Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Friday, October 12, 2007

How to Really Piss Me Off

Do all of the following:
  • Be an ER doc.
  • See a patient of mine seven times in the last two months for "migraines" that continue allegedly unabated despite prescriptions for multiple triptans, compazine, Topamax and Verapamil, among other meds, and who has specifically been told to call me instead of going to the ER.
  • Give him IM dilaudid and a script for Percocet, despite the fact that I've been ratcheting them down -- even though he swears they're the only things that help his chronic back pain -- because he keeps losing them and his alcoholic wife often "borrows" some, and that he can't afford NSAIDs or physical therapy.
  • Assume I'm an idiot who doesn't know any better while noting that he hasn't had an MRI of his brain, or a pain management or headache clinic referral.
  • Under no circumstances deign to notice that he has no insurance. Ignore the fact that his employer offers it but he has decided that it would take too much out of his paycheck.
  • Call me up to discuss the case.
  • At 4:30 am.
Please note that this is only one of several ways to accomplish your aim. It's just the most recent.


At Fri Oct 12, 07:15:00 AM, Blogger MedStudentGod (MSG) said...

Mmmm, yeah. Gotta love the ER flyin' headaches that only are taken care of by narcs. That's just terrible.

At Fri Oct 12, 09:36:00 AM, Blogger Dr. A said...

Yeesh! Great post. Thanks for writing what I'm thinking most nights on call.

At Fri Oct 12, 09:40:00 AM, Blogger tk said...

Wow. Yeah, I'd be pissed at the ER doc, but I'd get rid of the patient . . . It doesn't sound like he wants to actually heal. How many strikes is that? Sounds like he's out.

At Fri Oct 12, 09:54:00 AM, Anonymous Anonymous said...

Ah, let the ER rants fly! There's nothing better in the world than a good ER doctor. There is nothing more painful in the world than a bad ER doctor. Why would calling you at 4:30 in the morning be of any benefit to anyone besides the ER doc who wants to document that he "discussed the patient's care with Dr. X"?

And people wonder why physicians will do anything to get out of taking call for patients in the ER . . .

At Fri Oct 12, 10:42:00 AM, Blogger Linda said...

Hi Dino Doctor,

I’m the Linda with the migraines who commented a while back regarding drug seeking “migraine” pain.

I’m not sure if you’ll find this relevant, but here’s my last migraine/ER experience.

First day of menstrual cycle (yes, my headaches are hormone related):

Wake up to pounding migraine
Wake kids up, take Imitrex
20 minutes later throw up Imitrex
Get kids in car to drive to school
Take another Imitrex
On way back from school, stop in Lowe’s parking lot to throw up 2nd Imitrex (assure cop who pulls into parking lot and inquires that you are fine)
Get home, take 3rd Imitrex and go to bed
20 minutes later, throw up 3rd Imitrex and decide that rather than continue to flush $20 down the toilet every 20 minutes you will go to the ER
Call Mother because you are pretty much blind

How to piss of an actual migraine sufferer in the ER

1. Be a PA. If I’m paying for a visit from someone who went to medical school then I should actually be in the room with someone who went to medical school.
2. Be generally nasty from the get go and insist on turning on over head light in spite of fact that kind nurse has dimmed lights and patient has purse over eyes to get some relief.
3. Act offended when patient requests specific treatment (Shot of Imitrex)
4. Say “we don’t usually give IV Imitrex for Migraines here (WHAT???!!So it’s not just Narcotics I’m not supposed to ask for? You’re just going to not give me any requested meds on general principle and offer something less effective ???)
5. Offer anti nausea shot and pain killer described to Patient as “like a huge shot of Motrin”
6. Say, when informed by patient of Aspirin allergy (which is charted): “OH? You’re allergic to Aspirin?”
7. Tell me to take Benedryl, and when I say, I can’t because I have to be somewhere at 3PM and Benedryl makes me too sleepy to function, say to me “Oh do you want to get better or do you want to be somewhere at 3? It only lasts 4 hours anyway”

I never did get a shot of Imitrex, but he did make me stop throwing up so I could keep my last Imitrex down.

Cost to get rid of that headache: $80 in Imitrex and One ER visit applied to my deductible.

At Fri Oct 12, 11:42:00 AM, Blogger Lynn Price said...

Gee, Dino, maybe the ER doc figured if he wasn't sleeping, why should you? May I assume you chewed him a new orifice?

At Fri Oct 12, 04:29:00 PM, Blogger #1 Dinosaur said...

Linda: I don't think this is an actual migraine patient. I'm sorry for your bad ER experience, but remember...I'm not the ER doc.

