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Should I confront a patient?


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I work in ortho, in a big private clinic, with one surgeon. I have a patient who left a horrible voicemail to our practice coordinator. I will keep this vague on purpose. The first time I ever saw her (aged 75-85 years old), she was a post-op 1 following arthroplasty. I took x-rays and didn't like how her arthoplasty was positioned. I told her that there may be an issue, but I would discuss with the surgeon (who wasn't there) and get back to her. I guess she didn't like what I had to say, so at some point I know she said I was worthless to our practice coordinator.

Now months later after failing PT and having continued pain/limitations she had a revision. She had a lot of pain after surgery, and needed a different type of narcotic because the one we gave caused a mild allergy. She is calling staff hysterical because of the issue, you can barely get a word in. They explain that only the surgeon (who is out town for the holidays) has the ability to e-prescribe narcotics, I am in the office but would have to write a prescription and she lives roughly 2 hours away. I've been waiting for this ability for over a year (and so have probably 90% of the physicians, very few people have that ability right now). My staff tells her to ask her PCP, they give her a hard time. So I call her PCP to ask if they can please give her a weeks supply to hold her over to her post-op appointment. I'm only able to talk to the nurse, and I give her an estimate of what she would need as far as # of pills. Mind you it was a pain getting through to that office, I could have been a dick and told her to go to the ER or said we will just mail her an RX.

So she calls at some point leaving another hysterical voicemail. She calls me out by name, again saying I'm worthless. Conveying her disappointment in the number of pills I asked them to prescribe with choice curse words. She even said that she hopes I have a horrible New Year. After she got her pills, she called the practice coordinator with another message apologizing to her for speaking that way, but did not give an apology to me.

Now I am usually a very calm and understanding person, and in the 3 years of working, I can count on one hand the number of patients who have gotten under my skin. However, this lady took it to another level. I've never heard anyone saying such vile things about their worst enemies, much less someone who is trying to help you. I had my staff save the message to show the surgeon and possibly management. I've already put a note in her chart for her not to be put on my schedule. My question is, what do I do when I eventually see her in the office? To be honest, I'd like to confront her and give her a piece of mind. I don't know how someone got to so far in life with her obvious underlying psychiatric and anger management issues. Or should I ignore her, chalking it up to a demented and addicted person who doesn't know any better?

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8 minutes ago, AbeTheBabe said:

I work in ortho, in a big private clinic, with one surgeon. I have a patient who left a horrible voicemail to our practice coordinator. I will keep this vague on purpose. The first time I ever saw her (aged 75-85 years old), she was a post-op 1 following arthroplasty. I took x-rays and didn't like how her arthoplasty was positioned. I told her that there may be an issue, but I would discuss with the surgeon (who wasn't there) and get back to her. I guess she didn't like what I had to say, so at some point I know she said I was worthless to our practice coordinator.

Now months later after failing PT and having continued pain/limitations she had a revision. She had a lot of pain after surgery, and needed a different type of narcotic because the one we gave caused a mild allergy. She is calling staff hysterical because of the issue, you can barely get a word in. They explain that only the surgeon (who is out town for the holidays) has the ability to e-prescribe narcotics, I am in the office but would have to write a prescription and she lives roughly 2 hours away. I've been waiting for this ability for over a year (and so have probably 90% of the physicians, very few people have that ability right now). My staff tells her to ask her PCP, they give her a hard time. So I call her PCP to ask if they can please give her a weeks supply to hold her over to her post-op appointment. I'm only able to talk to the nurse, and I give her an estimate of what she would need as far as # of pills. Mind you it was a pain getting through to that office, I could have been a dick and told her to go to the ER or said we will just mail her an RX.

So she calls at some point leaving another hysterical voicemail. She calls me out by name, again saying I'm worthless. Conveying her disappointment in the number of pills I asked them to prescribe with choice curse words. She even said that she hopes I have a horrible New Year. After she got her pills, she called the practice coordinator with another message apologizing to her for speaking that way, but did not give an apology to me.

Now I am usually a very calm and understanding person, and in the 3 years of working, I can count on one hand the number of patients who have gotten under my skin. However, this lady took it to another level. I've never heard anyone saying such vile things about their worst enemies, much less someone who is trying to help you. I had my staff save the message to show the surgeon and possibly management. I've already put a note in her chart for her not to be put on my schedule. My question is, what do I do when I eventually see her in the office? To be honest, I'd like to confront her and give her a piece of mind. I don't know how someone got to so far in life with her obvious underlying psychiatric and anger management issues. Or should I ignore her, chalking it up to a demented and addicted person who doesn't know any better?

