Need advice

[Lordosis]

Okay I need some advice from a non-partial third party. Where better than an anonymous forum? I apologize for the long post and I appreciate all the people who stick it through and offer useful advice.

I work in a hospital alone family practice. There are several physicians and mid levels. One of the physicians has recently went out on medical leave. It was slated for a month then got extended the two months and then 3 months and now there is no return date but the story is he will be coming back at some point. I am not sure I believe the story but that is what is being told.

The problem

This particular physician trained in a different era and is a hard time saying no to patients. So he has collected a panel of needy difficult patients. And the rest of us do not necessarily agree with the treatment plans. When it is covering for a vacation or even a month absence I did not feel so bad for feeling medications for patients I haven't seen before even if I don't necessarily agree because I know that physician will come back and take it back over. However now that I think it is likely he will not come back I feel like if I endorse the plan I'm going to be stuck with this for potentially the rest of my career.

My biggest problems are the large amount of narcotic prescriptions. Everybody seems to be on something and many people seem to be on combinations of several. Also frequently given very high doses and 3 month supplies for some reason.

The patients also are quite demanding. Want things done over the phone without visits. Demand things like antibiotics and steroids for things where they're not appropriate.

For some reason he routinely puts refills on antibiotics "in case they don't get better" and reflexively gives diflucan to all women with antibiotic prescriptions to treat "inevitable" yeast infections.
Surprisingly no oral vancomycin to treat the c difficile lol.

My conundrum is there's just so much of it and we don't find out patients are out of a particular medication until they just use their last pill for example we have no time to even see and evaluate the person. We are basically forced to make a decision do we refill this or is the patient going to withdrawal. Admin is pushing us just to continue refilling the prescriptions until he comes back. But I am really starting to have some hesitancy over this and decided it's time to push back.

Am I crazy? Am I making a mountain out of a molehill? Should I refill prescriptions for patients I've never seen following a treatment plan I don't necessarily agree with because it's for somebody I'm covering?

Unfortunately we have absences for various reasons all over our primary Care Network and getting extra help is not likely any time in the near future.

Fortunately the other primary partners agree with my hesitation and I think we can stand as a block and because of the absences they would be very reluctant to lose us.

[CordMcNally]

As I tell patients when they say "Dr. So And So would always do this", I can't control how other physicians practice but I can control how I practice. You feel like this isn't good patient care and you're right.

[uksho]

Do what you think is good medicine . No one should be able to force you to do something which can jeopardize your license or to do something you can’t sleep with .

[Lordosis]

As I tell patients when they say "Dr. So And So would always do this", I can't control how other physicians practice but I can control how I practice. You feel like this isn't good patient care and you're right.

I agree. I am very good at saying that line as well. When I get a new patient who came from some terrible Doctor who gave them poor care I did not continue that poor care. I made changes as I saw appropriate and usually with some level of compromise. To be fair the compromise is always towards my end of the equation because I'm the one who's writing the prescriptions. And if they don't like it they moved on.

Unfortunately in this situation we are being asked to basically continue crappy care without evaluating the patients because in some cases we do not have the time or resources to do it all. And admin doesn't want all the grief of people getting weaned off of opiates and benzos

[CordMcNally]

And admin doesn't want all the grief of people getting weaned off of opiates and benzos

Sounds like admin could turn this into a new revenue line with a suboxone clinic...

[Nysoz]

If admin wants the meds refilled they can field the phone calls and refill the meds without seeing the patients.

Do what’s right for patients health, not their satisfaction/demands. Primum non nocere

[StarTrekDoc]

Okay, this is the same admin given you crap on PTO.

I think in an earlier thread we discussed this.

Not your patients. Admin needs to find locums to do the work. or pay you for the non-rvu coverage. Plain and simple. If they balk; you're under no obligation to cover. Especially since they appear to have significant practice style differences.

You and your colleagues and specifically state that only way you will refill is if the patient is seen in your clinic in F2F visit. -- get paid for the trouble.

[Lordosis]

Okay, this is the same admin given you crap on PTO.

I think in an earlier thread we discussed this.

Not your patients. Admin needs to find locums to do the work. or pay you for the non-rvu coverage. Plain and simple. If they balk; you're under no obligation to cover. Especially since they appear to have significant practice style differences.

