Now, if ALL places were run like this...tell me what you think!

[AngelfireRN]

Hey guys!!

I was reading a few threads on 'customer service' running amok, and wanted to share how things owrk at my current clinic. I swear, if all places would impart these rules/guidelines, the world of nursing would be so much better to work in.

First, I work in a general medicine clinic. My collaborating doc is well known for treating pain, but we are NOT a pain clinic. The patients get schooled on this at the first office visit, if not before. My OM, (the doc's daughter) is a gem, she is PHENOMENAL! She (well, all of us, really) has a zero-tolerance policy for bull, and once you're on her list, you're on it.

*We don't tolerate abuse. Period. If you come in and raise sand, you're out. Dismissed from the practice as a patient. If you have a friend or family member come in and raise sand for you, you're still out. If you bring a friend to your office visit, and that friend steals someone's wallet in the waiting room, you're still out. You brought them.

*We talk to each other. Actually had one lady tell me when I was new that the doc always gave her extra meds "in case she had a bad day". When I baked and said I'd have to verify that, she proceeded to tell me that our MA knew how to call them in, and no, he didn't write down the extra pills, just added them in when the script was called to the pharmacy. So, staff-splitting does NOT work.

*Behavior really does count. We have a 200-person strong waiting list to be a patient here. I databased it myself, from a tattered little book. Every time someone calls or comes by to ask where they are on the list, I can tell with a click of a mouse. People who come in and flip an attitude or demand to be seen immediately either get bumped to the bottom of the list, or taken off of it altogether. Posted a story relating to THAT on my other thread about things you'd love to tell patients. We even drew up a memo detailing the rules, that we hand out when someone comes by to add their name. For the ones that phone their order in, I call personally and explain the details.

* We keep records. Since we do prescribe controlled substances, if we hear or see that a patient has been arrested for DUI, selling, possession, or other offenses, we dismiss. If we get a call that someone is selling, we dismiss. If someone fails a drug screen, we dismiss. We have a closet full of dismissed charts, all carefully organized and databased (I love my computer) with names, reasons for dismissal, etc. You'd be amazed at what people will try to sneak back in. Different hair, different NAME, fit-throwing, wheedling, threats, etc. This souldn't be a surprise. All our patients are required to sign a behavior contract when they come to the clinic, that clearly states what comprises grounds for dismissal.

We have no doorknob leading from the lobby to the clinic proper. It was removed. We had people coming in without permission for 'sidewalk consults', demanding pain shots, and one lovely lady who proceeded to stand there, even though it was quite obvious that my OM was on the phone, shaking her pill bottle in her face and screaming, "WHERE are my %^&* refills?!?!?" Yep, bye-bye, sweetie!

We have a medication policy, as we call all prescriptions in. The meds are guaranteed by a certain time, period. No, you don't get an early call in without a darn good reason, and some people get REALLY creative. No problem, they get moved to the bottom of the pile. Every time they come back in (some of these people must LIVE at the pharmacy) wanting to know why they haven't gotten their meds yet, to the bottom they go. May sound mean, but they get the point after a while.

Point being, we just DO NOT reward bad behavior. There's no sense in it. Sure, we may lose a patient here and there that doesn't want to comply with the rules, but there are dozens ready to fill their spot in the chart rack. We're not outright mean, we just refuse to take abuse lying down.

So, my question...if it works for us, why on Earth can hospitals and other places make it work, too? Set policies and adhere to them, that's really all it is. Why is this phenomenon so difficult to replicate? They sure don't care to policy the staff to death, so I know it's not that. Why not go in the other direction?

[Biggirl71]

I just hope for the sake of the physician that those patients who are chemically addicted get his referral to the appropriate drug treatment facility because the first line of the Hippocratic Oath is. . ."First do no harm. . ." I full-on agree with the staff/MD having the backs of the nursing/office staff because NO ONE should be abused, verbally or otherwise. The whole notion that a "patient" is a "customer" has ruined us all as nurses! The idea that a patient has the right to refuse the medical help they sought in the first place is totally ridiculous to me!

Another issue I have is that I hope when you stop treating patient that got arrested for DUI's and the like, you are waiting for a conviction. To stop treating a patient that may be found innocent of the crime sounds a bit extreme.

[Guest372004]

Agree: I would give them one chance. Let them know their behavior may compromise their care. Next time poor behavior, they get enough meds for a month and dismissed. Believe me, if they know that, sign a contract, they will suddenly be appropriate.

