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How to discharge patients successfully

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  • How to discharge patients successfully

    Hello again,

    Thanks again for all the help here.

    New doc at busy outpatient IM practice. Inherited many patients from now retired physician. Many are, shall we say, difficult and quite frankly on numerous questionable med regimens (Ativan + ambien + trazadone + or - norco or some variety of the above). Lots of chronic pain. And they are all Medicare age or greater, some pushing 80.

    I am relatively new out of training but I don’t fee comfortable managing a lot of these patients with all the med med issues the precocious provider left me with. Some of the patients are also refusing my plan of care for other things.

    What are ethical and tactful ways to discharge patients?

  • #2
    Definitely avoid the precocious ones....

    Someone will be helpful I'm sure.


    • #3
      We had a lot of these "come to jesus" situations with new opiate laws in our state.  The PCPs basically say it is up to the pain management folks from now on.  As an ER guy, I got a lot of really really irritated patients for awhile, but things have sorted out.

      So, no practical advice from my specialty other than to say it will be super rough for a few months when you cut them off but then the long term job satisfaction will be much higher.

      But if they're all that old, you could just wait for the practice to turnover with natural causes....


      • #4
        Alright I had a very similar situation as you. The practice I inherited was previously a in the hands of a Candyman. Candywoman to be more exact. Never met her but I can tell she did not care about anything other then throughput. Tons of opiates benzos, sleep meds, stimulants, inappropriate antibiotics, etc. Also letting kids go unvaccinated, and a massive amount of inappropriate disability. She got canned because of it after admin caught wind 2 years later.

        I was fresh out of residency coming to fill the void I had to make a choice and do it right away. I chose to only do what I felt was right. If I did not agree with a treatment or it made me uncomfortable I said no. It was a miserable first year but I am much better off now. A lot of people got pissed and left. A few were willing to try new things. It is amazing how many are still my patients and doing just as well if not better off the drugs. I have a panel of over 2000 and I have 2 people who take hydrocodone AE NEEDED twice a day and 3 other people who take seldom benzos. I am sure I am way too far but it works for me. I have no problem being the bad guy. My "normal" patients like me and the drug seekers stopped calling.

        Toughen up and do the right thing. You are not their friend you are their physician.
        Best of luck. Feel free to PM me for more specifics if you want.


        • #5
          @Lordosis - surely you don't get Press Ganey counted towards you     On a more serious note, we run a program called PARS which highlights risks of being sued.  Interestingly I came up on this program radar with too many complaints when I started --- most from denial of narcs/bzd/abx.  I received 'counseling' and caution to change my ways.

          The following year after my practice matured.   I got compliments on changing things and the complaints resolved.   Was asked 'how did I do it?'  Well, my practice matured and those seekers self-attritioned out once they realized complaining didn't get them what they wanted.   I changed nothing.

          Now my practice still has quite a few hold overs of long time folk on opioids that I haven't transitioned solely to pain clinic.  For the newbies coming in, I'm sure to be viewed as a candyman.   I still vividly remember all the 'pain is the 5th vital sign' campaign we had at the turn of the century.


          • #6
            I have a hard line with things I'm not comfortable with.  And I say it to patients just like that: "I'm not comfortable signing/prescribing this.  You will have to look elsewhere if that's is what you need."  The ones who walk, I'm glad they are gone.  Be firm.  If not, you get their friends asking for the same thing.


            In terms of how to actually discharge a patient from your practice, some states (I'm referring to NJ) have a specific procedure to do so.  Notify them, send a letter, 30 days... something something.  So check with that.  And your employer/hospital/group/overlords.
            "Oh look another bajillion point declin-Ooooh!!! A coupon for pizza!!!!" <--- This is what everyone's IPS should be. ✓✓✓


            • #7
              Haha yeah we have press ganey. I have surprisingly understanding admin. I think they knew the screwed up with my predecessor and gave me the slack to fix it.


              • #8

                I still vividly remember all the ‘pain is the 5th vital sign’ campaign we had at the turn of the century.
                Click to expand...

