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.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
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.
Thanks :hug:. I am usually not quite so open, but I have hidden in the shadows afraid for my job for far too long. Now I can't work. So, now it's time to embrace the new me and move forward to advocate and educate.
I think as medicine moves forward the auto-immune diseases/difficult to diagnose, will become more prevalent as we become more aware of the poison we have been fed like "pink slime" over the years. Of course I come from the ERA of DES and DDT.
I think that's great idea for No one can care like a nurse.
A physician contracted for the purpose of a second opinion doesn't have a patient-provider relationship to be "abandoned".
Physician's contracted for the purposes of a second opinion are not obligated to treat anything, as the service/care being sought is an opinion.
Do docs rendering 2nd opinions often make med/treatment changes or refill a script? Sure, but they are not obligated to do so and (if they do) are setting themselves up for establishing a provider relationship with a patient they have no desire to continue to follow.
Hitting up a physician contracted to render a second opinion for scripts and refills, especially for meds of abuse is a huge drug seeking red flag. Even moreso when the patient has discontinued the (non-narcotic/benzo) treatment prescribed by the original doctor without involving them in the decision and is now requesting narc/benzos.
It sucks to have a chronic disease process and go through the hoops of trying to find someone, anyone, who can finally give a name to what you're experiencing and maybe offer hope of some kind of treatment.
If you look at my medical history, I probably look like a total loon. I'll probably need both knees replaced within the next several years due to arthritis, and I'm only in my mid-30's. Had to have a hysto due to pelvic congestion syndrome, which apparently a significant portion of the medical community believes is an "It's all in her head" disorder. Need to have C-spine surgery done due to a skeletal abnormality that affects 1-2 people per million and is causing progressive neurological damage to both arms, and again debate as to whether the symptomology is "real" or not.
I lucked out and was able to pick docs that I knew to be phenomenal in their areas, so my delay of diagnosis was minimal. I can't even imagine how totally frustrating it would be to have something going on for years and not be able to find out what it was, or have doctors who question your psychological well-being when you know damn well it's not that. The patient you're describing might well have been at her wit's end dealing with the process, and a tirade from the doc was all that was needed to send her over the edge. I can understand that he may been justified with some limit setting given the circumstances, but to yell at her as described was completely inappropriate. In the end, it's probably going to be to her benefit to have been "fired"...frees her up with no qualms to go find someone more empathetic.
I'm a provider and the red flag for me is the multiple controlled substances this pt requests. I would refer to pain specialist and would not give medsInsane amt of meds for a working nurse to consume.
Specializes in Critical Care, ED, Cath lab, CTPAC,Trauma.
I'm a provider and the red flag for me is the multiple controlled substances this pt requests. I would refer to pain specialist and would not give meds Insane amt of meds for a working nurse to consume.
I agree, and I only ask the prescribing provider to refill my Rx's, but we also need to consider that the opposite is true as well. With these auto-immune diseases poly pharmacy is very common as there are not actual treatments for the disease only control of the symptoms.
Yes, likely a seeker. Doc could have just told her that after HIS assessment, he concludes that he would not prescribe the meds in question. Then, tell her what he would prescribe. If she is not in agreement, then, stand firm but kindly state that he has given her his professional opinion. It's not like he hasn't seen a seeker before... there is no need to fight them. Just kindly let them know that you will not prescribe.
The OM should have taken him in back and smacked him one on the butt for throwing a fit.
He does not need to continue seeing her. No Doc has to continue the scripts written by another Doc - of course with careful considerations, cardiac meds, thyroid, diabetic, etc. etc. Now, if he had been her primary for a while, and didn't want to deal with her anymore, then they would need to fire her from the practice - and part of that is not leaving her cold turkey from "critical" medications/tx without advance notice. Most practices have legally reviewed steps for patient firing.
Specializes in psych, addictions, hospice, education.
I think the doctor may have gone overboard in his reaction to what was going on, if the situation was exactly as you were told. If that's the case, he surely lacked "warmth." Shame on him.
I have some opinions since I'm a psych CNS and have prescribed all the mentioned medications except Savella.