I’m only a patient care tech at a hospital, but I’ve encountered a handful of people that I would love to give a piece of my mind to for how rude, demanding, and awful they are.

Honestly, there’s nothing to be gained by confronting her..even though she is clearly in the wrong. The best thing you can do is fire yourself from her case, and move on. When you do see her, just ignore her as hard as it is. There are people out there who are mad at the world. And even though you are perfectly kind and decent to them...they will still be mad at the world.

My saving grace is to tell myself, if this person is like that in a professional setting towards me, someone who’s only trying to help...thank the Lord I’m not their family member or someone who has to regularly deal with them. It sucks to be the bigger person, but it sucks worse to give her the satisfaction of knowing she upset you, which I’m sure is what she’s after. 

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I think of it this way: when you are with a patient, you are a different person- you are essentially an actor, channeling certain emotions, like empathy, kindness, understanding.  This is beneficial, because it separates and insulates the real you from the craziness that we deal with daily.  

This person has identified you, for whatever reason, as the cause of her issues.  Has your sp stepped in?  

I frequently see patients who upset, either at me or at another provider.  This is where the acting comes in- even though I may be seething on the inside, I greet them- hello Ms xxx, I understand you have some concerns .. I would not argue with them, just listen; address each specific concern, then arrange an appointment with someone else.  You can even apologize if you want, but keep it professional; if she has a valid concern address it, but don't go overboard trying to i her heart.  Make sure every interaction with her is documented, and chaperoned, if possible.  Make sure the chaperone documents as well.

Anyways, the key is to think of yourself on stage, and control the emotions you are channeling.

Ps i assume every patient is like a wounded animal and approach them cautiously; you don't know how they will act.

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The bottom line is that you CANNOT confront her.  In most practices it would be considered unprofessional, if not worse.  But, if she is a "do not book" with you why will you see her to even have the chance to interact?

The unfortunate truth is that you are "just a PA" therefore must not be as capable as the SP (please read with dripping sarcasm), and the fact you can't eprescribe her meds just reinforces that thought process.  Just dodge and weave...

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a few comments

 

you made a pretty major mis step undermining the surgeon on your first follow up - not a wise move IMHO - no one wants someone other then they surgeon telling them the surgeon was wrong..... I would have just said nothing and talked to the surgeon out of professional kindness

 

Second - this is not your patient - it is the surgeons - so ask them what do to

 

this person likely (due to age, pain, use of narcotics and the like) have some type of delirium, dementia or other mental health process going on.  You as the provider need to realize this and work with them to help them....

 

 

A final note - and on a final note - and I have only done this a few times in my 17yrs of practice, simply decline to see her in the office.  My justification to this is that their is obvioulsy no therapeutic provider patient relationship and you are not comfortable with this.

 

I WOULD NOT CONFRONT HER - ever - that will come back to haunt you 

 

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I echo Ventana's advice, although I get that there was no intent to undermine the surgeon in your initial concern expressed to the patient.

By making the patient a "do not schedule with me," you're not doing anything she didn't already implicitly ask for.  Confronting her with her vileness would be different.

I would keep the voicemail as insurance, though.  Should she try and sue you or the SP, provide the vile VM to your defense attorney, and they will probably make the problem go away: No one on a jury wants to give a large award to someone with that much hate in their heart.

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Thank you everyone for your advice, I will just ignore her if I come across her in clinic. I have already put a not on the chart so that she won't be scheduled with me. Next time, I will not be going out of my way for this person.

lxtexas4 - Yup, I definitely feel bad for anyone who has to put up with her on a regular basis.

thinkertdm - No, my SP has not stepped in, he hasn't heard the VM yet he is out of town for the holidays. 

mrgriffiths - I share a hallway with my SP in clinic so that's basically when I would come into contact with her, but I can take care to avoid the hallway while she is checking in/out.

ventana - I've been with the surgeon 3 years, I know when something is wrong. I've reduced dislocated arthroplasties when needed. He does not hav a big ego, we have a good relationship, he's completely fine with me breaking bad news to the patient if necessary.

rev ronin - Thanks, that's a good idea. We should keep the VM just in case.