                Oh how things have changed!  Even in school it was drilled into our heads.  Now I get verifications from pharmacies, CME requirements, letters from insurance companies, etc...  I'm not discounting true pain.  I am saying a lot of people lie.
                "Oh look another bajillion point declin-Ooooh!!! A coupon for pizza!!!!" <--- This is what everyone's IPS should be. ✓✓✓


                • #9
                  in my practice, I had a number of patients getting narcotics from surgeries many months before.  I would usually see them for two visits.  The first visit I would give them a much smaller dose of the medication they were on with instructions to start coming off the medication. At the same time I gave them alternative ideas or medications to control things such as pain.  The next visit, if there was one, I told them this was the last prescription.  Most wouldn't come back after that.  They knew they couldn't get what they were looking for, but they were let down easy.



                  • #10

                    I’m not a PCP but I also find great luck with lines like “I just don’t do that” or “I’m not comfortable prescribing that medication.”
                    Click to expand...

                    Those lines work in our world too but we know that we are going to have an ongoing relationship with the patient which makes it harder.  It is hard to be the bad guy when you know you will see the person again and again and again.  It was easier when you know the chance of them coming into the ER and you being the one to get the hit was a very small likelihood.

                    So I can see why doctors cave and give people what they want.  Sometimes it is laziness but I think a lot of it is they just do not want to be the bad guy.

                    It is not just meds. I was shocked when a healthy 50 something asked me for a handicapped placard because his friends have one.

                    Do not even get me started on the ESA letters.


                    • #11

                      Isn’t the idea kind of that you are using lines such as these to help determine with whom you are going to have an ongoing relationship?
                      Click to expand...

                      Well yes a lot of people will leave when they realize they will not get what they want.  But not all.  It is hard to find a PCP and people have other ongoing health problems they may need addressed as well.  And in my experience about 10% actually want to get better and might hate you for it at first but come around eventually.

                      But just because I tell someone I am not going to give them percocet for their back strain doesn't mean that I will not see them next month for their DM.

                      Just yesterday someone was in for a blood pressure follow up and told me that they were still mad I would not give them antibiotics 3 months ago and they were sick for a WHOLE WEEK.  I tried again to educate how long viral infections last but momentum is a strong force.


                      • #12
                        For opioids, I have had some success with centering the discussion around the patient’s safety and well-being, including adverse affects like OIH and hypogonadism (esp effective for youngish men). Not everyone responds to this discussion but some do, and it makes the conversation about your concern for them.

                        Also, do you feel comfortable identifying who truly has OUD and would benefit from MAT? If not, and this is affecting a sig part of your patient population, finding resources for this would be helpful. I have been surprised how some patients who are angry at first are so grateful a few years later when they are doing so much better after proper treatment. Now the ones who are diverting, they are just going to get angry and leave.


                        • #13
                          Try to stick to your ground rules and be consistent.  It is hard but ORT and COMM 5 might be helpful to identify high risk.  It takes a lot of energy to have a productive conversation with those who are already dependent/addictive to narcotics since nothing else works for them.

                          I have inherited a lot as well.  I tried to keep track of it- drug test 2x a year (more if necessary). I read to them the contract so they understand all the contents of the  contract.  I wish I am in a state that narcotics are as per pain management.  Our pain specialists do not want to deal with this as well. Of course, it lands on pcp's discretion.

                          Before, I will discharge right away patients with abnormal drug screens. Our admin does not want allow us to do that anymore.  They want us to have conversations why narcotics are not meant long term.  I do have difficulty with those who are chronically on it.  I have one who still works as a carpenter at 80yo, he needs the money and hydrocodone helps with his severe back arthritis.

                          I think a lot of people also found it was the norm decades ago.  So here you are a new doctor saying it is bad for them.  I also blame the insurances, they gave such a hard time to give and approve anti inflammatories- but no problem with opiates.  So it was cheaper for them to get oxy's than to try voltaren. Now, it is an epidemic. It is up to us to clean up.

                          Word gets around so set your practice early on how you want it.  The other retired doctor here took over the narcotics from other retired doctors as well.  He just didn't want to say no to patients.  Despite having abnormal drug tests, never addressed it.  He had almost 3k patient panel.So when he left, I think 1 neighborhood panicked that those of us remaining are not as generous with narcs. Good luck!




                          • #14

                            told me that they were still mad I would not give them antibiotics 3 months ago and they were sick for a WHOLE WEEK
                            Click to expand...

                            i would have told them  "see, your welcome, i saved your life. bill will be in the mail......"


                            sigh, stupid is as stupid does. gj lord.


                            • #15

                              ive written 1 narcotic in the past year. kid broke his leg. i still yelled at the parents cause he didnt have a helmet....