more money for the shots?

 

When I worked at a walk-in/urgent care we rarely gave shots unless indicated.  I used torodol for migraines and back pain.  Rochephin was for the STDs and cellulitis.  We gave an occasional Tdap or Td booster.  I never gave any steroids to my recollection.  Once I remember using Oxygen and Torodol for a cluster headache presentation and it worked great. 

 

It is important to document why you are or are not giving "shots".

 

We must be as wise as serpents and gentle as doves as PAs and at times tiptoe around those SPs and practice professional schizophrenia.

[GetMeOuttaThisMess]

We must be as wise as serpents and gentle as doves as PAs and at times tiptoe around those SPs and practice professional schizophrenia.

 

Let me write this one down.  This is one of the better statements seen here.

[winterallsummer]

This is a growing trend in UC. It is flat out bad medicine. Give anyone in pain IM steroids or NSAID. Give anyone with infection rocephin. It's total BS and only exists to keep patients happy and increase business. I had a brief, similar experience with an UC and quit with short notice.

[GetMeOuttaThisMess]

This is a growing trend in UC. It is flat out bad medicine. Give anyone in pain IM steroids or NSAID. Give anyone with infection rocephin. It's total BS and only exists to keep patients happy and increase business. I had a brief, similar experience with an UC and quit with short notice.

Keep preaching the good word. I swear if we only saw what we could actually treat it would be <10% of what I see. No job, but it would be true care.

[Acebecker]

Keep preaching the good word. I swear if we only saw what we could actually treat it would be <10% of what I see. No job, but it would be true care.

 

 

This is the most accurate thing about UC that I think I've seen in print and I have been thinking it for a long time. 

 

People want their healthcare like they want their food - fast and on demand.  I hate that concept, but the number of truly sick people that I've kept out of the hospital because I have seen them same day is what keeps me coming back.  We *can* do a lot for *some* people. 

 

I wonder what the stats are regarding healthcare expenditure rates and the advent of UC medicine - I'd bet that when UCs started getting popular, we saw a significant uptick in healthcare spending.  What was that, about 15 years ago?  How long have UCs been popular?

[EMEDPA]

This is the most accurate thing about UC that I think I've seen in print and I have been thinking it for a long time. 

 

People want their healthcare like they want their food - fast and on demand.  I hate that concept, but the number of truly sick people that I've kept out of the hospital because I have seen them same day is what keeps me coming back.  We *can* do a lot for *some* people. 

 

I wonder what the stats are regarding healthcare expenditure rates and the advent of UC medicine - I'd bet that when UCs started getting popular, we saw a significant uptick in healthcare spending.  What was that, about 15 years ago?  How long have UCs been popular?

some of my pre-pa experience was at a UC in college almost 30 years ago. they were popular then too. guy owned 7 of them and staffed them with docs/pas/er techs/xray techs.

[Guest Paula]

Today was my day to work our primary care clinic's Saturday hours, 8-noon.  It is heralded as a way to bring in more patients to our practice, despite the fact that there is UC available down the hall in the ED. 

 

I was in glory land.  No SPs there, one MA and me.  I had the run of the whole place.  I was THE BOSS!!  I only saw 5 patients, one of whom was sent down from the ED (UC) area because they have been told that if it is "just a cold or something simple, send it to PC".  So they did, and indeed, it was a "cold" for 2 weeks duration, and yes I prescribed  the Z-Pack.  

 

Saw one person who just  wanted free wrist splints for her tendonitis.  She did not get them.  We don't dispense them in PC as we don't get reimbursed for DME.  I wrapped her wrist in ACE bandages, gave her DME order for wrist braces and referred to PT, with the discussion that nothing is free, including your medicaid state exchange insurance and she might expect to have to pay for the DME, or just go to Walmart.  (She can't do that 'cuz she only has $3 in her purse and is unemployed but looks like the walking well).  

 

Saw a person with a rash, who had already been seen 3 times in my PC system within the last 2 weeks.  Convinced she has scabies and already treated.  So, i unroofed a few papules on her palms, cajoled lab to let me have slides and cover slips (which we don't have in our stock in PC), took the samples to the lab, entered the lab on my own accord and had the tech set up the scope.  Looked for scabies and found none.......but boy....was I in charge...I was able to do stuff that the managers of the clinic would have a conniption if they knew the amount of precious time I was wasting taking good care of the patient.  But, I was the BOSS over myself and the MA.  BTW: the patient has neurodermatitis, I believe, so will see if she improves with my treatment plan.

 

Then treated the 102 year old for her fall   (looked 80 and spry as a spring chicken), and the cellulitis.  Was fun to take my time .  Saw only 5 patients total but realized that PC during the week would never be able to practice medicine in this manner.  My gosh, it takes time and attention to address the needs of patients, do the right thing, educate and be the gentle doves.

 

Monday I will be back to the normal routine.  Practicing professional schizophrenia.  ( I must say, tho, in my practice there really isn't any task master SPs, just task master managers).  I'm lucky for that reason, but have certainly had to do enough tiptoeing in the past. 

[DiggySRNA]

Funny this has been brought up. I work in UC as a MA and whenever I triage a pt with c/c of severe pain(head or back)/STDs, I automatically load up toradol or rociphen respectively ("to be more efficient"), and wait for the order to inject and send them on their way with a script.

 

We waste NO time because pts like to argue which backs up the provider...In and out under 30mins. 

