Transfer of patients when someone retires

[Colorado]

How have others dealt with the transfer of care of patients from a provider who is leaving/retiring?

Warning, there is a bit of a rant in this:

There is a provider at my clinic who is retiring next month and is feebly transferring patients to myself and another full time provider. The retiring provider has been at the clinic for almost 30 years and has a HUGE panel. Nearly half are on chronic narcotics. Granted, she has worked most of them down over the years to </= 50 MDE but some are still around the low 100's MDE. Additionally, many are in their 50s-70s and many are also prescribed benzos and/or stimulants. When I have inquired in the past about these med combinations, esp in older patients, she replies something along the lines of "well, they're doing well on them/they work". Or, if an outside provider prescribes the benzo or stimulant, she claims the "head in the sand" excuse of "Well, I"M  not the one writing those prescriptions". This aggravates me to no end. Okay.... so you may not have written them, but you wrote your Rx for their narcotics with the full knowledge that the patient is taking other potentially dangerous medications. 

I mentioned her feeble attempts to transition patients because she is continuing to see many of her patients for follow-up of routine care despite telling them that she's leaving and that they need to transfer care to another provider. Some of this may be the patient's preference, but its frustrating because they tend to be complex patients that require more chart review prior to my first meeting with them. I simply don't know them as well because they've been her exclusive patient for 30 years. I feel that she should be transferring more of these patients over to us other providers prior to her final day. When I asked her about this, she happily gives me some of the patients from her schedule, but typically keeps the above-mentioned type patients to herself for now. I have met with some of those former patients of hers, but after having a discussion about the potential dangers of their med regimens, they often return to see her and plan to until the very end. I foresee a metric shitstorm coming my way come next month when she finally leaves. Not to mention, a lot of initial visits with those patients are going to be difficult as we discuss their med regimens. They get quite upset when I talk about reviewing and considering changing their controlled substances.

 

Thoughts on how to make these transitions smoother? I feel that for one, starting to transition patients earlier is ideal. I am also curious because I myself may be voluntarily departing this position in the near future as well.

 

(again, sorry for the rant. I am genuinely curious on how others have dealt with transfers of care when providers leave)

[jmj11]

This is a big problem and I feel your pain. While I've never been in this situation, I've had to bear the outcome of it many times. In my cases, the older-narcotic-happy doctor retires and the new provider says "Hell no I'm not prescribing oxycodone for your headaches I don't care if 'old doctor' has done it for 30 years. So, I'm sending you to the headache clinic and they will do it."

Then I have the break the bad news that I might help taper them off ASAP,  help them get dependency treatment, but I will not rx them for chronic use. Then they are pissed.

[mgriffiths]

I have been on the receiving end several times and what I found is that word spreads quickly through the community.  Granted, I'm in a small, rural community so may be different if you are in a larger town.  But, I have found it's really only a headache for the first 1-2 months and then everything settles down, or maybe I just get used to it.

I also view it as: this is not a discussion, it's unsafe and bad medicine, I will NOT prescribe this dangerous combination of meds...end.of.story.

I know some on here don't like that approach, but I am done fighting with patients.  It is the same as antibiotics,  the patient came to see me for my professional opinion, whether they view it that way or not.  If they don't like my approach to medicine then drive two doors down.

[Colorado]

39 minutes ago, mgriffiths said:

I have been on the receiving end several times and what I found is that word spreads quickly through the community.  Granted, I'm in a small, rural community so may be different if you are in a larger town.  But, I have found it's really only a headache for the first 1-2 months and then everything settles down, or maybe I just get used to it.

I also view it as: this is not a discussion, it's unsafe and bad medicine, I will NOT prescribe this dangerous combination of meds...end.of.story.

I know some on here don't like that approach, but I am done fighting with patients.  It is the same as antibiotics,  the patient came to see me for my professional opinion, whether they view it that way or not.  If they don't like my approach to medicine then drive two doors down.

I too am in a small rural community. There is one other small primary care office in town. Other than that, patients will need to drive about 45min to 1 hour to the next clinic. The other clinic has recently cut down on these prescriptions and now we, as the community health clinic, are seeing patients looking to transfer care. Luckily, the organization I work for is very explicit in not allowing ANY new chronic narcotic patients to receive Rx's through us. We can see them for their other care though and work to get them resources (pain management, MAT program, behavioral health, addiction recovery, or specialty referral if warranted) for their pain. I do my best not to kick the can too much by getting fed up and referring them out if I can avoid it, but I also know my limitations.

Funny enough, the more of these conversations I have with patients, the less chronic pain patients I see. And my pediatric and Gyn patient panel is on the rise!! So maybe it will all settle out after a couple months. I'll try to keep ya'll updated.

[mgriffiths]

3 hours ago, mgriffiths said:

If they don't like my approach to medicine then drive two doors down.

I want to clarify that this is not kicking the can, I don't just ignore them, but I am not going to fight with them.  I only discharge patients for violating their controlled substance contract.  It is their choice to continue with me or go elsewhere, but it's very simple - chronic narcotics are not the right answer and should never be treated as a "right."