Lynn: Unfortunately, nastiness wouldn't have done any good. That particular ER doesn't usually do things like that anyway. Besides, the alarm goes off at 5:00 anyway, so I just got up, showered and blogged.

tk: I've been trying to get rid of him for awhile now. Haven't been able to drop the hammer, though, because there really isn't anywhere else he can go.

Anon: Rants against ERs are a dime a dozen, and their rants outnumber ours 10:1 (and are better written to boot.) Now we'll probably see a whole slew of "How to Really Piss Me Off" posts going around the blogosphere.

At Fri Oct 12, 05:02:00 PM, Anonymous Anonymous said...


Sounds like you are pissed at the wrong guy. You should be pissed at the pt for abusing the system and not seeing you. Also, how many times a week do you tell pts to "go to the ER" when they call to get an appointment. I would wager you dump on the ER more than they bother you. Besides the ER doc was probably tired of seeing your pt and wants you to get control. At 430 in the am you can roll over and go back to sleep. The ER doc is still up dealing with YOUR pt.

At Fri Oct 12, 05:33:00 PM, Anonymous Anonymous said...

Anon 5:02- actually, Dino said he's preparing to discharge this pt from his practice. Once Dino does so, this pt is well and truly no longer Dino's problem.

I suspect that this pt, particularly after the tasty narcotics script, now sees ER doc as his primary doc (and will soon memorize ER doc's schedule and move his uninsured butt into the ER waiting room). ER doc is hurting *himself* by the care choices he's making much more than he's hurting Dino, 4:30am phone call aside.

Dino, if you can disclose, what is the hold-up on the discharge from your practice? I would assume this patient is not paying you, as well as being non-compliant with your request he call you rather than go to the ER and allowing his wife to divert his meds? Is that not enough to cut the cord?

At Fri Oct 12, 06:17:00 PM, Anonymous Anonymous said...

How am I supposed to know that the guy turned down health insurance from his employer? And we also don't typically ask patients about their insurance status. They show up, we see them. The subject only comes up if I'm going to prescribe something expensive.

I don't think I'd call you at 0430 for something as obvious as another skanky drug seeker but on the other hand, how do I kow you're ratcheting him down? Much as I hate drug seekers I do have to give people the benefit of the doubt .

And you were on call so if you're on call, be on call.

What do you want us to do with all of those headache patients? Tell them to call you (or whoever is on call for you?) SInce the standard answer to almost anyone who calls their PCP at any hours seems to be "Go to the Emergency Room," we do tend to get swamped with bogus and/or incredibly trivial complaints.

At Fri Oct 12, 08:22:00 PM, Blogger #1 Dinosaur said...

Some stats: (I get a sheet faxed from the ER letting me know when a patient has checked in; no diagnosis or anything, but at least a heads up they were there) I would say over the last month, I've sent 3 patients to the ER from my office (ie, seen them, assessed that their chest pain was worrisome or whatever, called and spoken to the doc to let them know what was coming and faxed a med list), had about 5 others go there without calling me first (MVAs, r/o fractures, etc.) and offered ER referral to perhaps 4 more who called after hours, after speaking to them and assessing by phone that they could safely wait until the next day to see me in the office but, of course, having to add the standard butt-cover, "If you really feel you can't wait, there's always the ER."

However you cut it, I'm not "swamping" any ERs anywhere with a dozen patients a month.

Regarding the specific specifics of the patient and termination, please bear in mind there's enough fictionalization (mainly by omission) going on that it's not that clear-cut. In general I have no problem cutting druggies loose; there are unmentioned circumstances involved here.

Anon 5:02: I'm plenty pissed at the patient too. Unsurprisingly, there's probably some borderline personality stuff going on here as well.

Panda: Thanks for not calling at 4:30, but if you're concerned about why certain things haven't been done, doesn't it behoove you to at least ask the patient first? How about giving me the benefit of the doubt and assume I know what I'm doing? As for being "on call", there's not really any such thing for me as "off call." Solo; no cross-coverage; it's just me, 24/7. When you call, it's always me you get. You get to sign out and go home at the end of your shift. Not me. Day in, day out; office, pager, ER calls. I don't mind being available for my patients, but at least they understand that it's not fair to abuse my availability. This ER doc, this one time, wasn't. That's all.

At Fri Oct 12, 10:17:00 PM, Blogger Greg P said...

This is really a team effort -- the patient and the ER doc -- and medically dysfunctional.

There are ER docs that just can't say no to patients like this. I've had to tell a few the obvious when they mention that so-and-so has been back to the ER 32 times this year, "Look, they keep coming back because you give them what they want. If you stop doing that, they'll stop coming back."

