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Just curious, but what will you NOT do as a matter of principle?  I know they don't teach the Hippocratic Oath in PA school, but what are some non-obvious things* that you won't do on an ethical basis?  For which will you refer?

Example: I do not certify emotional support animals, but refer to psych.

Last week I was asked to do a boxing physical.  After brief reflection, I declined, and on further reflection believe that I should actually be thinking more proactively about this--what, if I honored the patient's request, would be violating my obligation to not harm them either directly or indirectly?

* By "non-obvious" I mean that I do not want to stray into big societal debates like abortion, physician-assisted suicide, or transgender medicine, and won't hesitate to close the thread if it gets taken in those directions.  Let's look at subtle, everyday questions of small decisions and modest harms.

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I will not certify medical necessity for disability or disabled parking permits for most requests, especially things like arthritis which might benefit from exercise and weight loss and parking further away. I will not certify emotional support animals. I do not refer to chiropractors, ever. I will refer to ortho or PT.

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I won’t refer to chiropractors.  If someone asks my opinion I will let them know that if they feel benefit for musculoskeletal complaints like low back pain I don’t recommend against but have as recently as this week told someone that they should find another chiropractor if they must have one due to the chiropractor telling them vaccines are poison. 

Wont treat chronic pain with opioids, may be appropriate for some but I love that my primary care practice specifically does not manage chronic pain.  I refer to pin management, specifically groups that use multiple modalities for treatment.  

Wont waiver on recommendations for return to play after concussions and other sports injuries  specifically in pediatrics.  I also make my opinion that a couple of the local coaches are idiots due to putting games before kids health known in the community.  Some coaches have gone as far as telling players not to come to our clinic for treatment of injuries/illness because “they will bench you”. 

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I won't certify people for handicapped stickers unless they meet the standard.

I won't give antibiotics for colds..patient satisfaction surveys be damned.

I won't give work/school excuses for days prior to being seen. You could have been at the horse track yesterday for all I know.

I won't sign trip insurance waivers unless they meet the standard. (Don't come to me 2 weeks later and say "I was sick and couldn't travel" if I didn't see you when you were sick.

I don't certify comfort pets. I have had more people try to abuse this just to get into "no pet" buildings or avoid pet deposits.

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- I have never certified a pet, but have written letters confirming patients' diagnoses of depression/anxiety/etc. that MAY potentially warrant a comfort pet (with .  Apart from the rampant abuse, I'm concerned about liability from a dog bite - maybe I'm paranoid.  But, I certified the person needed a pet, therefore is it conceivable that I am at least partially liable for the dog bite?  I've heard of weirder stuff in our legal system.

- I do not certify disability - I always refer for a functional capacity evaluation.  The out-of-pocket cost for that alone usually deters patients, or they just go down the road....ugh.

- I will NEVER again prescribe a narcotic with a benzodiazepine.  I've never started that combination EVER, but inherited a ton in my last job that I was trying to wean down.  New job, I have now drawn a "line in the sand."  I've only run into it once with the new job, but will never prescribe together again and from the first visit I now make it clear and CHART these will be weaned and replaced steadily.  I have even drawn up a contract that the patient signs stating they understand their narcotic/benzo/whatever is going to be weaned steadily and patient is in agreement.

- I will not prescribe controlled substances at first visit - and will not start without previous records that I can review.

 

Edited by mgriffiths
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No on emotional support animals...I've seen too many untrained ones piss/shit/bite where they shouldn't. 

No narcotics for chronic pain, they all go to pain management. 

I will not initiate stimulant treatment for adult ADHD without prior diagnosis from psychiatrist or psychologist, and I will request psych testing of some sort first if its an adult who has never been diagnosed as a child (MMPI , etc.). 

No benzos for anxiety. I will refill Klonopin if the patient is already maxed out on SSRI/SNRI. 

No stimulants for ADHD for someone who has a diagnosis of anxiety and is already taking benzos...pick one or the other...I dont care if a psychiatrist initiated treatment, he can follow up on it too. 

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I haven't referred a patient to a chiropractor, but that doesn't mean I wouldn't. I do believe that there is merit to what they do, and I think the horror stories we've all heard about chiropractic services occur in a minority of circumstances and do not reflect on their profession as a whole. I would only feel comfortable suggesting this as an option to select active/healthy adult patients. No children or elderly.  I think shared decision making regarding appropriate referral (PT, ortho, PM&R, and/or chiropractor) for the patient and the circumstance is sensible.  

Anecdotally, I sustained a minor neck injury while participating in CrossFit and saw a chiropractor. Five sessions later I was good to go. Can't say for sure whether it was anything he did or if it would've improved anyway by taking it easy on the weights, but either way I was satisfied with the experience and would consider going again. 

