How to not burn out

[PMROralBoards]

New attending, PP productivity gig

Two owners are great but one is old school and “limits” OME in the clinic to 90, one is younger and I think just happy to live life and go with the flow.

I’m fed patients from them and most end up wanting to stay with me because I touch and examine them rather than just a 2 minute refill visit. I set a monthly goal for myself to wean patients as possible to try and get my panel under 60 OME but I’ve been asking myself where the endpoint is and honestly I don’t know.

I’m getting fed patients from an Ortho practice after getting good relations with them after learning about bad experiences between our two clinics (patients from them will only go to me), but I occasionally have to put up with the “med management” patient request from them. If I say no I won’t get more patients from them.

A pill mill in town shut down with the owner under dea investigation apparently and my clinic management hired the mid level there stating that he was only doing what the attending told him to do. As a result we are now absorbing all of their patients as “new patient referrals” and I’m seeing at least four a day. I’m told I don’t have to write anything I don’t want to and that at least it’s an “easy 99204” by the business manager. In the end I spend 40 minutes with each one probably to go through different conservative management options for at least half of them to ultimately tell me to F off. Staff then get frustrated that I’m an hour behind in clinic at the end of the day. It is exhausting.

On the one hand I know I don’t have to write anything I don’t want to write, while on the other if I don’t write opioids I won’t have any patients who stay with me in this clinic. I maybe have a dozen patients who aren’t on opioids, but otherwise am seeing 25 patients a day.

Other than “find a different job”, does anyone have advice? Would have posted this in the doc only forum but I don’t have access to it.

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[po_boy]

I understand what you're going through, as I was in a similar situation recently. Feel free to PM me.

You and your office staff need to screen the "new patients" from the pill mill. If it's clear from their records and/or PMP that they are med management only, I don't think that you are obligated (ethically or legally) to see them. Also, 40min is a rather long new patient eval for a patient that is clearly seeking only med management. Just my novice opinion.

 

[PMROralBoards]

I understand what you're going through, as I am in a similar situation currently. Feel free to PM me.

You and your office staff need to screen the "new patients" from the pill mill. If it's clear from their records and/or PMP that they are med management only, I don't think that you are obligated (ethically or legally) to see them. Also, 40min is a rather long new patient eval for a patient that is clearly seeking only med management. Just my novice opinion.

Either I say I’ll see any of them or I don’t see any of them and then my productivity drops. It’s a lose lose situation. My NP evals are 30 minutes each. I meant that I am naive enough that I still think these patients deserve a full eval and to hear all of my recommendations when it’s obvious that they only want pills. No one else in the community will write for them.

 

[po_boy]

Either I say I’ll see any of them or I don’t see any of them and then my productivity drops. It’s a lose lose situation. My NP evals are 30 minutes each. I meant that I am naive enough that I still think these patients deserve a full eval and to hear all of my recommendations when it’s obvious that they only want pills. No one else in the community will write for them.

Sounds like you are relatively new to the practice. It takes time to build up a patient base in many circumstances. You can see them, and offer them what you think is appropriate. If they don't like it, they can go elsewhere. The last thing you want to do is build up a patient base of med management. The volume will come, but it takes time unfortunately. You will likely have to go around and market yourself aggressively to referral sources.

 

[bedrock]

Start applying for new jobs today. Yours sounds terrible. 95% medication management, and administrative and financial pressure to write opioids for 95% of the patients that come in the door?

That’s one of the worst job descriptions I’ve read. There are far better jobs out there.

I can tell that you’re trying to do the right thing for your patients regarding time spent with them and doing a full eval. However, you’re already on the road to burnout and that won’t allow you to help patients, because you can’t work like this for long.

One point to consider if you stay at this job for a while.
If I see a patient that only wants opioids and the patient refuses non opioid treatment options, then that patient is weaned off their opioids until they are compliant with the entire treatment plan, not just the “candy”. Or they just leave the practice.

Not only is this correct medically, but it also protects you legally.

 

[Bostonspine]

Other than getting a new job you have get a new source of patients. Every reasonable patient you get figure out the source and market directly…meet every spine surgeon, neurologist, Chiro or PT in town

 

[po_boy]

One point to consider if you stay at this job for a while.
If I see a patient that only wants opioids and the patient refuses non opioid treatment options, then that patient is weaned off their opioids until they are compliant with the entire treatment plan, not just the “candy”. Or they just leave the practice.

