I put Mr. Jones in a room and read him the riot act. There would be no more narcotics of any sort prescribed to him. Mr. Jones became irate and he threatened bodily harm to me and my staff. He also threatened legal action and vowed to fight back against doctors who do not treat patients who have real pain. His swan song was so inspirational that I have a tear in my eye as I write this.
Several weeks later I received a phone call from the urologist to whom I had referred him. It seems good old Mr. Jones had used this same ultrasound, as well as some blood in the urine for good measure, to gain access to more Percocet from this seasoned urologist. I called Dr. Y to express my concern and to compare notes.
After realizing that he had been conned, he agreed that Mr. Jones would not receive any further narcotics from him.
Several months had gone by and I forgot about my sweet friend. It seems that Mr. Jones had disappeared off of the radar screen until one day my secretary buzzed me.
“Doctor, an Agent White of the
Drug Enforcement Agency is on the phone
and would like to talk to you.”
After calming down enough to release my anal sphincter muscle, I got on the phone. The topic indeed was Mr. Jones and Agent White wanted to set up a meeting for the next day.
The agent informed me that Mr. Jones was a professional. He had hit twenty-six doctors in three states with his story and ultrasound.
He was obtaining Percocet at an average rate of 700 tablets per month!
Mr. Jones was obviously not consuming this amount, so we assume he was selling these on the black market.
I felt like a fool.
The agent informed me that my prescribing habits were not unusual and that most doctors are compassionate and willing to give the patient the benefit of the doubt (under his breath I am sure he really was calling me a dumbass). Agent White informed me that Mr. Jones was uncovered due to the fact he used his own Medicaid numbers to obtain the prescriptions. Another example of our hard-earned tax dollars at work. Mr. Jones was going to jail for Medicaid fraud. I was going back to work.
Trust is an important part of the doctor-patient relationship. This guy must have pricked his finger in the bathroom to put blood in his urine. He traveled with his ultrasound like some would travel with their nitroglycerin because “you never know when you are going to need it.”
I am sorry I trusted Mr. Jones, but you can't be distrustful of all patients.
Do you think he really earned a purple heart or bronze star for heroism?
Do you think monkeys are going to fly out of my ass?
10 Reminiscent of The Godfather, he gives the doctor a trinket worth all of three cents and subsequently believes the doctor owes him a favor to be repaid some day.
9 She dresses up inappropriately, because in reality she is almost a model, and talks to the physician in a seductive manner (actually we like that one).
8 He places tons of useless paraphernalia and “pseudo“ studies on the physician's desk and hopes the doctor doesn't catch him.
7 She tries to sit the physician down and teach him as if she were a professor putting the doctor through medical school again.
6 He begs the doctor to sit and listen to some ridiculous video or audio conference so she may receive a gift three months later (which is actually a book written by their company).
5 She uses hard-sell tactics that are so forceful it can be likened to kidnapping the doctor, throwing him into a van and deprogramming him as in some cult member rescue.
4 He dances and prances around the hallway and nearby the patients’ rooms hoping the physician will get excited when she sees him when in actuality the doctor really wants to just jab his eye out with his company insignia pen.
3 She leaves propaganda in the waiting room that is so biased it may as well say, “I lost 30 pounds in a week. Call me and ask me how.”
2 He out and out lies about his competitor's product and then denies he said it when questioned by the physician on the next visit. Three months later he changes companies and starts bad-mouthing his first company and product.
1 She moves her competitor's products around on the drug shelf like it is a side-street shell game, thinking the physician won't be able to find the other drug and therefore will pick hers.
A man went into the proctologist's office for his first exam. The doctor told him to have a seat in the examination room and that she would be with him in just a few minutes. When the man sat down and began observing the tools, he noticed there were items on a stand next to the doctor's desk:
a tube of K-Y jelly,
a rubber glove, and a beer.
When the doctor finally came in, the man said, “Look Doc, I'm a little confused. This is my first exam and I know what the K-Y is for, and I know what the glove is for, but can you tell me what the BEER is for?”
At that, the doctor became noticeably outraged and stormed over to the door. The doc flung the door open and yelled to her nurse …
“Dammit, Helen! I said A BUTT LIGHT.”
Yellow Bill
This Darn Narc Seeker is an interesting gentleman from the South. Yellow Bill was a 23-year-old male with lower back pain. Before coming to see me, he was treated for several years by an alleged pain specialist whose therapeutic plan consisted of weekly injections of undisclosed substances and a liberal hand with the prescription pad. At the time of referral he was on Norco, clonazepam and diazepam, among other things.
His physical examination was remarkable for bright yellow pointy hair (hence his nickname) and several decorative foreign body insertions. I tried not to be judgmental; after all, during the 70s I sported a rather Messianic appearance, the main purpose of which, looking back, was to:
Get babes and
Piss off old people.
