Difficult Patient

[Guest Paula]

I had a patient come to me 3 weeks ago stating:

 

"i'm finding a new provider because Dr. S just doesn't listen to me".   (BIG RED FLAGS WENT UP)

 

"I have pain and swelling to my feet and he won't listen".   (I review his notes: advice: stop smoking, needs oxygen, lose weight, take  your medicine).  Previously DVT ruled out. Cardiac studies already done. She has COPD and lower extremity edema, red, slightly bluish feet, left worse than right, cap refill high, and pain to her feet and legs. 

 

I do the exam, review previous labs, decide she needs studies for her claudication symptoms, do the O2 test for medicare which she handily passed with O2 sats at 81% on exertion, improved with O2, etc.  Look at labs and see she has a history of elevated Hgb and Hct for the last 5 years.  Her most recent is Hct: 64 % and Hgb 24 g/dl, I think platelets were normal and erythopoieten was elevated at >50.  I could not find any other workup and found a note from the doc that he thought she had secondary polycythemia.

 

She agrees to starting O2 and I get the order put in place, she agrees to the ABI's etc, and ultimately they were normal, showed no blockage.  She does not agree to stop smoking.  I discussed with my collaborating because the labs the previous doc did really bothered me and my knowledge of hematology is lacking and I have no energy or time to further work this up.  Both the CP and I thought a referral to hematology is in order, and I refer her to heme. 

 

I get a phone note back last week:  Patient is mad since her ABI's etc showed no blockage and she had to pay a $75 co payment for it, plus a $40 copayment to see me.  She canceled her heme appointment on the day she was to come in. 

 

I tried to call and got a voice mail, left message to call me, explained also why I thought she should at least have the consult.

 

Frankly, while I think this could be an interesting and educational case for me to learn hematology better, I do not have the time to sort out her complex issues, nor does my CP.  I expect she will be off to find another provider who will listen to her and find out what is wrong with her. 

 

Could her condition just be the smoking, low O2, obesity, HTN?  I gave her 15 tabs of vicodin on the day of the exam to get her though until her tests with the discussion that they will not solve her condition (whatever it is) and that it is a one time prescription.

 

Of course, she thought I was an angel who listened to her until she had to pay her $75 and $40 and got no definitive answer.

 

I will recommend she go back to Dr. S for care if she calls me back.

 

I feel lazy and stupid, but do not have the energy any more for trying to figure out a patient like this. 

[Guest Paula]

P.S.  I was thinking primarily of Polycythemia Vera (not due to secondary causes) but I realize there is a large differential for her abnormal labs. 

[mgriffiths]

(As a current student who is not questioning your clinical judgment, just looking for education) What was the indication or reason that you gave her the vicodin?

 

Also, isn't smoking a major cause of secondary polycythemia - exacerbated by all of her other comorbidities?

 

Again, I'm a student, but it seems to me like a heme consult makes complete sense and she is an entitled patient who feels like she should receive anything/everything she wants for free.

[GetMeOuttaThisMess]

Hey Paula.  Polycythemia for sure; only question is why?  In spite of normal ABI her vascular volume could still be "sluggish" due to the high Hb/Hct. (think sluggish motor oil).  COPD and smoker?  Carboxyhemoglobin induced polycythemia.  How about COPD and possible pulmonary HTN with back flow causing secondary venous insufficiency thus the discolored dependent extremities (liver big?).  Bet she spends a lot of time on her backside due to discomfort.  Hb electrophoresis would be helpful.  Elevated EPO->EPO secreting tumor (liver, adrenal, uterine, cerebellum)?  Needs a workup but won't want to pay for it.  I agree that I'd defer to Heme and let them play with her, argue about the workup, but learn from the workup results at their time/expense.

 

 

[Reality Check 2]

I feel your pain, Paula.

 

I have many patients like this.

This is surely polycythemia due to smoking and probably sleep apnea and everything GMOTM mentioned above.

 

Some patients just don't want to participate but continue to come in frequently because they don't feel good.

 

It is amazing how much better some of them get with a CPAP and then ceasing smoking. 

 

I have started having a mandatory sit down appt with them - make them come in to get meds and start with the education and then the consequences.

