jmj11 Posted March 17, 2012 Author Share Posted March 17, 2012 This is not about being a PA. Also, I'm probably not looking for any "answers" as I doubt if there are any simple solutions as this is part of life. Mostly my purpose is to vent and to see if others have had these experiences. I have a need for home infusion, usually in the case of status migraine or severe intractable chronic migraine with medication overuse headache. I had recently met with the owners of a private infusion company twice and decided to use their services. My first patient was this week (the later of the type-cases mentioned above). This is a patient whom had been followed by a reputable headache center in Seattle and she remained intractable and had come all the way to see me. I saw the patient once, with a very detailed (almost 2 hour) evaluation. I made the (confident) diagnoses and set up an aggressive treatment program. The fact she had been a DHE-45 nonresponder, I started her an aggressive preventative program and a series (three days) of IV valproate sodium and metoclopramide infusion. I set up the infusions with this new company. On the forth day, the patient called and cancelled her follow up appointment and wanted me to call her back. When I called her she starts telling me, "The infusion RN said that she had seen many cases like mine and this is usually caused by a unrecognized immunodeficiency syndrome and she told me about some blogs where patients got amazing results and that by doing these infusions only treats the symptoms but doesn't cure the underlying problem. So I want to pursue that first before I try other headache treatments." I was livid. I would have called the infusion company immediately but I was covered up with patients. But it wasn't two hours later that I had a messages that the infusion nurse wanting to talk to me. As soon as I could get my head above water I called her back. As soon as I got her on the phone, she starts with a cheerful voice, "Hi, I'm ++++++ and I am ======='s infusion nurse. I just wanted to tell you that I know what is behind her headaches. I've had 20 years of experience as an infusion nurse and I've seen cases like this before. Let me tell you about some web sites and blogs on immunodeficiency syndromes." I exploded on her and got back to patients. The next morning, I tried to reach her boss (whom I had met with before) and couldn't so I typed him a long letter sharing my views on how inappropriate this was and I was definitely firing them. My point is, do they think we were born yesterday? The infusion nurse had seen cases like this before? WTF? I seen new cases like this 4-5 times a day for the past 30 years. But the greatest harm is that this totally undermines the provider-patient relationship. This nurse's views are totally unmerited. There is zero research supporting her and her blogs. So now I've painted myself in a corner a bit, because I fired the only other infusion service a year ago. In that case, I had set up a Valproate+DHE-45 infusion for a 21 year old. The day after the first infusion I had a call from the patient's mother. "The infusion nurse said that this infusion made no sense to her because Valproate is only used for treating seizures. She didn't think my patient really had seizures and therefore the PA (meaning me) didn't know what he was doing so they should take her to Seattle." Idiots!!! Occasionally, I've run into the same problem with pharmacists. When you work in a specialty or sub-specialty as I do, most of what we do is "off label" or unheard of by the mainstream medical community. However, in our sub-specialty what I do is right down the middle of "mainstream." So, I have pharmacists tell patients that the medications I've prescribed (like methergine or zonisamide) "are not used for headache and it sounds shady." I have had to call pharmacists many times to vent and correct them in there attitude, supplying them with many studies that they could easily have looked up. So any similar experiences? How do these non-clinical (or certainly not in your specialty) get the nerve to do this? Why can't they do what they are getting paid to do and keep their diagnostic mouths shut? :;;D: I couldn't imagine seeing a patient who had neurosurgery (which I often do) and then me calling the neurosurgeon and saying, "Hi, I'm Mike the headache PA. I've seen a couple of causes like this in my career and I wanted to tell you that you made the incision in the wrong place. I saw on a blog that there is a better way to take out a pituitary adenoma and I was thinking you hadn't see those blogs.":=-0: Link to comment Share on other sites More sharing options...
