Need advice

[engerland66]

Whether he comes back soon or not is irrelevant. With his age, this will be your permanent problem sooner or later. I’d nip it in the bud now. Options include keying admin into his opiate proclivities and seeing if they realize it’s a problem. Otherwise, no refills, no chronic opiate patients, hard line etc etc. If admin doesn’t realize he’s everyone’s problem, and support the practice in moving it into 2021, I’d pull the band-aid off now and get used to saying “no” multiple times a day.

[Kamban]

We had a local doc who ultimately went to prison for his prescribing antics. When he first got arrested (with no bail and immediately suspended license), his patients were kinda up the creek.

We had such a doc in our local community too. By an odd coincidence his wife was referred to me for anemia a few years down the line while he was still serving a long sentence in prison. I usually take a good social history but luckily my MA informed me of who the patient was before I went in. To avoid an awkward conversation, I avoided social history completely. She was raising three girls on her own, poor lady.

[jfoxcpacfp]

Thought from a non-anonymous outsider - if you are worried about people going into withdrawal after they have taken their last pill (and I am skeptical about “last pill”), could you not send a form letter out to “All patients of Dr. X” telling them of the new policies? That would give them a heads up to start looking or to schedule an appointment for tapering oversight (if you want to deal with that). Then, for the few who still call for a refill (probably including some pretending they d/n read the letter), the nurse can inform them that the office sent a letter to this effect on 08/15/21 to their LKA. They can either come in or start looking. It would really gall me to be backed into this corner.

[uksho]

I would never ever prescribe any controlled substances without having an office visit and forming my own opinions. If the patients don't want to come, their choice. And if the admins make a fuss, show them NYS policies on prescribing controlled substances . Does the triplicates exist any more. or is all online now.

Apart from running to the attending to get triplicates in my residency ( more than 10 years ago), I haven’t seen or used them

we prescribe narcotics online . But very limited amount and the new rules have been very helpful . Most of the pts know about it too .

on the brighter side, I see a few pts who refuse any narcotics post op , either due to fear of addiction or relapse .

[StarTrekDoc]

Thought from a non-anonymous outsider - if you are worried about people going into withdrawal after they have taken their last pill (and I am skeptical about “last pill”), could you not send a form letter out to “All patients of Dr. X” telling them of the new policies? That would give them a heads up to start looking or to schedule an appointment for tapering oversight (if you want to deal with that). Then, for the few who still call for a refill (probably including some pretending they d/n read the letter), the nurse can inform them that the office sent a letter to this effect on 08/15/21 to their LKA. They can either come in or start looking. It would really gall me to be backed into this corner.

This would be a nice thing -- IF the patients were in Lordosis practice . They are not. Form my understanding, he has no legal obligation to cover these patients other than he is cross covering a fellow physician employed by the hospital. If you ARE in a group practice, then I would agree that there's a bit more obligation to cover and an option is to send out this type of letter to inform of status and setting the parameters of coming in for F2F evaluation and plan.

As a group practice in division, we cross cover 30+ clinicians and get all a lot these 'last minute/last pill' requests. Answering service knows 'no narcotics' and that stops it dead in the tracks after hours/weekends. For leave/extended absences we do bring them in after 3 months from last F2F to continue long term meds every 30 days.

This sounds like a very different situation where it's a different office that's separate from OPs own office. In this case, no obligation to the patient. It is the hospital's responsibility to arrange coverage and if not specifically spelled out in OPs contract to provide mutual aid to fellow clinician, OP gets to set much of the rules here if he has the gumption to bring the fight to hospital admin.

[Lordosis]

This would be a nice thing -- IF the patients were in Lordosis practice . They are not. Form my understanding, he has no legal obligation to cover these patients other than he is cross covering a fellow physician employed by the hospital. If you ARE in a group practice, then I would agree that there's a bit more obligation to cover and an option is to send out this type of letter to inform of status and setting the parameters of coming in for F2F evaluation and plan.

As a group practice in division, we cross cover 30+ clinicians and get all a lot these 'last minute/last pill' requests. Answering service knows 'no narcotics' and that stops it dead in the tracks after hours/weekends. For leave/extended absences we do bring them in after 3 months from last F2F to continue long term meds every 30 days.

This sounds like a very different situation where it's a different office that's separate from OPs own office. In this case, no obligation to the patient. It is the hospital's responsibility to arrange coverage and if not specifically spelled out in OPs contract to provide mutual aid to fellow clinician, OP gets to set much of the rules here if he has the gumption to bring the fight to hospital admin.

Unfortunately it is my office. But his patients are "very loyal" and most have never seen anyone else in the office. If this was another office I would not even give it a second thought.

[StarTrekDoc]

Then the letter is a way forward to set expectations patient facing while you and rest of office clinicians approach admin with set rules you are going to do to support the practice and patients while also practicing current guidelines and protect the entire system.