 

I keep the conversation to the level of their education and focus and try not to use too many tech terms if they just don't get it.

 

My biggest stress in the conversation is that THERE IS NO MAGIC PILL. If they don't feel good then I can make sure it ISN'T some really horrible things and then get them to the right people for the specialty things.

 

AND YES - visits cost money and I have no control over that but I know that if they were my relative, I would want the same care and attention.

 

I also stress that THERE ARE THINGS THEY CAN DO TO HELP THEMSELVES. Just like I could refrain from eating cookies....... Try to stress that I am not perfect and that I have to make choices too.

 

The conversation stresses very plainly that they don't feel good because of medical conditions caused by smoking. The specialist will drain blood from them to lessen the load but that is a temporary fix and NOT SMOKING is the only cure just like NOT HAVING SEX is the only way to not get pregnant for sure. I can't fix their other problems adequately unless they make some hard decisions. If they choose not to stop smoking - then they have to be willing to deal with the consequences - poor life quality, feeling sluggish, increased risks of clots, stroke, heart attack, organ damage and early death as well as lung cancer, esophageal cancer and a generally miserable end to life. 

 

I don't hold back. I paint the ugly picture and document it all in the chart in the same language. That way, I have done my due diligence in warning the patient about consequences, giving them ample warning and alternatives and support.

 

These patients are draining because they don't want to participate, take up an inordinate amount of time and resources and generally have poor outcomes. They worry us for litigation and just the idea that they are going to die because of poor choices. 

 

They are human. So, my focus has come to telling them the basic ugly dirty facts and figures and giving them an opportunity to change and get some medical help and then let them make choices. 

 

I have shown dictation to their kids (with permission or after they are dead) showing that I have tried and tried. 

 

It is part of the daily battle. Folks think there are pills or shots for everything and it is easier than not eating fast food or stopping smoking. I can't FIX their mindset but I sure can tell them it doesn't match the mindset of medicine and reality.

 

Fight the good fight - I am there with you

[rev ronin]

Assuming you've documented a signed patient financial responsibility statement, a patient failure to pay you for the work you've done is them unilaterally severing the patient-provider relationship.  Do make sure to give them your chart note, explaining the possible fatal consequences, in your letter acknowledging their initiation of the termination of your patient-provider relationship.

[Guest Paula]

To the student: vicodin since she couldn't take NSAIDs, pain kept her up all night, she had tried "everything else"....(except stopping smoking). YES, smoking is secondary cause but I didn't think the Hct would be that high....so my mind goes down rabbit trails, instead of thinking about the duck in front of me.

 

GMOOTM:  I did my reading on polycythemia and the sluggishness of the venous system, also told her she probably should wear compression hose, but she is simply too obese to bend over and put them on.  She also was unable to get up to the exam table so doing an abdominal exam was not done.  (Not that it would have added anything when there is too much in the way to feel the liver/spleen). 

 

RC2:  It was one of those days.  IF she does come back, it will lead to the raw ugly conversation of truth and patient responsibility for their own health.

 

Rev: She might pay the bill, I'm not sure, just mad she got one.  I just bet if she quit her ppd smoking habit the bill would get paid a lot sooner, No?

[Guest Paula]

Plus, the other thing that irked me.......

 

EHR and meaningful use:  I had to do the stinking diabetic foot exam since Dr. S avoids doing all that and eventually it catches up to one of us APC's when Dr. S. is out of the office.

[Reality Check 2]

Paula -- what a day that must have been!

Been there - they suck.

 

My PA partner has a guy w A1c of 10 who says it is fine since he doesn't feel bad. Refuses all intervention and referrals. Doc was out of town so we staffed it together. Sent a certified letter to him stating norms, expectations and consequences. Said we cannot be responsible for his outcome since we are telling him what needs to be done and what will happen.

 

Also said he could come in and participate or find another clinic since he has a disease process with deadly consequences.

 

Certified letter in the chart. Best we can do for this guy. He has rented a condo in Denial. Hope he has life insurance for his kids....

 

Those days make medicine painful.

