Background: patient makes appt at family practice for today to see different doc than her regular primary for second opinion on dx. C/O generalized discomfort, muscle and joint pain, fatigue, loss of interest in daily activities. Tried lexapro, zoloft, pristiq, no response from any. New dx Fibromyalgia, placed on Savella and a few percocet for pain until Savella started to work. Want to throw in currently on synthroid and not noticing much change there either. Anyway, not responding to Savella much either. Stopped taking it. So, appt is for another doc to say yes it is Fibro, then she will seek rheumatologist. In the meantime requests some pain management such as oxycodone because she did have some relief but doesn't want acetaminophen in it, only requests low dosage until seeing rheumatologist. Also while in office, wants to discuss restarting ADHD meds. Doctor starts yelling at her saying he is suspicious of her, "drug seeker" knows too much about these meds to come in asking for them by name. She says she has been on them and, oh yeah doc, by the way, she's a nurse, she is supposed to know medications, should she pretend she doesn't?? He then asks if she was diagnosed with ADHD as a child because it isn't in her chart (started going to this practice 2008) and that childhood is the only time to be diagnosed with that. She tells him her previous retired, possibly dead doctor gave diagnosis as late teen BUT her mother and her sister were both diagnosed as adults. As she is saying all of this, the doctor gets up, says he needs a break, and leaves the exam room!! When he comes back she tries to say she was only telling him what she responded to and what she didn't. Also asked him what she should do regarding trouble with attention, keeping track of everyday details, tasks etc. She is crying hard at this point too. He asks her if she wants to speak to the office manager and leaves again, yelling in the back hall that there was a problem and manager needed to come in here. Who knows how many patients and staff heard this. Manager comes in, patient explains everything she said and what she meant, look in her history, NEVER had a "seeking" incident or request etc. Manager says never saw doc like this, doesn't know why he is acting this way. Patient asks for alternative meds etc, manager brings doc back in, patient says she will try Lyrica, he asks about gabapentin, patient never took this, he leaves again to find samples, comes back says nope none, patient says she will take script for either to at least give it a chance, and her xanax needs a refill sent too. Doc gets up AGAIN, opens door, loudly says to the patient she will have to find another doctor. Now, patient has no meds, no scripts called to pharm, needs to find another doctor with no notice and was never even examined, no heart, no lungs, no painscale NOTHING! Manager did give patient contact number to report physician.
Wouldn't this be considered patient abandonment?? He refused to examine her, treat her, or even call in scripts she has been on for awhile. She will be without a physician for who knows how long, and she only wanted his opinion to see if maybe something was missed because she wasn't responding to the normal treatment for that dx.He also stated after calling her a drug seeker that she probably will refuse payment for his services today too!! That to me is very offensive to assume someone has no money to pay and implying she is a junkie.
It sounds to me like she was asking for a lot from him, instead of just a "second opinion" on whether it is fibro or not. We do not know what was written in her file by her regular doctor. It could be that he thought she was a "seeker," and had noted that in her chart. The office manager is only going to try to "smooth things over," she isn't going to go against the doctor, and possibly her employer. I know several doctors who have either lost their license, or had them restricted due to giving out too many narcotics, and other drugs, and I know quite a few doctors who refuse to give narcotics at all. They refer them to a pain specialist. I have also had doctors tell me that they have people call them every single day, begging for lortabs, etc. I wonder why she didn't just go to the rheumatologist for a second opinion. It also sounds to me like she may need a psych consult, too, for the depression, esp. since she was crying hard in this doctor's office. I am with the doctor on this one. And yes, the doctor can refuse to see her.
FYI anytime a patient requests a controlled substance without Tylenol in it raises a red flag for most health care providers. Why? because Tylenol doesn't dissolve in water so combo controlled substances containing it can't be used for IV use. I am NOT saying your "friend" is using her pain meds for IV use but it does seem suspicious that she specified she wanted an analgesic drug "without Tylenol" in it. Add in using Xanax and a stimulant and a break down with tears in the doctors office and the whole thing sounds like a badly written soap opera episode.
Some of this is written really close to the paper. When I boil it down I get this.
1. Came to the SAME office, different MD, for second opinion, Dx, fibromyalgia.
2. Needs oxycodone because she "doesn't want acetaminophen".
3. Needs stimulant meds. Diagnosed as child, by a dead MD, but not on her chart and she's been coming here for sometime.
4. Oh, and by the way, needs xanax refill, too.
5. She is not without a physician. She can see her regular MD for medication management. Why didn't she get her regular MD to write these scripts when she got her first opinion?
I'm with the doctor on this one. Sounds like a drug seeker to me.