She's tried 3 antidepression medications plus Savella, which is similar, without positive effect. They could have been either for depression or pain. It's possible she didn't get to the point of taking a strong enough dose. Antidepression meds are of the "start low, go slow variety." To just quit taking them isn't the answer. If she was at the max dosage each time, it's possible she doesn't have depression of the altered neurotransmitter variety and meds won't help that.
She's willing to give Lyrica and neurontin a chance. I wonder...does she expect them to not work? That would be logical if other things hadn't worked. A person gets so she doesn't think anything will work. Fibromyalgia is a bear to treat. It doesn't respond to much. And, if she expects them not to work, they probably won't work.
She wants oxycodone and ADHD meds (meds that would be new to her now) plus a xanax refill. This is big. Lots of docs wouldn't start the first two while someone is on the third, and starting even one of the first two could be seen as counterproductive since oxycodone is synergistic with xanax, and ADHD meds antagonize it.
She's a nurse so she knows meds, but she doesn't know how prescribing works, it seems. I think there's a bit more to the story.
I think she needs to go back to her primary care provider and have an at-length talk with him or her. She can tell the scheduler she needs extra time when she makes the appointment, so she doesn't get rushed, assuming the PCP will take the extra time.
Does she think she has fibromyalgia? What's the reason for a second opinion with a PCP? She doubts the diagnosis...or what?
I totally hate the word "med-seeker" due to the stigma attached to it. When people are med-seeking, there's a huge reason for it. It's not helpful for caregivers to mentally write their names in the column titled "scum." It's more helpful to spend time and get to the problem behind the seeking, if at all possible. This lady is suffering even if she's the biggest addict the world has ever seen. She needs help.
Doctors are just too busy! If only something could take care of that too.
Whispera...thanks for writing the above. I would like to make a needlepoint of it and post it in our staff areas. "When people are med-seeking, there's a huge reason for it. It's not helpful for caregivers to mentally write their names in the column titled "scum." It's more helpful to spend time and get to the problem behind the seeking, if at all possible." That's amazing.
Wow. I would agree that the patient's behavior is a bit suspicious but if the MD really felt strongly about it, a simple, "You will have to ask your primary for a refill as I am just offering a second opinion." would have been enough. No need to meltdown in front of the patient even if he or she has misdirected or correctly directed anger about seeking behavior.
Thank you all for your posts! You are all awesome! I have a little more info to add now
1. Wanted to mention maybe restarting ADHD meds at this appt due to being agency nurse, no insurance, didn't want to pay for two appts so just asked a question about it. She is interviewing for LTC position next week and is struggling to keep up with her childrens' schedules (school, sports, etc) and worries about focusing on that many patients since she has been private duty or doctor office nurse for many years and hasn't had but one-on-one for quite some time.
2. Medical Assistant asked her if she was still taking xanax, said yes and was taking a little more lately due to quitting smoking and will need a refill.
3. Did ask the doctor his opinion on the research about opioid use for fibro AND herbal remedies or something like acupunture etc etc, he only heard OPIOID and immediately became enraged. She's not one to cry easily so I believe her when she says he was out of control, also considering she now received an apology from admin for his behavior
4. Since she doesn't have insurance right now she wanted a second opinion due to cost of specialist. She thought (at the time lol) would be worth to compare another doc's opinion to her primary before spending the money for the rheumatologist. She even stated she felt like she was betraying her regular doc, he's great and she values his opinion but has never had much more than a cold and was kind of in denial. Actually has stated she was at one time a person who felt fibro was a "make believe" illness and could not accept this dx.
She feels super embarrassed that anyone would consider her more or less a junkie, as she put it. I don't know, she found all this research about opioid use for fibro and thought she would ask. She also joked about getting medical marijuana for it because of research proving that helps. She now doesn't know if she should find a new doc, will they think she is doctor shopping etc?
Esme12, ASN, BSN, RN
20,908 Posts
Thanks :hug:. I am usually not quite so open, but I have hidden in the shadows afraid for my job for far too long. Now I can't work. So, now it's time to embrace the new me and move forward to advocate and educate.
I think as medicine moves forward the auto-immune diseases/difficult to diagnose, will become more prevalent as we become more aware of the poison we have been fed like "pink slime" over the years. Of course I come from the ERA of DES and DDT.
I think that's great idea for No one can care like a nurse.