Not only is this correct medically, but it also protects you legally.

Are you talking about a new patient or established patient? Would you even continue a new patient on their opioid regimen in this situation if they were discharged from another clinic?

 

[bedrock]

Are you talking about a new patient or established patient? Would you even continue a new patient on their opioid regimen in this situation if they were discharged from another clinic?

Both.

However, I’d never see a COT patient that was discharged from another clinic. Easy pitfall to avoid. A bit different if their doctor retired or moved.

But if a patient was discharged by another practice, you’re asking for it if you choose to see them.

 

[Ronin1]

There are certainly some patients that are appropriate to maintain on opioids. I see about 10-15 a day(or my NP does). If you are going to Be a hard ass about pain meds it will take a long time to build up volume. In general I don’t take any patients on that are taking more than 50 mme a day. In fact I rarely take a straight med referral patient as I have a mostly full practice. The other question is how are you paid? A 99214 med refill is a decent wrvu and may be a decent office charge depending on insurance. If you only will continue pain meds on patients if they get procedures you are even worse.

 

[Agast]

There’s a stickie at the top of the forum explains how to gain access to the private doctors-only forum

Your job is probably not that different from 90% of the pain jobs out there. People here tend to get on their high horse about maintaining the perfect clinic, but no clinic is perfect. You have to learn how to develop thicker skin. When your job says Pain Management, 100% of people are going to think that means pain pills. You have to learn how to read your patients. Don’t spend 40 minutes on a pill mill patient who wants something you’re never going to give them. Practice saying “This is what I feel comfortable with but you may seek a second opinion”

 

[PMROralBoards]

There are certainly some patients that are appropriate to maintain on opioids. I see about 10-15 a day(or my NP does). If you are going to Be a hard ass about pain meds it will take a long time to build up volume. In general I don’t take any patients on that are taking more than 50 mme a day. In fact I rarely take a straight med referral patient as I have a mostly full practice. The other question is how are you paid? A 99214 med refill is a decent wrvu and may be a decent office charge depending on insurance. If you only will continue pain meds on patients if they get procedures you are even worse.

This is one thing I struggle with. I’m much more open to seeing/enjoying a working relationship with a patient who is open to procedures and therapies while they are on opioids than if they are not open to these. I’m sure there’s some part of me that wants the procedures, but the majority of it is that they are more reasonable people and I want to think that if I can get them pain relief then they will let me taper them down. 99214 is $180-200 Medicare here. Commercial is usually $250-$300 or so

 

[PMROralBoards]

Other than getting a new job you have get a new source of patients. Every reasonable patient you get figure out the source and market directly…meet every spine surgeon, neurologist, Chiro or PT in town

I’m getting a slow trickle each week of direct injection requests from an Ortho office. Do you make new patient appointments for these patients or just do the procedure?

 

[Ronin1]

This is one thing I struggle with. I’m much more open to seeing/enjoying a working relationship with a patient who is open to procedures and therapies while they are on opioids than if they are not open to these. I’m sure there’s some part of me that wants the procedures, but the majority of it is that they are more reasonable people and I want to think that if I can get them pain relief then they will let me taper them down. 99214 is $180-200 Medicare here. Commercial is usually $250-$300 or so

I’ve got many many patients on pain meds that get intermittent procedures. They just can’t come off these meds. Some patients will never come off meds despite’s injections RFA and scs.

 

[Ronin1]

I’m getting a slow trickle each week of direct injection requests from an Ortho office. Do you make new patient appointments for these patients or just do the procedure?

I never do injections without a new patient evaluation. The orthos /neurosurgeon le are wrong most of the time it seems as to appropriate interventions

 

[PMROralBoards]

I never do injections without a new patient evaluation. The orthos /neurosurgeon le are wrong most of the time it seems as to appropriate interventions

How do you/how did you initially approach them if you disagreed? If a patient had a clear SIJ 5/5 provocative maneuvers but the middle level asked for an epidural despite no radicular pain what would you do?

 

[Taus]

I’m getting a slow trickle each week of direct injection requests from an Ortho office. Do you make new patient appointments for these patients or just do the procedure?

How do you deal with prior authorization on those? Plus blood thinners, allergies, etc if they are not from within your own practice, without ability to review chart or directly see in expedited evaluation before hand?

 

[PMROralBoards]

How do you deal with prior authorization on those? Plus blood thinners, allergies, etc if they are not from within your own practice, without ability to review chart or directly see in expedited evaluation before hand?