jmj11 Posted March 17, 2012 Share Posted March 17, 2012 This is not about being a PA. Also, I'm probably not looking for any "answers" as I doubt if there are any simple solutions as this is part of life. Mostly my purpose is to vent and to see if others have had these experiences. I have a need for home infusion, usually in the case of status migraine or severe intractable chronic migraine with medication overuse headache. I had recently met with the owners of a private infusion company twice and decided to use their services. My first patient was this week (the later of the type-cases mentioned above). This is a patient whom had been followed by a reputable headache center in Seattle and she remained intractable and had come all the way to see me. I saw the patient once, with a very detailed (almost 2 hour) evaluation. I made the (confident) diagnoses and set up an aggressive treatment program. The fact she had been a DHE-45 nonresponder, I started her an aggressive preventative program and a series (three days) of IV valproate sodium and metoclopramide infusion. I set up the infusions with this new company. On the forth day, the patient called and cancelled her follow up appointment and wanted me to call her back. When I called her she starts telling me, "The infusion RN said that she had seen many cases like mine and this is usually caused by a unrecognized immunodeficiency syndrome and she told me about some blogs where patients got amazing results and that by doing these infusions only treats the symptoms but doesn't cure the underlying problem. So I want to pursue that first before I try other headache treatments." I was livid. I would have called the infusion company immediately but I was covered up with patients. But it wasn't two hours later that I had a messages that the infusion nurse wanting to talk to me. As soon as I could get my head above water I called her back. As soon as I got her on the phone, she starts with a cheerful voice, "Hi, I'm ++++++ and I am ======='s infusion nurse. I just wanted to tell you that I know what is behind her headaches. I've had 20 years of experience as an infusion nurse and I've seen cases like this before. Let me tell you about some web sites and blogs on immunodeficiency syndromes." I exploded on her and got back to patients. The next morning, I tried to reach her boss (whom I had met with before) and couldn't so I typed him a long letter sharing my views on how inappropriate this was and I was definitely firing them. My point is, do they think we were born yesterday? The infusion nurse had seen cases like this before? WTF? I seen new cases like this 4-5 times a day for the past 30 years. But the greatest harm is that this totally undermines the provider-patient relationship. This nurse's views are totally unmerited. There is zero research supporting her and her blogs. So now I've painted myself in a corner a bit, because I fired the only other infusion service a year ago. In that case, I had set up a Valproate+DHE-45 infusion for a 21 year old. The day after the first infusion I had a call from the patient's mother. "The infusion nurse said that this infusion made no sense to her because Valproate is only used for treating seizures. She didn't think my patient really had seizures and therefore the PA (meaning me) didn't know what he was doing so they should take her to Seattle." Idiots!!! Occasionally, I've run into the same problem with pharmacists. When you work in a specialty or sub-specialty as I do, most of what we do is "off label" or unheard of by the mainstream medical community. However, in our sub-specialty what I do is right down the middle of "mainstream." So, I have pharmacists tell patients that the medications I've prescribed (like methergine or zonisamide) "are not used for headache and it sounds shady." I have had to call pharmacists many times to vent and correct them in there attitude, supplying them with many studies that they could easily have looked up. So any similar experiences? How do these non-clinical (or certainly not in your specialty) get the nerve to do this? Why can't they do what they are getting paid to do and keep their diagnostic mouths shut? :;;D: I couldn't imagine seeing a patient who had neurosurgery (which I often do) and then me calling the neurosurgeon and saying, "Hi, I'm Mike the headache PA. I've seen a couple of causes like this in my career and I wanted to tell you that you made the incision in the wrong place. I saw on a blog that there is a better way to take out a pituitary adenoma and I was thinking you hadn't see those blogs.":=-0: Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 17, 2012 Administrator Share Posted March 17, 2012 I would have called the owner of the service and given them a choice... 1) Reimburse you for the lost revenue, reprimand their employee, and continue a working relationship, or 2) You file a complaint with the medical board for the RN giving medical advice--practicing medicine?--without a license. Fact is, they're going to lose revenue on this one, too, so they have a motivation to keep their RN from undermining you as well. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted March 17, 2012 Administrator Share Posted March 17, 2012 I would have called the owner of the service and given them a choice... 1) Reimburse you for the lost revenue, reprimand their employee, and continue a working relationship, or 2) You file a complaint with the medical board for the RN giving medical advice--practicing medicine?--without a license. Fact is, they're going to lose revenue on this one, too, so they have a motivation to keep their RN from undermining you as well. Link to comment Share on other sites More sharing options...
physasst Posted March 17, 2012 Share Posted March 17, 2012 Sorry to hear this Mike. I think you need to have a discussion with the IV nurses boss. A calm discussion. We use Valproate to treat migraines all the time. In fact, I try compazine first, sometimes DHE....and for others, it's Valproate. The drug seekers never get relief and leave pissed off..."Why couldn't you just give me dilaudid?" I try and explain the narcotic rebound to them, but it rarely works. Whatever. Valproate works for people that aren't hooked on narcs. I've had nurses say sh*t like that too. The few times it's happened I've talked to their supervisors....I've never had a repeat problem from the same person... Link to comment Share on other sites More sharing options...