I don't tolerate patients like this, and any good pain management clinic doesn't either. Patients like this are usually going to several ERs, getting narcotics from several physicians at once. I may not directly be able to stop someone like this, but I don't have to be an accomplice.

At Fri Oct 12, 10:56:00 PM, Blogger cynicalpa2002 said...

This comment has been removed by the author.

At Sat Oct 13, 12:33:00 AM, Blogger Nurse K said...

Stoopid question:

If you're a solo family practice doctor, aren't you always on call?

At Sat Oct 13, 02:49:00 AM, Blogger adventures in disaster said...

Because I am a nurse and I have worked in the ER I know to NEVER go to the ER for chronic pain.
Personally I think that term is crap made up by doctors who just don't know how to fix the problem. It's easier to give it a hopeless label that leaves the patient in a never ending limbo of non treatment. I do not consider throwing drugs at someone treatment. It is just hiding the symptoms so the patient will stop coming in to complain.
ER's hate chronic painers. They think we are all lying scumbags abusing the system and scamming drugs.
So I can be in abject agony and I will wait until office hours. And I don't use narcotics for pain relief because I know that opiates are useless in nerve damage but I still don't want those rolling eyes when I come for help.
I went once when the injury first occurred, that was more than enough for me thanks.
I WISH I had an ER doc like your patient did..You are pissed off at a guy who evaluated and treated a patient with care and compassion and even better an ER doc who followed up.
Yeah, right..that's just awful.
Much better to have a dick doc in the ER who screams drug seeker at your patient and throws him out.

At Sat Oct 13, 10:28:00 AM, Blogger #1 Dinosaur said...

Adventures: No, just wait until daylight to call me about it, as other, more considerate, docs (from that same ER) have done in the past.

Nurse K: Cor-RECT! See above (8:22, in response to Panda.) If you're only "on call" 1 in 8 or something like that, "suck it up" doesn't have quite the sting.

At Sat Oct 13, 10:46:00 AM, Blogger CrankyProf said...

Are you seeing the Metatron??? 'Cause it sounds suspiciously like him...

At Sat Oct 13, 11:07:00 PM, Blogger Ms. Mom said...

OUCH! I often wonder what those ER docs are thinking that late into their shift...

It definitely wouldn't fly during at the office

Ms. MOM at

At Sun Oct 14, 12:31:00 PM, Blogger Nurse K said...

Adventures: No, just wait until daylight to call me about it, as other, more considerate, docs (from that same ER) have done in the past.

Please tell me you're kidding...

If not, please call the nurse staffing office and inform them you would like the ER to hold all your patients who arrive on nights until daylight so we can at least have another nurse...

At Sun Oct 14, 06:23:00 PM, Blogger Midwife with a Knife said...

The other issue is that I'm sure you have many many patients, and although you remember this one in the middle of the night (for unfortunate reasons), sometimes you may not remember. And I'd bet you don't have charts at home to just look stuff up. So, calling you at 4:30am is unlikely to be useful unless you remember specifically the treatment plan, etc. for the patient in question.

Much better to just make sure there's no actual emergency going on and send the dude home to follow up with you.

At Sun Oct 14, 09:24:00 PM, Blogger Dreaming again said...

Am I weird or something ... I seem to be the only migraine sufferer who actually benifits from phenergan ... but it seems to be difficult to get ... I have to GO to the ER to get it! NO! I don't want to take my migraine to the ER ... my head hurts, I'm sick to my stomach and lights hurt!!!! GIVE ME THE PHENERGAN and my regular migraine and let me sleep!

I can't get a regular script of phenergan, so I have to get it on an immediate basis, but I can't do that either ... so it's "go to the ER" but I don't want to go to the ER when my head hurts because MY HEAD HURTS!!!!!

why is it that real migraine sufferers always seem to get stuck in the wrong line?

At Sun Oct 14, 10:29:00 PM, Anonymous Anonymous said...

I think the major issue here is that the ER doc's "default assumption" of you was set to "idiot." I know that we docs get frustrated for various reasons and sometimes project that as hostility towards peers. This blog post is a reminder for us all to give one another the benefit of the doubt and assume that our peers are innocent until proven guilty. If we just had the attitude of "hey - this patient's PCP probably cares a lot about this patient and has been doing his/her best (against crazy odds) to keep him well" then calls at any time of day or night would be better received.

At Mon Oct 15, 01:40:00 PM, Anonymous Anonymous said...

Hi, all. Migraines in the ER and urgent care are a perennial problem. I think it was very inconsiderate, dino, for that ER doc to call you at that time. People who work shifts sometimes forget that some people are on call 24/7, and it's polite to only call when something's actually urgent.