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I both echo Ventana's advice as well as rev ronin's. You are obviously too confident of your diagnosis after three years, your questioned your Surgeon's procedure, you made room for a malpractice suit against him because of your remark and obviously you are dealing with a senior citizen , who may be just cantankerous or possibly in early dementia. Under no circumstances should you call this patient, turf it where it belongs, with the surgeon. I have practiced forty-six years with the same surgeon and have never undermined his skill in the OR.

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I don't get why this thread has turned into whether or not it was appropriate for me to tell them something was wrong months ago. This was not the point of the post. If the surgeon was uncomfortable with me or did not want me to break bad news, he would not have me seeing all the first post-ops. No one here saw the x-rays I did, there was obviously an issue. Since she ended up having a revision a little while later, I was right. I'm not saying I know everything by any means, I'm sure I've missed plenty of things, but I know enough to tell an arthoplasty is malpositioned to the point of subluxation. I don't see what's wrong with being straightforward with a patient that there may be a problem, rather than pretend that there's nothing wrong.

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58 minutes ago, AbeTheBabe said:

 

ventana - I've been with the surgeon 3 years, I know when something is wrong. I've reduced dislocated arthroplasties when needed. He does not hav a big ego, we have a good relationship, he's completely fine with me breaking bad news to the patient if necessary.

 

 

 

I don't get why this thread has turned into whether or not it was appropriate for me to tell them something was wrong months ago. This was not the point of the post. If the surgeon was uncomfortable with me or did not want me to break bad news, he would not have me seeing all the first post-ops. No one here saw the x-rays I did, there was obviously an issue. Since she ended up having a revision a little while later, I was right. I'm not saying I know everything by any means, I'm sure I've missed plenty of things, but I know enough to tell an arthoplasty is malpositioned to the point of subluxation. I don't see what's wrong with being straightforward with a patient that there may be a problem, rather than pretend that there's nothing wrong.

 

it is honestly not about you, but instead the perception of you by the patients.  As you have found you saying something (even if correct in the long run) which goes against the surgeon (especially if it does not turn out to be true) just sinks you

Blame our  "dependent" status, not the patient, not the surgeon

 

I also question why a surgeon would let you tell patients bad news - just sort of strange when revision is likely needed, says he did it wrong, and in general is putting the PA in a strange position.  (granted I am not in surgery, but I rarely if ever say another provider is wrong)  only once did I go against my SP (in a case I was 100% correct in) and i still had to sit through meetings about it.  The establishment is physician driven.....  Besides why be the one telling the patient the bad news, it is not your news to deliver and something that is not time sensitive can be delivered by the Doc.  

 

I just don't like giving bad news unless I am 100% sure, and I try to never make another provider look bad - especially my SP as they hold a HUGE amount of control over my professional well being....

 

Just my $0.02

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I totally understand that, that may have been her perception back a few months ago. Problem is, I had no interaction with her this time around other than closing her wound while she was asleep and trying to help her get different narcotics. The way she treated me was beyond unacceptable. Wishing me a horrible new year almost felt like she was putting a curse on me, guess it doesn't matter to her I have a wife and daughter depending on me. I guess I'm taking it especially hard because I was recently sick for a bit and spent a few days in the hospital.

As far as going against another provider, I hope you guys don't misunderstand. My SP thinks of us as a team. I'm not going against him the handful of times I've had to break bad news to a patient. He would have done the same thing as far as being upfront about something being wrong. I did not blame my SP or his skill for the problem, and kept it as vague as possible. There are plenty of times when I'm not sure about something, don't say anything, and talk to my SP about it later.

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I both echo Ventana's advice as well as rev ronin's. You are obviously too confident of your diagnosis after three years, your questioned your Surgeon's procedure, you made room for a malpractice suit against him because of your remark and obviously you are dealing with a senior citizen , who may be just cantankerous or possibly in early dementia. Under no circumstances should you call this patient, turf it where it belongs, with the surgeon. I have practiced forty-six years with the same surgeon and have never undermined his skill in the OR.
No offense to OP
But it's Ortho. Doesn't take that long to be highly proficient and knowledgeable. Sorry not sorry.

Respectfully, I think you need to get off your 47 years high horse sometimes. I respect your career longevity and experience, but there's many times and ways to frame post operative events in less than incriminating ways. You don't need to bring your Demi God worship here. You and I both know we pick up dirty laundry constantly.

I do it all the time. There's an art to it. Especially when the MD is out of office.