[Guest Paula]

^^^^^  Been there, too.  Guy comes in with HgbA1c at 11%.  Wants a new provider in another system because his other PA wanted him to do "stuff" for his diabetes.  He just "needed refills". Drove 30 miles to the appointment rather than the 3 miles to his clinic.

 

I see him, tell him I will get him started on insulin, renewed his meds for 3 months, referred to the CDE to have her teach him the pen, titration, carb counting, etc.  Scheduled him to come back in 3 months. 

 

I've never seen him again.  Didn't follow up.  Didn't see the CDE.  Maybe he went back to his previous PA who recommended all the same things I did. (I found her chart note as the 2 systems share the same EHR!).

 

Gotta stick together, us PAs. 

[sk732]

Had a lady sent to my office by her boss due to having chest pain...2ppd smoker, SBP not quite in the "Patent Pending" range on the manual cuff, but over 200, LVH so blatant on the EKG a first year med student would have seen it, and probably about 150lbs overweight.  I started her on Ramipril, told her to stop smoking and look after herself better - or else I could guarantee she'd be having a stroke or MI within 6 months.  Tells me she can't afford meds - told her she can afford 2 decks of smokes a day at about $40, she can afford $25 a month for her meds.  Stomped off...with the Rx. 

 

Fast forward about 11 months - my SP tells me she'll be coming to see me regarding stroke rehab (she was actually his patient in the town he monitored me from).  He told me about the conversation I'd had previously and I apparently scared her...but I guess not enough.  And I was about 5 months late on the stroke.  :Lucky for her she presented to a stroke centre within the window and got tPA'd.

 

I've often wanted to put the statements "My job is to tell you things you don't want to hear" and "I told you so" on my business cards, but since I still have a tiny bit of a filter, I haven't yet...instead I'm brutally blunt with people that present like that, even more so the ones like you're talking about, expecting the next opinion will they hear will be the same as their own.

 

SK

[Reality Check 2]

In Washington we have bright green POLST forms for DNR status and declining ventilation, tube feeding etc.

 

Supposed to be posted on patient fridge for EMS to locate.

 

Typically used in patients over 70 or with terminal illness so they don't end up on a vent.

 

I felt a tad snarky with one guy who was meeting criteria of patients we are discussing here. He was in his 50s.

 

Handed him a POLST and told him to consider filling it out so I could sign it since his denial of his medical conditions would likely lead to an EMS visit in his near future.

 

He started to get indignant and downright mean but saw the dead stare on my face and realized I was serious.

 

It was a method of communicating seriousness to him that hit the right button. He started making changes and attempts to comply.

 

Deep Sigh - the old adage that you can lead a horse to water.....

[rev ronin]

R45.81 (low self-esteem)

X83.8XXA (intentional self-harm through other specified means)

T65.222 (intentional self harm using cigarettes), maybe

 

This in addition to the obesity, tobacco use, and other ICD-10 codes.  If the patient is simply not doing the right thing that a reasonable and prudent patient would do, then document that and code for it.  Given all the other codes that apply to such a visit, it's not being vindictive (and can't possibly hurt their coverage or insurance rates...), just depressingly accurate.

[UpRegulated]

In spite of normal ABI her vascular volume could still be "sluggish" due to the high Hb/Hct. (think sluggish motor oil).  

 

Heck, yeah.  You so have to be a dude to refer to sluggish motor oil.  She doesn't need heme/onc.  My rx is Chantix, whole blood every 3 months or 3,000 miles,  whichever comes first, and a Royal Purple high performance spleen. :)

[Reality Check 2]

Sad but true - sometimes we NEED the specialist to regurgitate what WE ALREADY told the patient to get it to sink in.

 

I can pick out which patients are going to need that back up and I know my specialists well enough to know who to go to for what. Sometimes reassuring the patient they aren't dying and do NOT need surgery and Physical Therapy is actually needed.

 

Having some fancy board cert makes patients listen more sometimes.

 

My patients often don't know my background in ortho and when I tell them the rehab on an ACL or rotator cuff they smirk and make faces -- then come back and look shocked because "that is exactly what the SURGEON told me".

 

As long as they HEAR the message - good by me.

 

Speechwriters creedo - tell them what you're going to tell them, tell them, tell them what you told them.