I'm a doc and have migraines and would do just about anything to avoid a noisy ER for a headache, plus I know they'll at least consider whether or not I'm just a seeker--I know I do, it's our job to try not to give narcs to obvious abusers (plus they really don't work that well for migraines).

Linda, you're my dream patient. I can't believe the PA wouldn't give you an Imitrex shot--I'm ecstatic when I get someone requesting something other than Demerol. Why not ask your primary doc to give you a script for injectable Imitrex to use when you need it (there's also nasal spray but I guess that tastes nasty). The Imitrex comes in a nifty little self-injector. It might be hard for some people to get used to injecting themselves, but if you can avoid the ER...

Ditto for the person wanting Phenergan--I'd be more than happy to give out boatloads of Phenergan as long as you don't require Demerol with it.

At Mon Oct 15, 09:16:00 PM, Blogger #1 Dinosaur said...

Dreaming Again: Give me your pharmacy number and I'll call in the f-ing Phenergan for you.

Many thanks, Val. You hit the nail on the head.

Nurse K: I hope you didn't intentionally misconstrue my comment about waiting until daylight to call (not wait to see the patient.)

Bottom line here: my input was not required for this patient's disposition. Whenever it is, you can call me any hour day or night, whether I'm sleeping, eating, reading, screwing (though I may take a little longer to get back to you) or whatever, and I'll never complain. If it's not, then wait til the goddamn sun comes up.

At Tue Oct 16, 12:47:00 AM, Anonymous Anonymous said...

>>tk: I've been trying to get rid of him for awhile now. Haven't been able to drop the hammer, though, because there really isn't anywhere else he can go.

Dino, respectfully, why is that your problem? If a patient is abusive, nonpaying, etc., I discharge from my practice pursuant to the general guidelines in my state. The guidelines cover notice, providing care for a certain period of time, forwarding records, and all that.......but the requirements say nothing about finding another doc for the person. I do not see what we should make that our problem.

.....future dinosaur

At Tue Oct 16, 08:55:00 PM, Anonymous Anonymous said...

Thanks for the lovely words. As a PA-C who just got out of ER medicine after a number of years, it always brings a smile to my face when people refer to us as just another piece of crap in the system who ISN'T a doctor. Appreciate that. Guess all of the money and time spent sitting in lectures in the chair beside MD students, carrying a higher GPA than a lot of them in pre-reqs, and being told in practice by patients that I was better than most doctors they had seen was all for not.
By the way, if you came into my ER, told me you had a migraine, then requested an Imitrex shot, I'd ask you to marry me. I would be that impressed. The general rule for people we normally see, claiming they have a migraine, usually involves allergies to all triptans, NSAIDs and compazine and/or reglan.

Just a PA

At Sat Oct 20, 02:26:00 PM, Anonymous Anonymous said...


I'm sorry for insulting you. If you treating patients well and they are satisfied then kudos to you. However, I stand by my assertion that I should not pay the same amount to the hospital for a visit if I see a PA or nurse practitioner. Healthcare costs are outrageous and the excuse given for that is that we are paying for very high level of expertise and the experience of the Med School-Residency-Physician system. If I am not receiving the benefit of that for whatever reason, especially if my problem doesn’t require that level of expertise, then I shouldn’t be charged for it.

I’ve never had a good experience with a PA. This particular PA was rude, condescending and gave me less than ideal treatment. He also could have really messed me up because he didn’t bother to read the chart and it’s a good thing I had enough faculties to argue with him about his “big shot of Motrin”…I had to ask him twice what the drug he wanted to give me was because he was being cagey and calling it a “pain killer”. My whole point of commenting here was to try to offer a genuine migraine snuffer’s perspective when juxtaposed against those who use “migraines” as a narcotic seeking excuse.

At Sun Oct 21, 12:40:00 AM, Anonymous Anonymous said...

Linda-Why don't you ask your doctor for the self-injectable Imitrex, instead of the oral? ..... Just another PA

At Sat Nov 03, 06:04:00 PM, Anonymous Anonymous said...

I would have to be near death to go to the emergency room. And not because the doctor might hurt my feelings by rolling his eyes (believe me, if I was in THAT much pain, and decided to get to the hospital, I would be alert ONLY to whether or not I got some help; cutsiness from the staff would be water off this duck's back). I'm very unlikely ever to go to the ER just because...I'm old, and sucking-it-up is second nature now. Yes, someday it will be SERIOUS and I should go, but heck...gonna die sometime anyway and had just as soon go while at home and no excitement.


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