 

2 hours ago, Colorado said:

Funny enough, the more of these conversations I have with patients, the less chronic pain patients I see.

But this is 100% true

[SCAR123]

I've been in this situation and I tell patients bluntly "I don't prescribe those medications.  I'm more than happy to refer you to pain management (or other appropriate specialty) and they can prescribe them for you, but I don't do it here".

I don't leave any wiggle room on the table.  I haven't gotten much push back on it because I don't say that I'll only prescribe it for xyz or that "I won't prescribe it", I say I don't prescribe it.  If they push I just stand my ground and say I don't prescribe those medications. 

It is a bear picking up another providers pt's, especially when notes consist of "pt here for f/u, doing well, no complaints".  I don't have any great words of wisdom for a smoother transition, they're going to come to you eventually and it sounds like your doc isn't being helpful or considerate.

[susiemw]

you can't do anything about the other doctor and how she turns pts over unless there is someone administratively

above her that can push the issue.  You can only control how you practice medicine.  How she practices medicine does

not mean you have to do the same when you see her patients.  

I tell pts at the very first visit I do not write for benzos.  I particularly do not write for benzos and norco/percocet etc.

If they haven't been tried on nonnarcotic meds/tens unit, PT etc, they will have to do that. 

I let them know they can go elsewhere: pain clinic, psychiatry etc.

If on xanax long term  I will give them one script to wean them off 

They often choose to go elsewhere.  People like their xanax. 

At that first meeting. If there chart is large and I can't quickly find what I need like xrays and MRIs. I'll have them return so I have more time to review.  If the previous provider didn't have any documented cause with xray and MRI (we had one doc who retired who was giving out xanax and pain meds like candy without any studies)

they do drug test and contract at the first appt. 

the drug test weans out many patients.  sorry. no narcotics or xanax with an abnormal drug test.   On a rare occassion depending on the pt will give them a second chance. 

Most of the time If there isn't good documentation as to cause of pain they don't get pain meds. until I get tests that document cause. There is always the patient you darn well know has a real problem and needs the meds so I write enough til I can get appropriate testing.

The bottom line is that I don't care how their previous provider cared for them, no one can make me write for medications I don't feel are safe or warranted.  A lot of times pain meds are warranted but the pts have been getting bad care and I'm playing "clean up" type medicine. That's ok. It's not the patients fault their last provider was not great/good/adequate/safe.  

We have a doc one town over that just lost her license so we are getting an influx of her patients.  Some of the med combinations are scary and other patients seem to be treated appropriately.  

I'm happy to explain to anyone that it is *my* medical license and I will write for what I am comfortable with and what I feel is safe/good for the pt. 

Good luck with that doc's retirement.  It was hell and  took a long time for us to clean up after our problem doc that retired.

[Reality Check 2]

Prior to coming to the VA, I worked in a solo owned private family practice with the son of one of the founding docs who was retiring.

I inherited an immediate 3500 patients - many on horrid combos of drugs, A1cs not monitored, etc etc etc.

As one approaches retirement there is a complacency and fatigue - "just get them out the door happy". The fight is gone. Bad things happen.

It took me a year to wean over 50 people off chronic ambien. I printed the data and handed it out. Had the conversation that if this person was my aunt, uncle, mom, etc - would not want them on it. It worked 98% of the time. I didn't give options - "we are going to work you off of ambien, it is not a good drug". No open ended flubbering - these are the choices. I got told to stuff it a couple of times and a few folks left. Oops.

Next - the combo benzo and narcotic crowd. What a stupid idea in the first place. And using benzos for "muscle spasm" - WTH? Printed out any data on the bad mix - think about 5 yrs ago - handed it out. Laid out the concept - "it appears you are on a combination of medications that is quite dangerous according to new studies and data" - never dissed the old doc - just pointed out new data.

Gave the plan - "we will be weaning off of lorazepam at 1 mg tid - slowly to avoid severe complications. Once you are off it or down to a rare dose, then we will address your narcotic use. There are so many other things we could do that wouldn't be so dangerous.....". Plant the seed, limit the options. Be polite. Use data.

Got a lot more pushback on this end. Benzos are sooooo habituating and ugly. Why deal with life's stressors when you can be pretty stoned?

Then, the random dx of adult ADD put on a stimulant with no testing or supportive therapy. In the same patient taking benzos and narcotics and maybe even ambien. It was not an uncommon combo in this little universe.

Inherited one woman on HALCION for over 25 yrs - are you kidding me? After looking at the situation - zero chance I would ever get her off of it - gave her the spiel about all the badness - she didn't care. Charted everything, counted my losses and moved on.

I had to decide that patients didn't necessarily have to adore me and want to buy me presents - do good medicine, use the data, stay strong and the cream will rise to the top eventually. Or I would win the lottery and float off to a private island. Guess which one happened?

Sometimes doing the right thing doesn't feel great or win you a parade but in the end - you sleep at night and fewer people die unnecessarily.