Seriously? Xanax refill threw me over board too while reading it! And she is a NURSE?? Yes people re-read the OP post, the patient in question is a NURSE...... wants something without tylenol.... NURSE + IV + Narc+ stimulant+benzo
As this was a second opinion, this MD neither left her without an MD, nor accepted a long term pt/MD "relationship". Therefore, was not abandonment, in any major sense.
In virtually every MD office that have been to, a physical exam occurs about midway through, after discussing symptoms/signs. After exam is usually when refills are discussed and new med therapy.So your friend goes to an MD who doesn't know her from Adam, after being noncompliant w/meds from MD 1. She then, before even getting to exam stage starts asking for refills on sedatives, stimulants, and a script for narcotics. Which she could easily have gotten (if her story is legit, from her PCP).
I suspect the first MD and second have spoken. And that there is ample documentation in the chart.
Your friend, in most cases, also could get the more definitive second opinion from the specialist, the rhuematologist. After all that is the diagnosis that counts. Is there a
reason that she did not do so? Said MD could have easily referred her to pain control, which are better able to manage her seds/narcotics/stimulants.
Is patient in school where all of a sudden she needs to be restarted on her ADHD meds and how old is this person that she managed to go this long w/out stimulants that she needs to be asking for 3 controlled substances at first appointment. Glad doctor refused to prescribe stimulants to a patient w/out proof of diagnosis and need of medication, handled it poorly though. What was the reasoning behind not wanting the tylenol?
I can't tell you how many people I have admitted that give me a long list of narcotics for their med reconciliation and when I call to confirm w/ their pharmacy they inflated their prescriptions.
The whole post you wrote just sounds like someone drug seeking and physicians are burnt out by the psychological games, lies these seekers tell. Whether or not this person is a seeker I don't know, but the people who really need medications are not treated fairly because of these drug addicts are abusing the system and raising everyone's guard.
The rheumatologist is the person who is supposed to be evaluating and treating her at this point, no? Primary gave her the referral, and instead of going to the rheumatologist, she went to see another primary? Going to someone in the same office is not a second opinion.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I am going to react first to nursing's quick to judgement and toss the patient down the drain, as a teaching moment from a patient's perspective. So, we, as nurses can improve our everyday practice and remember how vulnerable our patients are when sick and frightened and what an HUGE influence we play in their care.
Fibro patients are often misdiagnosed and treated poorly......especially if they are a nurse who "knows" the system. I don't have fibro but I do have a rare inflammatory muscle disorder, called dermatomyositis.....
Dermatomyositis is an idiopathic inflammatory myopathy with characteristic skin manifestations. Although the disorder is rare, with a prevalence of one to 10 cases per million in adults and is associated malignancies. Poor prognostic indicators include poorly responsive disease, delay in diagnosis and the presence of malignancy.
....... that went undiagnosed for YEARS while I was diagnosed as depressed, over worked, and middle aged. I was once called an obese, sleep apnea, narcoleptic, with cataplexy, carpal tunnel syndrome, complex migraines, depression, muscle strain, multiple slipped discs, being out of shape, chronic fatigue syndrome, epstein barr, and fibromyalgia, Rosacea, GERD, hypothyroid, contact dermatitis, and sunburn (from secretly going to tanning beds). I have been told I have ALS, Guillain Barre, Multiple sclerosis, Myasthenia Gravis, munchausen's and conversion reaction........nothing wrong at all.
Since 2002.
Unfortunately, I don't have the benefit of early diagnosis and improved prognosis.
I have seen so many doctors it is shocking and shameful. I, too, have been accused of "doctor shopping" and "seeking" behavior. YOU BET I HAVE SEEEKING BEHAVIOR. I AM SEEKING A COMPETENT MD!
If you don't help me.....Bye Bye.
You know how I got diagnosed? A dermatologist came up to me in a grocery store (in an electric cart because I couldn't walk more than a few steps without falling) about 18 months ago and wanted to take pictures of my skin because he had never seen such a classic presentation of DERMATOMYISITIS in his career........he's been an MD for 32 years. I burst into tears. My GOD, an answer.
Now, I just need to find someone knowledgeable in the treatment.......sigh.
