Family Medicine: Another Thursday in the Office

Four messages from or about patients on my "hot pile" greet me right away.
1.  Someone over 80 died in a hospice situation in a nursing home where she was placed after terminal metastatic cancer piled on to her deteriorating general health.  I reflected on she and her husband, also terminal from various chronic problems plus acute events. We've dealt with rheumatoid arthritis, hypothyroidism, stroke, cancer, depression, hypertension, foot problems, back pain, skin cancer, hospitalizations, arrhythmia, alcohol, nicotine, dog's death, housing changes, discussions of heritage, dying, family issues and aging.  A long, rich and meaningful relationship.  Amen.

2.  Fat chart with note on front saying the mobility device (e.g., scooter or powered chair) sales company wants the form changed that we submitted after our nurse practitioner spent 45 minutes with patient carefully answering each question on the multi-page questionnaire.  Looks dishonest to me.  My comment: "No, we won't change the answers on the form, even if it means that the patient doesn't get the chair."  I've seen this before, where a vendor says that the form has to be filled out a certain way, even though it's lying, or the payor won't approve payment for the product.  That's not how professionals function.  Lying isn't our strength.

3.  The"back pain is unbearable" in a patient, "someone has to do something.  It's worse than ever."  She doesn't want to come in because she was just here.  I look at the note and remember that the recent visit wasn't about the back.  It was hypertension and urinary problems.  I ask the MA to get the medical record for this patient.  Sure enough, the reason for the appointment, the chart note and prescriptions written had nothing to do with the back.  These type patient comments are confusing and troubling.  We're not connecting somehow with this patient.  I feel disappointed that we're not on the same page.  And the time/money isn't available to facilitate my direct calling of patients instead of seeing those who make appointments.  And a back in severe pain needs a history and physical exam if a physician is expected to relate to its owner as a physician.  It's the minimal expectation of our profession, inside and outside of it, we see, listen, think, touch, speak and act.  Less is less quality and maybe not real medical practice.  I write a note at the bottom of the patient call note. Call pt. "I'd have to see her to help with the severe back pain, we didn't relate about it at the recent visit."

4.  A subspecialist discerned that the weird pain in one of our patients was a rare side effect of one of his diabetic medications.  Patient would like to stop that medication and get a replacement.  I know offending drug is a $4 drug and replacement is about $130, tier 3 on most prescriptions benefit programs.  It may even be disapproved by his plan until he uses one or two other drugs.  OK, I write a note to stop the first drug and call in the new one #30, one daily with one refill.  And to schedule a follow-up visit with lab test in four weeks regarding the pain, chronic disease and the new drug for the chronic disease.  Also, I ask the MA to call patient and let him know the new drug is costly, just as a heads up.

5. I look at my schedule for the day again, noting that two acute illness slots are still available at the end of the day.  While looking, one of the MA's informs me of a cancellation at 2 PM by someone recently found to have another physician, also prescribing anxiety and pain medication.  An MA from that office called to let us know about the duplication, which is an illegal act by the patient.  I already called the patient personally to inform him of this situation.  He knew he was about to be caught.  I just don't know if he's addicted and abusing the drugs, or selling drugs.  Anyway, it's a felony in Ohio to lie to a physician to procure controlled substances.  If the patient comes in and I find that he's lying to me to procure these medications, I call the county Sheriff and a deputy shows up with a simple form the next day.  The patient is arrested one or two days later.  I feel professionally obligated to report the violation instead of ignoring it.  The patient may need an addiction program and get their life back.  Or, they may get jail time and save lives by terminating their sales of controlled substances.  We'll see, unless the patient never comes in.

6.  Now it's time to see my first patient of the day.  A typical day in family medicine.

PS. The patients here are assemblages of multiple persons over the years and not just one specific person.