That’s why I’ve been insisting on getting them in for a new patient visit, but I am the only one in my clinic who does this from external referrals for orders. Our billing team generally just runs the cpt code with the icd10 for PA otherwise.

 

[interjectionreflection]

There’s a stickie at the top of the forum explains how to gain access to the private doctors-only forum

Your job is probably not that different from 90% of the pain jobs out there. People here tend to get on their high horse about maintaining the perfect clinic, but no clinic is perfect. You have to learn how to develop thicker skin. When your job says Pain Management, 100% of people are going to think that means pain pills. You have to learn how to read your patients. Don’t spend 40 minutes on a pill mill patient who wants something you’re never going to give them. Practice saying “This is what I feel comfortable with but you may seek a second opinion”

I tell them something along the same lines. This may be a silly question but in your consultation note how would you document that under impression/plan I struggle when they have had "side effects" to any meds and tried "everything"

 

[Ronin1]

How do you/how did you initially approach them if you disagreed? If a patient had a clear SIJ 5/5 provocative maneuvers but the middle level asked for an epidural despite no radicular pain what would you do?

I don’t give a crap what a mid level wants. For a surgeon I find they don’t really care. Th

 

[BobBarker]

Most of the surgeons really aren’t that particular. I had one send a 500lb man in for a gt bursa injection. They just want the non surgical patients out of their office.

 

[Agast]

Most of the surgeons really aren’t that particular. I had one send a 500lb man in for a gt bursa injection. They just want the non surgical patients out of their office.

I was a little tipsy at a physician networking dinner and during introductions I told the surgeons I bury the bodies so they don’t have to deal with them. Fortunately they laughed.

 

[Asclepius186]

If you are managing COT you need to develop some hard lines for what you will or won’t do. Pull PMPs and screen out new referrals above a certain MME or on opioids and benzos. While getting the 99204 if nice for billing, if you know based on a PMP or a brief record review that you would never be willing to give a patient what they want, then just save yourself and the patient the headache and cancel the NP appointment.

 

[jsaul]

New attending, PP productivity gig

Two owners are great but one is old school and “limits” OME in the clinic to 90, one is younger and I think just happy to live life and go with the flow.

I’m fed patients from them and most end up wanting to stay with me because I touch and examine them rather than just a 2 minute refill visit. I set a monthly goal for myself to wean patients as possible to try and get my panel under 60 OME but I’ve been asking myself where the endpoint is and honestly I don’t know.

I’m getting fed patients from an Ortho practice after getting good relations with them after learning about bad experiences between our two clinics (patients from them will only go to me), but I occasionally have to put up with the “med management” patient request from them. If I say no I won’t get more patients from them.

A pill mill in town shut down with the owner under dea investigation apparently and my clinic management hired the mid level there stating that he was only doing what the attending told him to do. As a result we are now absorbing all of their patients as “new patient referrals” and I’m seeing at least four a day. I’m told I don’t have to write anything I don’t want to and that at least it’s an “easy 99204” by the business manager. In the end I spend 40 minutes with each one probably to go through different conservative management options for at least half of them to ultimately tell me to F off. Staff then get frustrated that I’m an hour behind in clinic at the end of the day. It is exhausting.

On the one hand I know I don’t have to write anything I don’t want to write, while on the other if I don’t write opioids I won’t have any patients who stay with me in this clinic. I maybe have a dozen patients who aren’t on opioids, but otherwise am seeing 25 patients a day.

Other than “find a different job”, does anyone have advice? Would have posted this in the doc only forum but I don’t have access to it.

Agast is right most jobs out there whether people admit it or not are some degree of variance from yours. Your problem is that it should not take you 40min to say no
You can still bill a new patient eval and.say no to continuing the new patient pain meds in a way that won't piss off the patient and make you feel scared in less than 15min.

 

[IAmTheOne1]

This is one thing I struggle with. I’m much more open to seeing/enjoying a working relationship with a patient who is open to procedures and therapies while they are on opioids than if they are not open to these. I’m sure there’s some part of me that wants the procedures, but the majority of it is that they are more reasonable people and I want to think that if I can get them pain relief then they will let me taper them down. 99214 is $180-200 Medicare here. Commercial is usually $250-$300 or so

Where are you that Medicare pays 180-200 for 99214?