Op. The lady sounds like a crotchety drug addict maybe with underlying mental health issues including dementia. Pain makes people do and say mean things as well. She's frustrated, concerned, nervous and who knows maybe partially deranged.

I think you just need to let your manager and sp deal with it and move on. Do your Sunday best to just block it out and move forward.
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I read your opinion and have been an expert on many malpractice cases and comments like yours are great for the plantiff’s attorney. It’s not my 47 years that should bother you but ten years is enough time regardless of how knowledgeable you are to remember that whatever happens in Las Vegas stays in Las Vegas.  You should send me a bottle of good red wine for my comment. I’ll reach from my high horse and accept them.

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I do EM so my patient relationships are different and not part of an ongoing course of treatment.  I do confront patients who have been abusive to the nurses and techs.  I tell the patient what they can and can't do when interacting with them.  Short version, it's OK to bring things to the techs' and nurses' attention, to complain, etc., but it's never OK to be rude or abusive.  In a very few cases where the patient's conduct was way over the line and they didn't have anything critically wrong with them I made it clear that if their behavior continued unchanged they would be discharged immediately and escorted off the premisis if needed.

In OP's case discussing the situation with the surgeon and refusing to see the patient is the right path.  The surgeon can decide whether to fire the patient or not.

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House of God rule: The patient is the one with the disease.

She has to live with the consequences and you just have to deal with the interaction. Keep the high road; be thankful that you don’t have to deal with her though the physician still does. Who knows what else is going on in her life that you aren’t aware of which makes her the way that she is?

I’ve been in this exact same situation, in different settings (lucky me), and if the worst that comes of it is hurt feelings then all is good.

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We have two distinct situations here, first is the telling a patient that her surgery was sub-optimal, this is inappropriate. If you have concerns you present them to the surgeon and allow him the opportunity to discuss with his patient the issue. I have been in orthopedic surgery for 20 years and despite this depth of experience would not feel it appropriate for me to discuss a failed surgery without first discussing my concerns with the surgeon. Simply don't do it again. Secondly, is the issue of the patient's mistreatment of you and staff. I take it that you feel you have a firm grasp of orthopedics at this point in your career but what you are lacking is practice maturity. In my younger years I too may have wanted to confront the patient. At this point in your career I simply do not think you have the maturity to artfully carry it out.  I am in no way trying to belittle you or your abilities but, dealing with these sort of patients takes incredible restraint and a wisdom that comes with years of experience. I was in my 30's when I graduated from PA school, completed a postgrad residency in EM and spent 5 years in a high volume level II trauma ED before going into orthopedic surgery. This after 10 years as a firefighter medic. A little humility on your behalf at this point in your career would serve you well. 

 

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Ok I would be pissed too but I would be annoyed with  the practice manager for not halting the behavior. After 30 years of being a female pa and most of it in the  ED I can truly say many people are a-holes. Just not nice. Meh... this is why I have pets

Sadly, don’t confront her it doesn’t work.   Just quietly comment how disappointed you are to the practice manager that the practice is not able to hold her accountable for her behavior.

good luck and ortho is tough, be glad she isn’t your primary care pt!!

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I read your opinion and have been an expert on many malpractice cases and comments like yours are great for the plantiff’s attorney. It’s not my 47 years that should bother you but ten years is enough time regardless of how knowledgeable you are to remember that whatever happens in Las Vegas stays in Las Vegas.  You should send me a bottle of good red wine for my comment. I’ll reach from my high horse and accept them.


You are beyond petty. You want me to bow to you, now? All of my urologists but one so far have told me I function at their level. Quite specifically. They share patients, ask my opinion, and give me as much respect as I give them. I have collegial banter with them as they do amongst themselves. Maybe you're not used to that after 47 years? Sorry it didn't take me that long to get there.

I remember one PA that influenced my career before it started, more than any other. One I know you know.

Patients are far less apt to start a malpractice claim against a PA and/or surgeon that they like. Showing them respect, humility, dignity, and general compassion trumps all else. I've seen that play out both ways.

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Sounds to me like your surgeon is not taking care of his patients.  The clinic should have called him and told him to e-script the narcotic while he was on vacation.

That's a pretty major failure IMO -- a surgery clinic should ALWAYS be able to provide narcotics post-op regardless of whether the doc is out of town or not.

Asking the PCP to script narcs?  Completely inappropriate.  

Did anybody actually bother to call the surgeon?  He should have been made aware of this situation immediately and he should be the one to fix it by e-scripting the narcs.

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