[AngelfireRN, MSN, RN, APRN]

Again, we only dismiss for DUI if it is classed as a "mixed substance" DUI, meaning that meds AND ETOH were involved. If a patient becomed addicted, we see a problem, or the patient requests, we do refer to rehab. AFter that time, the patient will receive no further controls from our practice.

And, with the exception of popping positive for cocaine on a drug screen, forging scrips, forging the doc's name on an insurance form (yes, really) or verbal abuse, we typically will give them a chance.

However, being serially negative for what is prescribed for them, positive for what's NOT prescribed, constant haranguing for early visits/refills, and noncomplaince (filling only controls and not taking meds for B/P, cholesterol, etc.) will get you booted if it's not remedied.

I had to explain this to a guy I really did like as a person today. He was on Methadone, which con not be mixed with opiates. He cam in, tested + for both. I counseled him, but the mext time he came in, same thing.

"Well, my sister stole my meds, so I took some of Daddy's Percocets."

Counseled him again, you WILL DIE if you keep mixing Methadone with this. We WILL DISMISS YOU if it happens again.

Last time he was seen, he lit up the tox screen like a Christmas tree. Methadone, Percs, Oxy, AND Darvocet for good measure. Gone. Per my OM.

He again tried to blame family, but, after 6 months of this, you know, you'd think he'd learn to keep his meds put up. I'll but them getting stolen once, but after that, I get a tad skeptical.

OTOH, a dismissed patient came back in, asking could we please fill his metformin. A former employee had stolen his records, and had called in meds under his name for herself. He was arrested and convicted of tampering with a forged instrument, and was dismissed. He brought us paperwork stating that the conviction was overturned, and boom, not only did he get his metformin, we took him back as a patient. It helped that we knew who did the tampering, too.

But, notice, he didn't come in raising Cain and throwing a tantrum for his controls, just his controls, and only his controls. All he wanted was to keep his DM in order. So many gray areas, but with what we prescribe on a daily basis, we have to be careful.

[AngelfireRN, MSN, RN, APRN]

Oh, and yes, the contract was approved as legally binding by our attorney. That was a very good point.

[Bruin's Mom]

I just left a facility of drug addicts and alcoholics where they would be discharged on monday and back on wednesday. The facility would take anyone back even if they left AMA and were adm. discharged the first time. It had to do with money. As long as the census was up and the money was rolling in the administration did not care about the staff and how they were being treated. Staff including myself were called everything in the book and we had to stand there and take it.

Nurses should not have to tolerated any kind of abuse especially from low life scum that choose to shoot, snort, or eat any kind of illegal substance or drink themselves to an oblivion everyday. Nurses are too good for that.

[juzme]

i love the rules of this office! my wife works at a no-nonsense office like this. what many posters may not realize is that if the providers are this strict about patient behavior, they are also expecting much of themselves and their staff. some posters obviously have never had any dealing with a pain clinic either. i would imagine that most honest patients welcome the strict rules because they don't want to be associated with a pill mill. when you deal with people face to face over time, it's not that hard to tell the good ones from the bad (the good ones don't get attitude & apologize if they do). get rid of the demanding drug seekers. this problem is by far the worst of any drug epidemic. i have always been taught to listen to the customer, but never to allow them to abuse me or my staff. my nursing school emphasized the need to defend one another on the floor and our staff when we become charge or management. when people don't take crap, it doesn't take long for the crap givers to take notice. then they take it to another clinic or do it on another shift.

way to go op!

great points!if you are truly having pain issues, then yes you should want to adhere by the rules and not want to be involved in a pill mil. everyone in this country by now has to be aware of the prescription drug abuse problem.! so yes, the doc and staff have to protect themselves and their patients who really need the pain meds. if a place does not keep careful records and runs their clinic like the ops then they have the chance for the feds to come in and close it down...you hear about it all the time on the news and what good does that do for the legitimate pt who needs pain meds?!

[cherrybreeze, ADN, RN]

I live in constant pain, most days I have a period of time where it rates as what I'll wager most would consider severe.

I've experienced pain crisis that leave me unable to do much more than lay in bed and cry. Or pace to the point of exhaustion.

Nothing and I do mean NOTHING gives me or any other chronic pain patient the right to abuse my doctor's office staff or demand special treatment.

Prescriptions don't suddenly run out creating a situation where they have to be filled immediately, be it pain meds, BP or allergy meds. You know darn well how many is left in the bottle every time you open it. Having to wait your turn (and possibly go without) is the price you pay if you're too busy or stressed or keep forgetting to call for a refill. If calling for refills in a timely manner isn't a priority for the patient it's unreasonable to expect the doctor's office to staff to make it a priority for them. If you can't make time to call in advance for appts, refills, etc then it just isn't that important to you. If it was, you'd make time.