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"No narcotics for chronic pain"...

This makes me think the pendulum is swinging too far again, and we are not practicing good medicine.

Example - pt with chronic back pain, treat a with daily mobic, stretches, and exercise.  Uses ibuprofen, lidoderm patches, and ice packs for flares, and 1-2 times a month takes a norco before bed so he sleeps better (pain frequently wakes him up).

Would you family practice guys turf him to pain mgmt??

 

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I won't give sick notes retroactively - they get what I think is necessary based on what I see at that point.

I'm trying to figure out how you all would have to certify someone's service dog/pet - those animals have to be certified as service animals from a service animal school do they not?  Don't the handlers/owners also have to attend to ensure they're a good fit?  We can certify that the person is a nutter/whiner/too emotionally immature to cope with life/has an actual mental health diagnosis requiring the animal,  but how are we non-veterinary/animal training folks supposed to certify the animal?  I'd have to say that's a big scope of practice issue that I don't recall learning about in PA school.

Parking permits - I used to actually watch people wandering in from the parking lot and back out, then compare from the waiting room to the office (I had my receptionist do it too) and casually mention it to them if I felt there was a discrepancy.  

Disability for welfare - not without a prior chart from folks and if red flags like "referred to physio for chronic knee pain, continues to be no show at same and only shows up here to have disability reconfirmed/renewed", they were confronted and usually didn't return.

 

SK

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33 minutes ago, sk732 said:

I'm trying to figure out how you all would have to certify someone's service dog/pet - those animals have to be certified as service animals from a service animal school do they not?  Don't the handlers/owners also have to attend to ensure they're a good fit?  We can certify that the person is a nutter/whiner/too emotionally immature to cope with life/has an actual mental health diagnosis requiring the animal,  but how are we non-veterinary/animal training folks supposed to certify the animal?  I'd have to say that's a big scope of practice issue that I don't recall learning about in PA school.

In my experience this is more about stating they need an emotional support animal which has a significantly lower threshold than a true service animal.  Usually ESAs don't require any actual documentation from a vet.  We are not truly certifying the animal as much as certifying they supposedly need one - but our note/form is good enough for apartments, airlines, etc. assuming we are willing to sign...

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48 minutes ago, Cideous said:

Won't fill out an FLMA form...

For me that is only if they are sitting in front of me and only for real things.  I once had an uncontrolled DMII ask for intermittent FMLA form due to complications from her DMII.  I refused simply stating that if she did what she was supposed to she wouldn't need the FMLA.  Utter disbelief from her.

 

1 hour ago, Boatswain2PA said:

"No narcotics for chronic pain"...

This makes me think the pendulum is swinging too far again, and we are not practicing good medicine.

This is a hard one, and I can understand why some have drawn this line.  I have not personally, but definitely understand, especially in the day of Press Ganey where it is far easier to tell patients we "cannot" prescribe narcotics than "you don't need them" or "I just won't give them to you."  One of the things I learned VERY early on is that patient's talk and will ask, "but you gave 'Jane' a script, why not me?!?!?!"

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39 minutes ago, mgriffiths said:

In my experience this is more about stating they need an emotional support animal which has a significantly lower threshold than a true service animal.  Usually ESAs don't require any actual documentation from a vet.  We are not truly certifying the animal as much as certifying they supposedly need one - but our note/form is good enough for apartments, airlines, etc. assuming we are willing to sign...

Sounds like something their head shrinker should be signing as an Rx then...As much as I think this "poor me" society thing makes me shake my head, reading this has me thinking that maybe I should get an ES parrot I could have on my shoulder at work and train it to squawk things like "Manager X is a phuquetard" when they walk by, since that would be insubordinate of me to do it to them in a public place and they frankly make me angry all the time.  I could just blame it on the parrot hearing someone mentioning repeatedly...

You might have me onto something ;-).

 

SK

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I can certainly agree with not giving chronic pain meds, benzos/narcotics combos, or ADHD meds to adults who "just can't concentrate".

Not filling out FMLA paperwork? I wish I had that luxury, but patient satisfaction is still a thing around here. In all honestly, if they take the time and spend the co-pay to come see me, I don't mind filling out reasonable FMLA documentation. It's not like society is any worse off if the call-center is missing an employee for a few days, regardless of the reason.

 

 

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FMLA paperwork annoys me, but it is what it is.

I am surprised about reluctance to write work/doctor's notes. I am more than happy to write those. People have shit jobs and often need a break for whatever reason. I think it is crap that many employers actually require them. Maybe they were legitimately sick. Maybe not. What I do know is that if my little note can keep them employed and provide a small bit of relief from the brutal grind that many on the lower end of the socio-economic spectrum endure, that I am doing my job well.