Jealous of your commercial rates. In CA commercial pays an avg of 80 for 99214, so bad.

 

[BobBarker]

Where are you that Medicare pays 180-200 for 99214?

Jealous of your commercial rates. In CA commercial pays an avg of 80 for 99214, so bad.

I think that has to be 99214 plus a moderate complexity urine drug analysis. The Medicare fee schedule is public. It is too high for an e&m alone.

 

[callmeanesthesia]

I think that has to be 99214 plus a moderate complexity urine drug analysis. The Medicare fee schedule is public. It is too high for an e&m alone.

Or meant 99204

 

[powermd]

Thank you all for this wonderful reminder of how it was worth it to put the energy into building an opioid-free practice.

What the OP is describing sounds a bit like my first gig out of fellowship. My contract was not renewed at one year because I was "too conservative", and "insulting" to the PCPs for prescribing non-narcotic pain meds and recommending PT. That worked out well because I hated the cigarette smoke-infused paperwork, the coke positive UDSs, and the young, healthy patients on oxy 30 mg QID and still not f'ng happy. Honorable mention to the patients who would drive five hours to get sedated with propofol for a "therapeutic" MBB.

After that experience, I vowed, 'never again', and joined an opiate-free practice. Then ten years later left, and started another one. It can be done, if you play your cards right and are patient. Once patients see that you are willing to be a real doctor- talk to them, examine them, explain things in language they understand, and present logical plans, they will only ever want to see you, and word will get around.

 

[Agast]

I tell them something along the same lines. This may be a silly question but in your consultation note how would you document that under impression/plan I struggle when they have had "side effects" to any meds and tried "everything"

Just document it.

Patient reports side effects to neuropathic pain medications such as pregabalin, gabapentin, etc. Discussed specific alternative options patient does not recall trying, patient defers as they feel they “have tried everything.” Advised patient I do not think oxycodone 30mg is appropriate for their condition and therefore would not continue this. Discussed hydrocodone 5/325mg however patient is adamant to stay on oxycodone 30mg, he may seek a second opinion.

 

[callmeanesthesia]

Just document it.

Patient reports side effects to neuropathic pain medications such as pregabalin, gabapentin, etc. Discussed specific alternative options patient does not recall trying, patient defers as they feel they “have tried everything.” Advised patient I do not think oxycodone 30mg is appropriate for their condition and therefore would not continue this. Discussed hydrocodone 5/325mg however patient is adamant to stay on oxycodone 30mg, he may seek a second opinion.

All of that should be on your intake paperwork to save your time - what meds have you tried before, and what are you currently on? Have you tried PT or injections before and did they help? Also paperwork asks what helps their pain and what makes it worse. If they check every box, and say the only thing that helps is pain meds, and “everything” makes it worse, it’s a very brief conversation: “I can see that you’ve already tried everything, and I’m sorry to say I don’t have anything new to offer you.”

 

[Laryngospasm]

So much wrong with your job. Not much that hasn’t been said. Taking patients from pill mills even with the best intentions will at best cause your hair to fall out.
Opioid refugees are nightmares. When the medical board comes a knocking none of those “managers” opinions will matter. It will all be on you.

 

[po_boy]

Just document it.

Patient reports side effects to neuropathic pain medications such as pregabalin, gabapentin, etc. Discussed specific alternative options patient does not recall trying, patient defers as they feel they “have tried everything.” Advised patient I do not think oxycodone 30mg is appropriate for their condition and therefore would not continue this. Discussed hydrocodone 5/325mg however patient is adamant to stay on oxycodone 30mg, he may seek a second opinion.

While I agree that detailed documentation is very important, why does it really matter in this specific scenario? Why document in detail why one won't prescribe an opioid? Is it to justify billing a level 4? CYA?

 

[Agast]

While I agree that detailed documentation is very important, why does it really matter in this specific scenario? Why document in detail why one won't prescribe an opioid? Is it to justify billing a level 4? CYA?

Patients can file a complaint against you to the medical board alleging poor quality of care. They will then ask to see your records. Clear documentation that you offered good quality of care will save you. I’ve had 2 board complaints and after reviewing my records they declined to start an investigation.

 

[Asclepius186]

I tell them something along the same lines. This may be a silly question but in your consultation note how would you document that under impression/plan I struggle when they have had "side effects" to any meds and tried "everything"

Also, latest CDC guidelines really harp on benefits to function outweighing risks of opioid therapy.

