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.

Monday, March 01, 2010

Last Schmuck Standing

Much has been written about the doctor-patient relationship. How to start one (call for an appointment); how to end one (ask to have your records transferred if you're a patient; send a registered letter if you're a doctor). If you're a specialist enlisted to treat a specific problem -- an orthopedist consulted for a fracture, for example -- you can discharge the patient from your care once the problem is resolved. I can never do that. The last line of every progress note reads, "Re-check" sometime; two weeks; six months; or the all-purpose "as needed."

I try never to discharge (also termed "fire") patients. Before I'll send someone that certified letter, return-receipt-requested, telling them that I'm only available to them for thirty days more (and then only for emergencies) they have to really piss me off. Usually lying to me about their narcotics (repeatedly; I'm awfully forgiving of lost prescriptions, pills down the sink and so on) is enough to do it. See, my view of these patients isn't that they're just out for the drugs. I know a lot of them have real pain, and I feel responsible for treating it. In fact, most of the time I don't actually discharge the patient from the practice altogether; I just refuse to write narcotics for them. Granted they usually then switch physicians voluntarily; still, I remain available to them if they decide what they really want is medical care.

But what happens when the patient has already been discharged by every other practice in town? Not just in town, but in the entire region. What if they've even been discharged from Pain Management, for heaven's sake, for a positive urine test for illicit drugs? She comes back to me, begging and pleading for the pain meds without which she cannot function, care for her home or her kids. Although I've already been around the block with this woman in the past, I agree to resume her care with the explicit understanding that my goal is to find modalities other than chronic narcotics to manage her back and leg pain.

For awhile, everything is fine. She keeps appointments. She claims to be following the tapering dosage schedule for her medications. Then she starts missing appointments. (They only have one car and she can't get a ride.) She calls for early refills. (The pain was so bad this weekend she just had to take a couple extra.) Finally, she shows up for an appointment with obviously slurred speech. Has she been drinking? Just one beer, although her blood alcohol level is more consistent with four, given her body weight. She has driven to my office while legally intoxicated to receive a prescription for over one hundred narcotic tablets that will only last her two weeks.

Find another doctor, I say.

But doctor, she sobs, where can I go? No one else will take me. You're the only one left.

Finally I manage to come to the obvious conclusion: That this is not my problem. Your situation is entirely of your own making. It is not my fault. You are responsible for the results of your own actions.

Yet it takes weeks longer than it should have. It's tough to be the last schmuck in town.


At Mon Mar 01, 10:27:00 PM, Blogger Allen said...

No, the last schmucks in town are in your Emergency Department.

True, they probably know your former patient very very well, but now she's theirs.

ED's can't fire patients. We wish we could, but we can't.


At Tue Mar 02, 10:25:00 AM, Blogger Jennifer George said...

any way you could get her into rehab?

At Tue Mar 02, 12:00:00 PM, Anonymous hashmd said...

You can't force someone into Rehab. It can only be done voluntarily on the patient's part. As a doctor, you can STRONGLY recommend it.

But it only terminates the patient-narcotic relationship of which obviously the patient does not wish to part with. Thus, we are left with terminating the doctor-patient relationship to perhaps finally bring that patient to the very bottom, for which she hopefully will seek Rehab.

At Tue Mar 02, 12:18:00 PM, Anonymous ndenunz said...

You are extremely forgiving.

At Tue Mar 02, 01:04:00 PM, Blogger The Happy Hospitalist said...

I told a patient once I wouldn't precribe him any narcotics for his chronic unexplained pain. I told him he needed treatment for an addiction and he told me to get lost. He threatened to kick my ass and report me, blah blah blah. I told him good luck and discharged him. Six months later I get a letter in the mail thanking me for making him face his addiction.

That's how you treat an addict. By telling them no.

At Tue Mar 02, 06:58:00 PM, Blogger Leigh Ann Otte said...

Good for you for not giving them to her. I think many doctors would.

At Tue Mar 02, 08:33:00 PM, Blogger Sarah said...

As an ER (EM if you're White Coat) doctor, there is very little I hate more about my job than looking at someone who is miserable from addiction+psychiatric issue+? pain and know that her entire life sucks due to addiction/psych/pain and know that a) my conscience won't allow me to give her narcotics and b) I can't do anything actively to help her have a healthy, productive life she is satisfied by.

At Wed Mar 03, 03:49:00 AM, Anonymous Anonymous said...

Wow -- you have my undying respect! What a great attitude; what a tough job.

Continue to march forth, supplying your patients (and blog readers) with your best -- for many years to come.


Kensington MD

At Wed Mar 03, 11:48:00 AM, Anonymous Anonymous said...

You want her to go to rehab, but she said no, no, no?

At Sun Mar 07, 07:48:00 AM, Blogger RoseAG said...

Getting to rehab is a process.

I think the words aren't wasted even if the person spits in your face after you say it.

A lot of times other people in their life have been muttering the 'rehab' or 'AA/NA' words at them also.

Someday they'll hear it.

At Mon Mar 15, 11:47:00 PM, Blogger TrishaGal said...

I can emphathize as a fellow member of the "last schmuck in town" club.

At Tue Mar 16, 09:12:00 PM, Anonymous Anonymous said...

As the daughter of a man who suffered lifelong, severe, chronic back pain -- complete with a half-dozen back surgeries to fix the increasingly unfixable -- I have to tell you "THANK YOU!!" for giving your pain patients the benefit of the doubt for as long as you can. That doesn't make you schmuck. It makes you a compassionate human being, of whom there are far too few.

My dad owned his own business, actively participated in his children's lives, and did his damnedest not to let anyone outside the family know what misery he was in, every hour of every day. He gritted his teeth and endured and he taught his children the value of doing what you need to do and taking care of those you love even when it hurts.

He needed pain drugs simply to live his life. And because he had them, he lived it.

Bless you.


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