I decided Bill was just a regular garden-variety Gen-X'er, or is it Gen-Y? At any rate, it was one of those chromosomes. I am pushing 50, but I'm not some old fogy. Well, I am, and I think Bill O'reilly is God incarnate, but I'm not going to let these young pissants know that their stupid hair and body mutilations get to me. I gave Yellow Bill the benefit of the doubt, having somehow forgotten the prodigious consumption of mind-altering substances that went with my rebellious appearance 30 years ago mostly in the pursuit of #1 (vide supra).
Yellow Bill successfully switched from Norco to a Duragesic-25 patch which I took as a favorable sign, since Norco is much more fun. He also underwent several invasive procedures for his pain including successful prognostic lumbar medial branch blocks followed by good pain reduction with lumbar facet injections.
He then developed radicular pain, which clinically and on EMG looked like L5 radiculopathy (spinal injury). We did selective L5 blocks with good relief. Bill seemed like a legitimate pain patient. With his pain under good control he was referred to physical therapy for reconditioning. I continued his Duragesic-25 patch and Zanaflex pending his physical therapy. I felt good. This is how pain management should be. I had renewed faith in my fellow (alleged) man.
After 23 years in medicine you'd think I'd learn. Three months after that visit, the pharmacy called to check on the dosage of three scripts my “office” had called in: seventy-five Vicodin, seventy-five diazepam with one refill, and forty-five phenobarbital with one refill. The alert pharmacist called because the phenobarbital was for 50 mg and they don't make a 50 mg pill. He wanted to know if we could substitute two 30 mg pills or three 15 mg pills. Talk about picking up on subtle discrepancies. This guy was a wiz with math.
Who called that in? Well, it was very busy at the pharmacy so they didn't write down a name. We informed the pharmacist that we do not call in scripts for controlled substances, and we certainly didn't call in that mess. It was suggested that perhaps a consultation from the local constabulary was in order.
When Yellow Bill showed up to pick up his prescription the cops were there waiting with shiny new bracelets to go with his earrings. The police can be your best friends sometimes. I think Yellow Bill wil
l be very popular in prison and have a lot of dates. For me I can go back to being judgmental.
THE
EXPERIENCED
DOCTOR
“Dr. Farrago, your next patient is in the room.”
“Great, what's the story?”
“Well, she is new to the practice. She just needs a referral to a neurologist. She said she goes to a methadone clinic because she used to be addicted to Vicoden.” “Oh.”
Even though I was in a great mood, I was still a little leery about that last statement. But the fact that she fessed up to her narcotic addiction to my nurse did put me at ease. Honesty from my patients is very important for the relationship. I figured I would just go into the room with an open mind and lay down some simple ground rules if she wanted any pain medication from me.
As I walked into the room I saw the patient sitting comfortably in the chair. She was relaxed and in her mid-forties. She had appropriate attire on and was smiling. I looked at her, said hello and sat down. She looked somewhat familiar but, when I glanced at her name on the chart, I definitely didn't recognize it.
“What can I do for you today?” I asked.
“I just need to get a primary care doctor and a referral to a neurologist.”
Simple enough. I shook my head and was about to speak. As I opened my mouth, it hit me. That voice! That face! I took a second and responded to her in a very calm but direct manner.
“Ma'am, I can't be your doctor. You have to go somewhere else for your care.”
“But why!” she protested.
“Because the last time you were here you tried to choke me.”
By the time you read this book I will have been practicing primary care medicine for more than a decade, but I am still in that transition period between being a new doctor and a fully experienced doctor. I think my reaction in the story above, which is entirely true, shows that I'm on my way. As a medical student, resident or new doctor, I might have called the police, yelled at the patient, screamed at my staff for letting her sneak back in, or left the office in a pissed-off mood. As I get older, I realize that we can choose our reactions. In this scenario, I chose to laugh about it and use it as a teaching tool. From what I've observed, this is what experienced doctors do.
When I first saw this patient, about two years earlier, she was drunk or hopped up on drugs when I declined to give her any medication. She became obnoxious and verbally abusive before lunging at me in an attempt to choke me as I escorted her from my office. The lisp in her speech tipped me off as I found myself again escorting her out into the hallway.
“Why did I try to choke you?” she asked.
“I actually don't know.”
“Well, you must have done something to deserve it.”
Physicians are humans and they go through all the emotions that anyone else does. What separates us from other professions is that we see into the most private and darkest parts of our patients’ souls. Unfortunately, what we find there, along with years of torture at the hands of the medical axis of evil (HMOs, pharmaceutical companies and medical malpractice insurers), may weigh heavily on our shoulders and drive some of us to burnout. After years and years in practice, many physicians start to go off the deep end.