You and your colleagues and specifically state that only way you will refill is if the patient is seen in your clinic in F2F visit. -- get paid for the trouble.

I'm leaning towards something like this. There's no amount of money that can get me just to do it. I will not be bought and definitely not bought for any level of money they'd be willing to offer me.

However I will gladly meet with the patients and come up with a reasonable treatment plan. That is what I do all the time and I don't particularly enjoy pissing people off but I'm willing to do it if it is the right thing to do. I just don't know if I have the time to do it with everybody. It is a real boatload of trouble.

[Anne]

From your prior posts it sounds like you can get people in relatively quickly. So if it’s last minute and there is no time, refill for 1-2 weeks or however long it will take to get them in. Then evaluate and get them on a weaning schedule or refer to eval for OUD or whatever else you think needs to be done.

Does your system have peer review for these types of issues? I think this doctor’s practice needs to be looked at via whatever your process is when issues are identified and recs made regarding performance improvement/whether he should be recredentialed in the practice etc.

[familydocPA]

As a FM doc who has been put in a similar position several times, I understand your pain and realize that it doesn't feel quite as easy as "tell them you won't do it." I have found the most difficult thing to do is to change course after you personally have already done it for him in coverage - now a precedent has been set to continue to prescribe, and these patients are commonly very difficult and/or pushy.

This is unfortunately one of the hard parts of sharing a practice with someone of a different "practice style."

The only thing that I have found effective in this type of situation is to have a set of written standards / policies, and to make sure my staff is well versed in them and can forewarn the patients. Now, a year after taking over for one of these types of docs, the nurses just respond to the patients and say something like "I will forward your request, but I'm sure he's going to need an appointment to go over this with you." Additionally, by treating everyone the same, it reduces chances for bias or being accused of discrimination.

A year later, 95% of the controlled substance patients have found a new home (not me) after 0-1 visits with me.

[HikingDO]

Do what you think is medically correct. When patients tell me “We’ll, Dr. X would give me Percocet for my migraines, or a Z-Pack for my 8 hour cough”, my answer has always been “I’m not Dr. X, and all doctors practice differently”. Refer opiate patients to pain management, and let them know “if Dr. X returns you can come back then, but I don’t refill chronic pain meds”. I’m sure they’ll be pissed, and he may be pissed when or if he returns, but he brought that on himself by how he practices.

[familydocPA]

I'm leaning towards something like this. There's no amount of money that can get me just to do it. I will not be bought and definitely not bought for any level of money they'd be willing to offer me.

However I will gladly meet with the patients and come up with a reasonable treatment plan. That is what I do all the time and I don't particularly enjoy pissing people off but I'm willing to do it if it is the right thing to do. I just don't know if I have the time to do it with everybody. It is a real boatload of trouble.

Yeah, this. Amen.

[pulmdoc]

It's amazing how much of this BS disappeared overnight when my state passed very strict limits on controlled substances (first rx opiates 7 days only, need F2F for 2nd 7 days, need F2P for next 14 days, then F2F monthly).

I am dealing with a similar situation as well with an "old school" colleague on extended medical leave. Technically he might still return to work, but since all acute rx had to come in, most of his panel has now passed off to other docs. "These are my recommendations" is my standard line.

[Lordosis]

From your prior posts it sounds like you can get people in relatively quickly. So if it’s last minute and there is no time, refill for 1-2 weeks or however long it will take to get them in. Then evaluate and get them on a weaning schedule or refer to eval for OUD or whatever else you think needs to be done.

Does your system have peer review for these types of issues? I think this doctor’s practice needs to be looked at via whatever your process is when issues are identified and recs made regarding performance improvement/whether he should be recredentialed in the practice etc.

Normally yes and I'm always willing to be flexible with my time and work through lunch if necessary however I was just quarantine for 10 days eight of which were work days. So I have about 150 patients of my own to squeeze in over the next few weeks extra.

As for the other part. We have voice our concerns over the years and sometimes we see little bits of action but never anything definitive.

[childay]

As for the other part. We have voice our concerns over the years and sometimes we see little bits of action but never anything definitive.

Naturally, the candyman probably has glowing patient satisfaction surveys..

Tough situation. I certainly wouldn't be refilling for another 3 months without an actual visit. What's wrong with the guy medically? Seems relevant as to what you should do.