 

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I will not tolerate anyone who is aggressive, belligerent, hostile towards my staff. i have zero tolerance for #&*@$^^holes/bags/ect

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I will not prescribe to friends and family. I'm happy to listen and advise, but I'll tell them the Rx needs to come from a provider with the ability to formally document the encounter and monitor progress/arrange follow-up. I'm a new grad and I realize there are PA's who do prescribe to friends and family, but at this early stage in my career it's just not in my comfort zone. 

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46 minutes ago, karebear12892 said:

I will not prescribe to friends and family.

Many states have made this either illegal or at minimum unethical - so just to add to the idea of not doing this.

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13 hours ago, PAMEDIC said:

I am surprised about reluctance to write work/doctor's notes

I'm not reluctant to give notes...I do it several times a day. I'm reluctant to give notes for the time period before I saw you. If you clearly have something going on that has been happening for a few days I'll stretch that juuuuuuust a little. But if you come in healthy as a horse and say "I was out for three days because I had a cold and I need a note"  it isn't going to happen.

I know it sounds corny but we have a duty to the truth and if we compromise our integrity in small ways how can we be trusted in other ways?

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57 minutes ago, sas5814 said:

I'm not reluctant to give notes...I do it several times a day. I'm reluctant to give notes for the time period before I saw you. If you clearly have something going on that has been happening for a few days I'll stretch that juuuuuuust a little. But if you come in healthy as a horse and say "I was out for three days because I had a cold and I need a note"  it isn't going to happen.

I know it sounds corny but we have a duty to the truth and if we compromise our integrity in small ways how can we be trusted in other ways?

If a fellow is sitting there drinking a starbucks and is asking for a note that he was "sick" prior to me seeing him, nope.  I won't do that.

However, if he is febrile, vomiting in the office and looks like death warmed over, I will give him a note for the days prior to the appointment.

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I won't discriminate against a patient for having racist tattoos or saying disparaging things that go against my faith and ethnicity - it has been very hard over the years - very very hard in the Deep South. I don't wear religious markers of any kind - never will - different topic - but hearing anti-Semitic things from patients or racial things when I have a multiracial family - sometimes it hits deep.  I take care of the patient - even when it nags to my core. 

I do write FMLA papers - comes with my territory but I am strict.

I do write for companion animals - I live in a world full of PTSD. 

I do write a ton of handicapped parking apps - veterans with hard issues.

I do write work notes if you come in with obvious signs of illness - but you have to come in. Don't call me - you could be in Florida or Vegas for all I know. 

I do NOT perpetuate medical myth - Dr Oz is not an authority on a lot of things and neither are many media snippets of horrible attention grabbing stories. I will counter medical myth with fact and examples and data - compassion for the patient's level of education but will not allow idiocy to grow.

I do not sign vaccine exemptions any more. Unless there is a life threatening illness that prevents vaccines. I don't see kids anymore but this was a choice for me about vaccines. People in my state are dying and spreading totally preventable illnesses. Again, medical myth and I won't let idiocy find a root to grow from. 

I do not write for benzos much at all and NEVER with narcotics. I do not write for ADHD without testing and counseling/behavior change therapy in tow. I do not write for Ambien at all - psych can do it if that is the only sleep thing they can come up with. Period. 

Everyday I try to do right things and get a little smarter and better at what I do. Finishing my 27th year at this. Still so much that can be learned.

 

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2 minutes ago, Reality Check 2 said:

I won't discriminate against a patient for having racist tattoos or saying disparaging things that go against my faith and ethnicity - it has been very hard over the years - very very hard in the Deep South. I don't wear religious markers of any kind - never will - different topic - but hearing anti-Semitic things from patients or racial things when I have a multiracial family - sometimes it hits deep.  I take care of the patient - even when it nags to my core.

I admire you for this. I worked in Community Health (deep south) and had a patient who ranted racist garbage all the time. When he came in one day bragging about shooting a guy (you can imagine the language) and how his buddy the Sheriff was helping him not be charged I threw him out. It was a simple matter of no longer caring if he lived or died. I could not provide him quality care so he needed someone else.

before anyone asks...yes I called the Feds regarding the shooting but they were apparently too busy.

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I can't stand insurance companies (although they are paying through their nose for my care right now, over 200K). However, I will never lie on a prior auth. form just to get the treatment for the patient. I will fudge a little, but not lie on questions. I know some providers that do all the time (saying patient as failed x,y,z when they have never tried them). It seems unethical. It also seems unethical to have an insurance doctor reject the patient, simply out of ignorance. 

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