There are those doctors who no longer smile. There are those doctors who no longer laugh. There are those that are socially withdrawn and don't talk much anymore to their colleagues. Many consider retirement about as often as they have dinner. Many are bitter toward the system and even their patients. They neglect to keep up with the advances of medicine. They have difficulty handling the new technological advances because they rebel against progress. Some become depressed. Marriages get shaky. Some remarry. Others become lonely. Many physicians put in impossible hours because being a doctor is all they know – they define themselves by their job and their self-worth is measured by how many hours they put in on the job. As their lives and their families fall apart, this sometimes leads them to question their choice of profession. I have seen doctors whose own health has suffered because they care for everyone but themselves. This type of experienced doctor is the pessimist. Their glass is always half-empty; in fact, they're usually pretty sure that someone stole their glass.
Luckily, there is another type of experienced doctor. They are the optimists. These doctors continue on like a well-oiled machine. They know their patients and their idiosyncrasies and more importantly, they know their own. They are aware of what lines they can cross when they joke with patients because they have built solid relationships with them over the years. The minor stressors of the job roll off their backs. They are both efficient and effective on the job. They still care about medicine, but they also have a healthy outlook on life and have other interests outside the profession. They are financially secure and, unlike the burned-out physician, they are not working to support their own monetary indiscretions. They actually don't need to work anymore but continue because they enjoy it. They know that the job isn't perfect, but see it for what it is. These wise old owls have found peace.
To these physicians, the glass is neither half-full nor half-empty. Their success and survival is based on the ability to experience the good and the bad equally without letting the worst parts get to them. Their glass is not lost but in fact created in a manner of their liking. They have molded it and it lasts forever.
This last section has lots of stories that will give you an idea of what it is like to be a physician for many years. Though many different specialties are represented, I can assure you that all the stories are from optimists. They are the doctors who will make you laugh and they are the ones I aspire to be like. Humor is their best weapon to survive, and this is the common thread tying these stories together. Perspective equals longevity when defining a long career in medicine. After decades in this arduous profession, these doctors truly tell the tales that show how they not only endured in their career choice but actually flourished in it. Some may do this with a joke, while the rest of us just try not to get choked.
The Pareto Principle is in full effect in the practice of primary care medicine.
You know the rule where you are more productive by concentrating on the most prioritized issues.
20% of your work is more important than the
80% of the other stuff.
I think we can apply that in another way on our job 20% of our patients take up more than 80% of our time. The problem is that those 20% are the neediest.
They are not necessarily bad people, but they do need a lot of attention. What makes this worse, however, is the fact that these patients are the most annoying and give you the least satisfaction on the job. These are the same patients that complain the most, have the most admissions, and are the least happy with your care.
In fact, you have to almost neglect the other 80% in order to handle these 20%
This happens to all of us without exception.
Let's add more to the mix. These are the patients that give you the most gastritis on the job. They are your narcotic seekers, chronic complain-ers, somatosizers, and are the least appreciative of your help. They are the first to fire you. They are the first to complain when you don't give them all the attention or are late to their appointments.
It does not matter how successful you were in the past either.
“Oh, Doctor, you were so great today spending all that time with me.”
The one time you had to concentrate on another emergency and had to speed up their appointment or even worse, didn't return their call about the boil situated on the crest of their gluteal cleft, you get …
“Doctor X never gives me enough time. I deserve more. Send me my records!”
Sure, they may let one “episode” where you neglected them slide, but it will haunt you later. These patients keep a scorecard and have no statute of limitations. You can never win because you were set up to lose from the get-go. These patients have the worst disease that is caused by their own destructive behaviors or are the ones that h
ave the fewest “real” symptoms. They are also the ones who will doctor shop and leave you at any time for someone who really “cares” (and subsequently leave that doctor in one year's time).
80% of the time they have nothing you can really treat, but 20% of the time they may have something that needs real medical help.
For that reason, you are medically liable if you ignore that headache that is actually a malignant tumor. It is because of this you never give up on them because of doctor guilt and therefore, you keep trying.
The 80% of patients you have that are basically healthy, but need help occasionally, get the least of your attention because they are relatively easy. They are hardworking and from solid families and are a breath of fresh air when you walk into the exam room. These are the ones that almost make you feel weird because they are so normal. You walk out of the room energized and wish you could have stayed longer, but unfortunately you had to go see Mr. Gibbons with his backache of thirty years, or Mrs. Myers with chronic dizziness.
How does one rectify this situation?
One way not to fix it is to hire a midlevel provider. Not that there is anything wrong with them. They definitely fill a niche in a busy practice. Unfortunately, many physicians use them as a way to clear out the easier cases or “low-lying fruit.” Sure you may think that they handle your extra volume, but they are actually getting to see the 80% of your practice that makes the job enjoyable. This again leaves the needy 20% with you!
A slow and insidious death for most practitioners occurs at that point. The hourglass turns over until one day all the sand is out and you're selling crafts at a mall boutique because you needed a change.
The Placebo Chronicles: Strange but True Tales From the Doctors' Lounge Page 16