[sk732]

I'm thinking that the one and only time I've ever given anyone IM steroids was on a field exercise for horrible poison ivy because we'd run out of PO Prednisone and hadn't been able to get a resupply...otherwise, I can't think of too many reasons to do that.  I'm a big fan of IM Toradol, especially since I started giving it around 1990, experience showed that it is very effective and if you want to give the PO stuff, it works better if there's been an IM dose prior to the PO stuff, particularly for biliary or bad dental pain.

 

IM Rocephin I reserve for gonorrhea, since we've hit a threshold in Canada where we've had to up the PO cefixime dose to 800mg and the new guideline is the Rocephin instead... there was also a national shortage of cefixime, so we had no choice. I can't think of too many other reasons to give that way, unless there's a bad cellulitis and you're having a hard time getting a saline lock into someone in your outpatient clinic...and even then, if they're that sick, they should come into hospital for a few days.

 

$0.02 Cdn

 

SK

[Guest ral]

Hi all.  I have managed to stretch it out another month but, I'm officially done.  Sending them an email after I get off tonight.  Today was an absolute hoot.  Clinic manager tells me she is catching hell from the clinic owners for us referring too many patients to the ER.  Here is the breakdown of the patients that I have recommended go there: (yes, I can recall each case because there are only a few)

1. Early 20's male, shows up with a crooked face.  Dad punched him five or six times.  Loss of consciousness greater than 5 minutes as reported by his fiancée who was a witness.  He has malocclusion, and visual changes in one eye.  I do not have a CT on site.

2. Early 50's female, had a sore in her nose two days ago, presents with severe swelling, pain, numbness in the area of the philtrum, malar erythema and tenderness, and the beginnings of loss of the nasal fold.  Her upper lip is so tender and swollen, that I am unable to adequately raise it for a thorough oral exam.  I tell her that I work ER, and if I saw her there, she would be getting at a minimum, an i.v. dose of vancomycin, and possible admission for her obviously developing facial abscess/cellulitis

3. Late 60's male, comes in for his "gout". Peels off his shoe and the great toe is completely purple, as is the tip of the second toe, barely perceivable PT pulses, and no appreciable DP.  I tell him he needs an arterial Doppler, that his toe that started hurting last night, may become insensate and black if he waits until tomorrow (since he asked if he could just go some other day).

That's about it.  You know, the simple UC stuff.

Again, I don't refuse to give injections.  I have used them numerous times, for very good reasons.

[CAAdmission]

The place you work is officially a looney bin. You do not want your professional reputation tied up with a place like that.

 

Who are the clinic owners? Are they physicians and they have a problem with this?

[ventana]

Hi all.  I have managed to stretch it out another month but, I'm officially done.  Sending them an email after I get off tonight.  Today was an absolute hoot.  Clinic manager tells me she is catching hell from the clinic owners for us referring too many patients to the ER.  Here is the breakdown of the patients that I have recommended go there: (yes, I can recall each case because there are only a few)

1. Early 20's male, shows up with a crooked face.  Dad punched him five or six times.  Loss of consciousness greater than 5 minutes as reported by his fiancée who was a witness.  He has malocclusion, and visual changes in one eye.  I do not have a CT on site.

2. Early 50's female, had a sore in her nose two days ago, presents with severe swelling, pain, numbness in the area of the philtrum, malar erythema and tenderness, and the beginnings of loss of the nasal fold.  Her upper lip is so tender and swollen, that I am unable to adequately raise it for a thorough oral exam.  I tell her that I work ER, and if I saw her there, she would be getting at a minimum, an i.v. dose of vancomycin, and possible admission for her obviously developing facial abscess/cellulitis

3. Late 60's male, comes in for his "gout". Peels off his shoe and the great toe is completely purple, as is the tip of the second toe, barely perceivable PT pulses, and no appreciable DP.  I tell him he needs an arterial Doppler, that his toe that started hurting last night, may become insensate and black if he waits until tomorrow (since he asked if he could just go some other day).

That's about it.  You know, the simple UC stuff.

Again, I don't refuse to give injections.  I have used them numerous times, for very good reasons.

 

it is wrong to get micromanaged like this.....

 

it is your license, your reputation, your care delivery

 

nope  nada   

 

 

clink, clank, slam - that is the sound of walking out the door.......

 

 

Honestly - call the clinic manager up short on it - ask her to have a clinical justification on why they should have been seen in the clinic and then absolutely floor them with medical Ddx, and bad outcomes - make it obvious this is a human life and they are not providers and they should never ever tell you how to practice.  If they want to practice they can go back to school to earn a degree, pass boards, get experience.... otherwise bugger off......

[EMEDPA]

yup. I do some shifts at a UC and our medical director is a great guy. he gives folks more crap for NOT sending certain pts than for sending them. I have never gotten flack from the sending side for transferring a pt to the ED. a few lazy ER docs have called me to ask whi I can't manage xyz at the uc, but generally there is a good reason like we don't have xyz drug, test, or the ability to do certain procedure.

[Guest ral]

I feel good about leaving. Unfortunately, the experience has reinforced my skepticism with regard to the prevalence of UC clinics popping up everywhere, and their intent. Don't get me wrong, medicine needs to be profitable in order for me to get paid but, not at the expense of sound judgment and practice. When money and "people pleasing" become the driving force behind delivering care, and the actual care becomes a secondary fleeting thought, I am out.