I, to, have sobbed in many physician offices for another let down about how to help me as I became weaker and weaker. I have had more than one nurse roll their eyes, been dismissive, whisper around corners (I can hear you by the way) and give each other "The look" when they find out I am a nurse. I too have been sent to another internist in the office who's "speciality" (interest is more like it) is "auto-immune disorders" while waiting for a speciality appointment (which can take months, by the way) and wouldn't think twice to ask for refills when there.....it's the office I am seen in. Any combo of meds can be seen as "suspicious" or suspect......I just want us to "do better when we know better" (Maya Angelou). With the chemo meds I'm on and heavy toxicity to the liver....I, to, request no acetaminophen
So, my wish is that we stop "profiling" patients an are mindful of our presence and body language. That we become cautious with our rush to judgement that everyone is looking for drugs (because frankly they can be bought on the internet) and treat them poorly because of preconceived notions because of preconceived notion. MD's pick up on the nurses opinion and behavior and have a huge influence on their impressions. I have found if the MD can't really figure out what is wrong, by the quickest simplest way possible, it is obviously the patients fault especially if she is female....and send her to a shrink.
I understand that we need to be aware of certain behaviors but be ever cautious or prejudice and our influence on how others treat the patients in our care by the precedent that we project. We set the tone.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
That MD is out of control. A simple yes or no, I can't/won't write for those meds you need to see your PCP DR. So and So..... would have sufficed....his over reaction makes me wonder if someone got busted for excessive script writing. While he was a jerk, it is not abandonment because he knew and could document and verify that she had adequate medical care.
Abandonment is tough.....Abandonment is defined as the termination of a professional relationship between physician and patient at an unreasonable time and without giving the patient the chance to find an equally qualified replacement. According to the AMA's Code of Medical Ethics, Opinion 8.115, physicians have the option of terminating the patient-physician relationship, but they must give sufficient notice of withdrawal to the relatives, or responsible friends and guardians to allow another physician to be secured.
Physician-Initiated Termination of CareWhen a physician-patient relationship must be terminated, the physician must carefully document the circumstances in the patient's medical record. This termination note should review the patient's previous medical treatment and the current state of the patient's health. If the termination will not affect the patient's health, this should be stated and explained. If the patient is in need of continuing care, the note must explain how the physician has ensured that the termination will not compromise the patient's health.
Esme, I am so sorry you have had these troubles. I have several friends who have struggled trying to get diagnosed in similar situations. I've struggled trying to get diagnosed with asthma, of all things, and yelled at by docs and told that my symptoms were all in my head, and even yelled at in the emergency room. It really sucks. Struggling to breathe, and getting yelled at too? Really? I imagine it's similar for people who really are in pain, and really having the weird, invisible, unpredictable, quality-of-life reducing symptoms, getting blown off by docs.
I'm strongly considering a focus on rheumatology/autoimmune, because I see that NP's really have a place there, getting a deep medical history, self-management coaching, the time-consuming stuff doc's don't necessarily focus on.
Specializes in Trauma, ER, ICU, CCU, PACU, GI, Cardiology, OR.
unquestionably, the physician's beside manners are lacking in this case, he should have compose himself as a professional, and address the patient in a more proficient manner, after all even "med. seeker's deserve the benefit of the doubt". i'm my opinion the physician didn't abandon the patient, however, he could have handle the situation a bit more discretely, by yelling at the pt. he complicated the situation. having said that, i'm going by one side of the story, remember there's always two sides to a coin.
We are getting a third party version of the doctor's behavior. I suspect his behavior has been exaggerated by the second or third telling.
I also don't understand why a rheumatologist was not consulted for the second opinion-makes no sense.
Another reason people will request narcs with no acetaminophen is because educated seekers know that it is more dangerous to abuse the prescription (taking more than proper dose) because you run the risk of liver damage. A nurse would know this.
I am very intolerant of knee jerk reactions to people in pain (labeling them seekers), but in this scenario, it is totally understandable that the doctor became suspicious, for reasons already discussed. How one handles that suspicion is a totally different thing, of course. However, any nurse who has actually dealt with a seeker knows there is often a huge discrepancy with regard to what actually happened, and how the seeker describes the incident to others later.
The patient needs to see a rheumatologist, and probably a pain specialist as well.
The doctor, a second opinion consult, did not abandon the patient-not even close.
applewhitern, BSN, RN
1,871 Posts
It sounds to me like she was asking for a lot from him, instead of just a "second opinion" on whether it is fibro or not. We do not know what was written in her file by her regular doctor. It could be that he thought she was a "seeker," and had noted that in her chart. The office manager is only going to try to "smooth things over," she isn't going to go against the doctor, and possibly her employer. I know several doctors who have either lost their license, or had them restricted due to giving out too many narcotics, and other drugs, and I know quite a few doctors who refuse to give narcotics at all. They refer them to a pain specialist. I have also had doctors tell me that they have people call them every single day, begging for lortabs, etc. I wonder why she didn't just go to the rheumatologist for a second opinion. It also sounds to me like she may need a psych consult, too, for the depression, esp. since she was crying hard in this doctor's office. I am with the doctor on this one. And yes, the doctor can refuse to see her.