There is no sin in calling for a refill in the last hour of the day. The 'sin' is in expecting it to be taken care of that same day and being a jerk when you don't.

To the OP...I wish your practice was in my community.

Due to a job relocation I've had to go from a well run, hospital based, rehab & physical medicine clinic that also does pain management (my Physiatrist was my primary doc) to an area where no such practice exists.

kids, I completely agree with you! That is also what I was trying to say earlier.

When I signed on with my pain clinic, I had to sign the agreement, just like every other patient...I had no problem doing that. I actually laughed at some of the things that were part of it....."calls to the clinic should be limited to one every 24 hours." I couldn't believe this was something that needed to be SAID, I RARELY call in between my appointments! Apparently, though, it IS a big problem.

For me, I know what the rules are and I know why they are in place. Count my pills, do a urine screen, all is well. There is a reason for it, and I follow my treatment plan, so I have no reason to NOT want to do it (or to give them a hard time about it). Been a patient there now for 4 years, with no problems.

[nola1202]

I'd be scared to breathe. I'd be looking for a different doctor so I didn't have to deal with this snooty-sounding bunch. I only hope all of the staff, OP included, get to experience severe and chronic unrelieved or insufficiently relieved pain, and see how it feels to be put to the bottom of the stack, dismissed, and left to beg and plead and live in terror.

Seriously, this sounds so vicious, so selfish, so cruel that I'm surprised no one has physically assaulted them yet. It probably works well enough in real life and perhaps comes across to patients only as firm, not cruel, but it really sounds like they think they are so much better than all those millions of people begging to be taken into their high-falutin' practice. It's not enough that people are in agonizing pain and are looked down upon as filthy scum welfarites, but to have to be afraid to even move on top of it - wow, just too much. I think I'd prefer to take my own life than deal with this practice if I were in chronic pain.

No LOL from here. And just what is the sin in calling in the last hour of the day for a refill? Is it ok to call in the 2nd to last hour?

Ok, here we go again, this seems like a big set up to create a big long drawn out post where everyone calls everyone else who doesn't think like them a "doo-doo head. This is just an obsevation, not an attack. It seems there has been a leap to judgement.

An office that has a behavioral contract, in place to address specific common behaviors. (manipulation, threats, temper tantrums, inability to delay gratification, entitlement) is not unusual. A matter of fact non-judgemental approach works well. That way everyone gets the attention they need and deserve.

I remember one patient who had horrible diabetic ulcers on his legs. He was getting worse over time and more depressed, using more pain meds etc. His clinic MD told him unless he agreed to stop smoking, drinking, moniter his blood sugar, take his hypertension meds, he would drop him as a patient because he didn't want to see him slowly kill himself. This guy turned it around in a matter of days and he talked often of that MD. Different approaches work for different people.

I

[AngelfireRN, MSN, RN, APRN]

Just an update...the waiting list has hit 300. The behavior contract is being adhered to more than ever, mainly because Doc is not feeling well and does not need any controversy.

That being said...I did have to dismiss one lady I truly liked. Had no choice, positive for an illicit. An ILLEGAL illicit, at that. I moped about that for a week, but she knew the rules, she'd been coming there for years.

Another, who had a laundry list of complaints every time he came in (but who was able to go clubbing on the weekends with no problem) also popped positive. He tried to blame it on secondhand smoke. Sorry, Charlie. Kudos for the try, though.

OM did approve of one method, even if it was rather grade-school, to enforce our policy about standing in the door, waiting for us to unlock it in the mornings and after lunch. Sign on the door clearly states "DO NOT STAND IN THIS DOOR. WAIT IN YOUR CAR!", but on the day in question, there were about 10 people hovering. The ringleader even took it on her self to rattle the door, bang on it, and cup her hands around her head to see if she could see anyone inside to yell at. This was a full half-hour before we were to open, mind.

So, we sat and watched all this, having bolted the back door. Yes, the bolder ones have been known to saunter in the back to ask what the holdup is, never mind if we're eating. Never an emergency, just tired of waiting. Quite a few of those are gone now.

At precisely time to open, I walked out with my keys and held them up so the crowd could see. Response looked something like what you see on the news on Black Friday. I made a shooing motion so they'd back off the door, pointed to the sign, and was rewarded with a BUNCH of horrified looks. I bet I could have caused ten heart attacks if I had enforced the dismissal rule for hanging in the doorway. But I didn't. And now they know. And word will spread. Just takes enforcement.

Oh, and we ARE looking for a part-timer...if anyone's still interested.