physasst Posted March 17, 2012 Share Posted March 17, 2012 Sorry to hear this Mike. I think you need to have a discussion with the IV nurses boss. A calm discussion. We use Valproate to treat migraines all the time. In fact, I try compazine first, sometimes DHE....and for others, it's Valproate. The drug seekers never get relief and leave pissed off..."Why couldn't you just give me dilaudid?" I try and explain the narcotic rebound to them, but it rarely works. Whatever. Valproate works for people that aren't hooked on narcs. I've had nurses say sh*t like that too. The few times it's happened I've talked to their supervisors....I've never had a repeat problem from the same person... Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 18, 2012 Moderator Share Posted March 18, 2012 I have found being the aggressor a little bit can be helpful - stating that sometimes that infusion company nurses try to offer other theories to the treatment plan that you have outlined then throw in something that undermines their credibility - i.e. they have previously tried to sell patients on some new unproven headache pill or something like that to really undermine their credibility before they undermine yours.... In my world I use it for therapy referrals I say that I only refer to clinic's that do not double book or use aide's - go on to say that if the patient is going to put the effort into going to PT they deserve to get the PT for each treatment - and then allude to the fact that the clinics that use aides tend to do it to make more money off the service, not to provide better service. Is a really fine line but it does prep the patient to the 'load of bull" that is out there in my area about therapy clinics (which are owned by Doc's and are productivity mills and will double book all there therapists and uses a ton o aides at $10-$12/hr) oh yeah, and if you could I might consider filing a complaint with the nursing board about her (but that has lots of ramifications beyond the short run....) could you hire your own nurse and bill for infusions? Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 18, 2012 Moderator Share Posted March 18, 2012 I have found being the aggressor a little bit can be helpful - stating that sometimes that infusion company nurses try to offer other theories to the treatment plan that you have outlined then throw in something that undermines their credibility - i.e. they have previously tried to sell patients on some new unproven headache pill or something like that to really undermine their credibility before they undermine yours.... In my world I use it for therapy referrals I say that I only refer to clinic's that do not double book or use aide's - go on to say that if the patient is going to put the effort into going to PT they deserve to get the PT for each treatment - and then allude to the fact that the clinics that use aides tend to do it to make more money off the service, not to provide better service. Is a really fine line but it does prep the patient to the 'load of bull" that is out there in my area about therapy clinics (which are owned by Doc's and are productivity mills and will double book all there therapists and uses a ton o aides at $10-$12/hr) oh yeah, and if you could I might consider filing a complaint with the nursing board about her (but that has lots of ramifications beyond the short run....) could you hire your own nurse and bill for infusions? Link to comment Share on other sites More sharing options...
Contrarian Posted March 18, 2012 Share Posted March 18, 2012 ... [brevity edit]... could you hire your own nurse and bill for infusions? ^^^...That's the way to go...^^^ My medical director has a IV certified nurse come in on Thursdays. His office staff schedules all infusions back to back on Thursdays. I have IV therapy in my business plan for my practice. I've already had the training and am/was IV certified as a nurse. Why not pay for IV certification training for your wife (RN)...??? Link to comment Share on other sites More sharing options...
Contrarian Posted March 18, 2012 Share Posted March 18, 2012 ... [brevity edit]... could you hire your own nurse and bill for infusions? ^^^...That's the way to go...^^^ My medical director has a IV certified nurse come in on Thursdays. His office staff schedules all infusions back to back on Thursdays. I have IV therapy in my business plan for my practice. I've already had the training and am/was IV certified as a nurse. Why not pay for IV certification training for your wife (RN)...??? Link to comment Share on other sites More sharing options...