This is where getting risk management involved works well and admin tends to listen to them

The admin also has to realize this cannot be done virtually.

[WorkforFIRE]

Sorry you’re going through this.
my advice would be that going forward, patient needs F2F. And then you can establish some ground rules. Like no benzo with opioids. CDC clearly recommends to not mix these meds. Get paid for F2F.
and, if opioid script not indicated, then don’t fill it. Give them a one month supply to wean.

[Cubicle]

Admin is pushing to just give refills? Tell admin they have to attend to the patients with you. Or tell them "this is not how I will do things".

I'm a jerk I guess. I get people who say "my last doctor did xyz". I really don't mind if a patient says they won't return. My time in the hospital & now on my own.

Admin won't spend a day in jail or give you a penny towards fines. That's all on you.

[legobikes]

Let me clarify something. The doc is a good person. He does what he does because he thinks it is right and helping the patients. Again just cannot say no to people. Cannot disappoint anyone. Spends 45 minutes with everyone. That makes it harder to confront him about it. Plus being my senior and established in the community for decades.

As for a backup plan there are other systems outside my restrictions that I could easily work for. I have friends in both other major players. It sounds like they struggle with the same kind of crap though so I am not eager to start over. Plus I like working 3 miles from my house. And I like many of my patients and it would suck to leave.

Haha I know I brought this up before but I'm in the same situation re: certain dissatisfactions with my employer but overall pretty much married to them due to various pros such as knowing my patients and living a mile from the clinic.

[Dont_know_mind]

Sounds terrible.
I wouldn’t find it tolerable.
It would be super difficult, even with a supportive admin, which yours doesn’t sound like it is.

Depends on how financially secure you are and your attachment to the place.
Personally, if it was me (and I am in psychiatry not primary health so not sure if your setup allows), I would stitch up 3 days/week elsewhere with option for 5, put in my resignation letter to current place. Maybe stay 2 days/week at current place if they are reasonable. Or maybe quit ASAP and come back if things improve.

I would rather drive an hour a day and work elsewhere than have to prescribe opiates or BDZ in an unsafe manner, that as others have mentioned is high medicolegal, licensing and adverse patient outcome risk.

[WorkforFIRE]

Are you near FIRE? Can you give your admin the finger? I read this post again this morning and got upset thinking about your situation. Sorry about this. Admins and business trying to tell you how to practice medicine is not why we went into this field.
Another reason that anyone reading this to strive for FI, so you can walk when you want.
Fwiw, I’m not at FI yet but am trying to get there ASAP.

[Lordosis]

Sounds terrible.
I wouldn’t find it tolerable.
It would be super difficult, even with a supportive admin, which yours doesn’t sound like it is.

Depends on how financially secure you are and your attachment to the place.
Personally, if it was me (and I am in psychiatry not primary health so not sure if your setup allows), I would stitch up 3 days/week elsewhere with option for 5, put in my resignation letter to current place. Maybe stay 2 days/week at current place if they are reasonable. Or maybe quit ASAP and come back if things improve.

I would rather drive an hour a day and work elsewhere than have to prescribe opiates or BDZ in an unsafe manner, that as others have mentioned is high medicolegal, licensing and adverse patient outcome risk.

I honestly don't think it's going to get to that level. At least I hope not. I have basically flat out refuse to do anything I am uncomfortable with and I don't see a way that they can force me. I guess they could fire me but I really don't see that happening either. However I keep getting requests for things and we have to deal with it Case by case. It's going to be a real slog to get through the next couple of months. And I don't expect any help from higher up.

No, unfortunately I'm not nowhere near fire. Only in my 30s

[TheDangerZone]

Prescribing months of narcotics for your partner without an exam at the behest of your administration? Eff that noise, it’s your DEA number on those prescriptions. You and your partners absolutely right to push back.

PS hope your household is recovering well from last weeks events.

[billy]

I honestly don't think it's going to get to that level. At least I hope not. I have basically flat out refuse to do anything I am uncomfortable with and I don't see a way that they can force me. I guess they could fire me but I really don't see that happening either. However I keep getting requests for things and we have to deal with it Case by case. It's going to be a real slog to get through the next couple of months. And I don't expect any help from higher up.

No, unfortunately I'm not nowhere near fire. Only in my 30s

There's FIRE, but there's also having what I call miniFU money- enough that worst case you can easily sit around for a few months until having to locums or perdiem while waiting for a new job. Ideally you have a new job lined up before presenting your current job with an ultimatum or threat to leave.

Anyway, good luck with the next few months. But for sure take care of all the medicolegal stuff to protect yourself. Admin's response will be "we dont tell drs what to prescribe" if any legal questioning occurs.