I would include a bit about how risks of high dose opioid therapy outweigh the benefits for this patients condition, and patients function does not appear to be improved by use of these medications as patient is still largely sedentary and not working etc…

 

[CleanUp]

Either I say I’ll see any of them or I don’t see any of them and then my productivity drops. It’s a lose lose situation. My NP evals are 30 minutes each. I meant that I am naive enough that I still think these patients deserve a full eval and to hear all of my recommendations when it’s obvious that they only want pills. No one else in the community will write for them.

Not your monkey not your circus. You don’t have to absorb someone else’s headache. You didn’t create this mess. You have a heart that’s good. But please consider setting limits.

I run a very very clean practice and it’s very productive. It just took time to build it this way. Patients who select me, like someone else said, know what they are getting into - someone who takes the time to explain the options, go over the MRI, honestly give them a shot at PT, and follow up.

1. Screen them out when they call
2. Tell them your opioid policy when they check in
3. Someone else tell them again when someone rooms them
4. You tell them in the room. Lead with this. Don’t wait until the end.
5. Provide a list of recommendations (other local practices, EDs, complementary meds, stretches etc). This shows you are going above and beyond and connecting them with options. When you go to court and they paint you as someone who doesn’t care you can show them Exhibit A which shows the name , address, fax and phone number of a curated list.
6. Create a dot phrase that is iron clad about risks versus benefits and in your medical opinion in this scenario the decision was made to not prescribe. Again, make this incredible. It’ll be what you lean on when/if the state board comes knocking.
7. Include objective measures on the intake form so you can defend them a bit (pain catastrophizing score, COMMS or whatever it’s called etc)
8. Have a written policy. Don’t waiver from it. Consider saying you do writing opioids just not on the first visit. That way the patients who are fishing for them weed themselves out.
9. Get a dot phrase for withdrawal. Send these meds in. It is easy to find the meds. Most are otc. Shows you are compassionate.
10. Do send in meds (lido patch, apap, etc) to show you are offering medical treatment. It is then the patients decision to not continue with you. This is not illegal on your part.
11. Always include the 5 As if you do prescribe.
12. Put in a line about referring to pain psych or addiction medicine.

Please remember it is NOT your medical obligation to continue someone else’s opioid plan. It IS your medical duty to weigh the risk benefits and alternatives.

Sorry I get riled up with this stuff.

 

[specepic]

New attending, PP productivity gig

Two owners are great but one is old school and “limits” OME in the clinic to 90, one is younger and I think just happy to live life and go with the flow.

I’m fed patients from them and most end up wanting to stay with me because I touch and examine them rather than just a 2 minute refill visit. I set a monthly goal for myself to wean patients as possible to try and get my panel under 60 OME but I’ve been asking myself where the endpoint is and honestly I don’t know.

I’m getting fed patients from an Ortho practice after getting good relations with them after learning about bad experiences between our two clinics (patients from them will only go to me), but I occasionally have to put up with the “med management” patient request from them. If I say no I won’t get more patients from them.

A pill mill in town shut down with the owner under dea investigation apparently and my clinic management hired the mid level there stating that he was only doing what the attending told him to do. As a result we are now absorbing all of their patients as “new patient referrals” and I’m seeing at least four a day. I’m told I don’t have to write anything I don’t want to and that at least it’s an “easy 99204” by the business manager. In the end I spend 40 minutes with each one probably to go through different conservative management options for at least half of them to ultimately tell me to F off. Staff then get frustrated that I’m an hour behind in clinic at the end of the day. It is exhausting.

On the one hand I know I don’t have to write anything I don’t want to write, while on the other if I don’t write opioids I won’t have any patients who stay with me in this clinic. I maybe have a dozen patients who aren’t on opioids, but otherwise am seeing 25 patients a day.

Other than “find a different job”, does anyone have advice? Would have posted this in the doc only forum but I don’t have access to it.