jmj11 Posted March 18, 2012 Author Share Posted March 18, 2012 ^^^...That's the way to go...^^^My medical director has a IV certified nurse come in on Thursdays. His office staff schedules all infusions back to back on Thursdays. I have IV therapy in my business plan for my practice. I've already had the training and am/was IV certified as a nurse. Why not pay for IV certification training for your wife (RN)...??? Actually that's what I'm looking into right now. But not my wife. She was just promoted to Assistant Director and is working full time. But she has a colleague that I was thinking about using. Now this leads to another question. You've seen my space, and while lovely, it is small. So, do we do infusions in my office when I'm doing remote clinic on Fridays? But then the RN is by herself. But home infusion RNs are by themselves, out in the field. Or do I have her go to the homes to do the infusions? I've asked my biller for weeks to figure out reimbursement for us doing infusions and so far she has not come up with hard numbers. I want to make sure that I do more than break even. Link to comment Share on other sites More sharing options...
jmj11 Posted March 18, 2012 Author Share Posted March 18, 2012 ^^^...That's the way to go...^^^My medical director has a IV certified nurse come in on Thursdays. His office staff schedules all infusions back to back on Thursdays. I have IV therapy in my business plan for my practice. I've already had the training and am/was IV certified as a nurse. Why not pay for IV certification training for your wife (RN)...??? Actually that's what I'm looking into right now. But not my wife. She was just promoted to Assistant Director and is working full time. But she has a colleague that I was thinking about using. Now this leads to another question. You've seen my space, and while lovely, it is small. So, do we do infusions in my office when I'm doing remote clinic on Fridays? But then the RN is by herself. But home infusion RNs are by themselves, out in the field. Or do I have her go to the homes to do the infusions? I've asked my biller for weeks to figure out reimbursement for us doing infusions and so far she has not come up with hard numbers. I want to make sure that I do more than break even. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted March 18, 2012 Share Posted March 18, 2012 Seems to me that you have a group of PAs giving you some very good advice. Good luck. Link to comment Share on other sites More sharing options...
CAdamsPAC Posted March 18, 2012 Share Posted March 18, 2012 Seems to me that you have a group of PAs giving you some very good advice. Good luck. Link to comment Share on other sites More sharing options...
Contrarian Posted March 18, 2012 Share Posted March 18, 2012 ... I want to make sure that I do more than break even. Fo Sho... if YOU do the infusions yourself... say Saturday mornings. :wink: Link to comment Share on other sites More sharing options...
Contrarian Posted March 18, 2012 Share Posted March 18, 2012 ... I want to make sure that I do more than break even. Fo Sho... if YOU do the infusions yourself... say Saturday mornings. :wink: Link to comment Share on other sites More sharing options...
jmj11 Posted March 19, 2012 Author Share Posted March 19, 2012 Fo Sho... if YOU do the infusions yourself... say Saturday mornings. :wink: Contrarian, then when to I get to sit around in the morning in my boxers watching cartoons? No, I'm actually thinking about doing it in the evenings. BTW, I just talked to the patient in question and the infusion company. The situation is becoming more clear. The IV nurse, never raised the questions about the diagnoses, It was the pharmacist who owns the company. She saw the orders, looked at the complaint and then called the patient (without calling me first) and told her that it was her assessment that she had an immunodeficiency syndrome. So, I'll be reporting them to the pharmacy board and not the nursing board. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 20, 2012 Moderator Share Posted March 20, 2012 So, I'll be reporting them to the pharmacy board and not the nursing board. good for you Link to comment Share on other sites More sharing options...
user1234556 Posted March 20, 2012 Share Posted March 20, 2012 I was just wondering whether you've heard back from her boss? Link to comment Share on other sites More sharing options...
jmj11 Posted March 21, 2012 Author Share Posted March 21, 2012 I was just wondering whether you've heard back from her boss? Turned out she was the boss. It was my misunderstanding. The pharmacist who called the patient to her, her dx, owns the infusion company. Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 21, 2012 Moderator Share Posted March 21, 2012 self referal violoation? Stark violation? Link to comment Share on other sites More sharing options...
Moderator ventana Posted March 21, 2012 Moderator Share Posted March 21, 2012 self referal violoation? Stark violation? Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 21, 2012 Share Posted March 21, 2012 Don't know WA scope of practice law, but could you hire a paramedic on a PRN or PT basis to do your infusions? Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted March 21, 2012 Share Posted March 21, 2012 Don't know WA scope of practice law, but could you hire a paramedic on a PRN or PT basis to do your infusions? Link to comment Share on other sites More sharing options...
Contrarian Posted March 26, 2012 Share Posted March 26, 2012 JmJ11... did you try "Infusion Solutions Inc."... ?? Or where these the ones you are talking about above...? Link to comment Share on other sites More sharing options...
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