[Reality Check 2]

Paula's post brings up an associated topic

 

If the govt wants insurance to start paying us for "performance" - where do these patients fall in or out?

 

Currently, some peds offices fire anti-vaxxer families because they don't want unvaccinated kids in their practice or the fight. If vaccine rates are a metric for "performance" and "success" then firing these patients takes out the "failures" in measurement and makes the practice look better and probably get more reimbursement.

 

So, a practice in New York fired fat patients. They told the patients their obesity made the practice look bad and their "measures off". 

 

How is this going to proceed?

 

Do we FIRE all patients with A1cs greater than 7?

Smokers?

BMI over 33.

Uncontrolled asthma?

Poorly compensated CHF?

 

WHO WILL BE LEFT?

 

One in 3 Americans is diabetic. 

We are one of the fattest countries on the planet.

 

As I have screeched before - I don't go home with my patients at night. They smoke, they eat fat and fast food. They don't wear their CPAP. They don't exercise. They don't take their meds or take someone else's or take too damn many anyway.

 

HOW can any legitimate source think we can be reimbursed on OUR success when humans have free will and make their own choices?

 

In my mind, the story goes like this:

 

The US has spent millions on "experts" and research to make these stupid metrics to pay us.

Then we all start firing patients to tone our practices up and look good.

Community Health Centers cry foul because they HAVE to take all comers per their federal funding but they get all the "losers" and they have no chance at "success" and reimbursement.

So, the govt spends more money on research and decides that each practice can have a certain percentage of "losers". But who decides your acceptable percentage or the metrics for chronic failures?

 

Then, after several more millions or billions - we are back to where we are now - we all have a mix of patients - "winners" and "losers" - and we all get paid anyway.

 

So, why are we wasting time on holding all the providers responsible for free will and human nature when we could have spent ALL that money on actual health care?

 

Just a musing on a cold, rainy day while contemplating my future...........

[corpsman89]

^^^ We've got a lot to work on. :/

[ventana]

pay for performance, and cost savings metrics for payment are going to die a slow painful death.....

[Reality Check 2]

pay for performance, and cost savings metrics for payment are going to die a slow painful death.....

 

I can only hope that this idea dies before full implementation......

[cbrsmurf]

Did you get a serum transferrin and transferrin to r/o hemochromatosis?  

 

It sounds like secondary PV, but I usually don't see hgb get that high even in smokers.  Sounds like a EPO was already done, but I would run a JAK2 mutation test as well

[jmj11]

This is the first time I read this so, my comments are a little late.

 

Regarding the patient, here is how I approach these kinds of patients now. First of all I use myself as the benchmark for "normal." (I know that might be a big mistake). So when patients behave a certain way, I put myself in their shoes. How would I have reacted to this circumstances? I would  have thought 1) My smoking is part of the problem so either I am going to do my best to stop, or understand that I am killing myself and it is no one else's fault. And, 2) I start out trusting my provider unless they make some big mistakes and none were made here. 3) health care cost a lot and insurances pass the buck to someone, so I would not be surprised in the cost of the tests. This is how I would have reacted, I would come back in and say thank you for trying to help me and the concern you have expressed.

 

If I came in complaining about the cost, being angry at you, not wanting to see you again . . . all of those would indicate abnormal behavior. These would mean that I have some anger issues, borderline personality issues and etc. So, you should see them as mentally ill, like the person who comes in and says that a little man crawled out of their nostril that morning wearing a pink thong and a Davy Crockett coon-skin hat and told them that they were God. So I would dismiss the attitude as mental illness talking and nothing you did wrong.

[Guest Paula]

Did you get a serum transferrin and transferrin to r/o hemochromatosis?  

 

It sounds like secondary PV, but I usually don't see hgb get that high even in smokers.  Sounds like a EPO was already done, but I would run a JAK2 mutation test as well

 

No, I didn't get either one of those tests as the panel had been run a week or so before I saw her.  I considered the JAK2 AFTER she left the office and once I decided to refer to hematology, decided against it since the Heme/Onc doctor would likely order it and other test.  

 

I've never heard back from the patient, she did not return my call.  I expect she will not return to see me.  "Shoulder Shrug".