Stick to your guns. You sound ethical and reasonable. The slope gets slippery quicly

1. Personally triage all outside NPs. Designate one staff member you trust to be your gatekeeper. They tee up the referral (ensuring records and imaging in place) then send summary to you. You approve or not. The telephone script they tell the pt is that it is a 'consult'. there is no guarantee of opioids (in our office they are told no opioids will be restarted or continued when started elsewhere), and then ask if the the pt still wants to be seen

2. If you do not feel high dose opioid therapy is the right thing for pts then either don't see those pts or put your helmet on and wean them. The upshot of the latter is you can see them frequently and it will increase your productivity, btu make sure ethically you are doinf it for the right reasons. DOING MORE OF THE SAME FOR THESE PTS WILL GET YOU A VISIT FROM THE DEA TOO

3. if the practice will not allow you to practice ethically then move on

 

[bedrock]

Patients can file a complaint against you to the medical board alleging poor quality of care. They will then ask to see your records. Clear documentation that you offered good quality of care will save you. I’ve had 2 board complaints and after reviewing my records they declined to start an investigation.

Were both of these complaints because you decided not to prescribe opioids ?

 

[Agast]

Were both of these complaints because you decided not to prescribe opioids ?

Actually, no. One was just a whole ‘nother level of ridiculousness (and actually sent a portal message apologizing for their actions a few months later) and the other also called the police on me, filed a complaint with Medicare and had me investigated. So I speak from experience when I say good documentation and eye witnesses save your butt. Also people can be secretly crazy and reveal it at the very end. Even nice little old ladies.

 

[Orin]

New attending, PP productivity gig

Two owners are great but one is old school and “limits” OME in the clinic to 90, one is younger and I think just happy to live life and go with the flow.

I’m fed patients from them and most end up wanting to stay with me because I touch and examine them rather than just a 2 minute refill visit. I set a monthly goal for myself to wean patients as possible to try and get my panel under 60 OME but I’ve been asking myself where the endpoint is and honestly I don’t know.

I’m getting fed patients from an Ortho practice after getting good relations with them after learning about bad experiences between our two clinics (patients from them will only go to me), but I occasionally have to put up with the “med management” patient request from them. If I say no I won’t get more patients from them.
...
On the one hand I know I don’t have to write anything I don’t want to write, while on the other if I don’t write opioids I won’t have any patients who stay with me in this clinic. I maybe have a dozen patients who aren’t on opioids, but otherwise am seeing 25 patients a day.

Other than “find a different job”, does anyone have advice? Would have posted this in the doc only forum but I don’t have access to it.

There's many things buried in this, but to address your overarching question, if you're trying to avoid burning out, then ask yourself what is burning you out and fix it if you can.

Having been there myself, I think it's important to remember this is not just a you issue (resilience training) or a practice issue(system fixes), but more a mismatch of expectations/reality or some other variables.

I'm pretty frank in my discussions with clinicians about this as it's often framed as a problem with the clinician, but it's not that you're weak, naive, or incompetent. That just isn't the right system for you, currently. As a new attending, that's common. A large chunk of people leave that first job in 3 years, as they realize what they really want, instead of what looked good coming out of the gates.

Don't get me wrong, it sounds like you've got some you factors here:
- "I'm getting fed" suggests that you don't appreciate your value. People want to stay with you over your partners after they meet you. People are sending you patients. Don't discount that. You're accruing a panel. Feel empowered to say no, because odds are they'll still keep coming. Physicians sending you bad referrals will still send you good ones if you show them value.
- "I know I don't have to" suggests you're burdened by a sense of obligation. As the posts above suggest, unburden yourself by giving patients other options and giving yourself the freedom to say no. I would go one step further and share those options with referring doctors while teaching them what you want. Explain to them just like you wouldn't send a surgeon a non-operative patient, don't waste your time with someone that isn't ready to listen.

Long term though, if you want to change things in your system, you've got to know what it is you want and then understand how to communicate it. Practice that with someone, or on here.

As the other folks said, figure out your boundaries or someone else will keep violating them. Admins can't read your mind, and odds are if you're hustling, they don't want to struggle to backfill your job in the boonies. You can pick how hard or soft those boundaries are.

I've never actually met a doctor that said I really want to dump patients on you. They generally want your help but don't know what's right for you or a better option. They don't want you to be miserable, but they have expectations of a pain doctor, just like you have one of a PCP/endocrinologist/etc. Figure out how to get to a win for both sides here.

 

[pastafan]

Actually, no. One was just a whole ‘nother level of ridiculousness (and actually sent a portal message apologizing for their actions a few months later) and the other also called the police on me, filed a complaint with Medicare and had me investigated. So I speak from experience when I say good documentation and eye witnesses save your butt. Also people can be secretly crazy and reveal it at the very end. Even nice little old ladies.

That is why it is important to always have a chaperone in the room. They can scribe and witness.