No-Win Weird situations

[whopper]

1) Patient doesn't want family member in the meeting, but family member is paying for the visits and won't pay for visits unless that family member is included in the meetings.

2) Patient needs a dental consult because of a severe dental problem. Most hospitals don't have dentists, but patient is involuntarily committed in the psych unit and too dangerous to discharge. IM pretty much tells you to eff off cause it's dental and not something they treat when you ask them to consult.

3) Patient has severe ADHD. Patient is also in their 70s, not in the best of health making stimulants have some risk (Hypertension, patient is a smoker). Non-stimulants were tried without benefit. Only med that helps is a stimulant. Do you cut the stimulant off?

4) Medication is on a tradename med, and it works great. Several generics were tried and failed. Medication goes generic so now insurance won't pay for the tradename medication cause it went generic. Problem is the medication JUST WENT GENERIC and the generics aren't expected to hit the shelves for several months. (This happened with Latuda in January and will happen with Vyvanse around August).

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[Celexa]

3 doesn't seem that hard to me. Maybe that's coming from the CL perspective and dealing with the most medically ill pts on a regular basis. Assuming the pt still had all their wits and has capacity to make the choice, I'd let them keep their stimulant and thoroughly document. Might reach out to their pcp or cardiologist to make sure everyone is on the same page. Would see pt at least q3 months and keep a tight monitor on major health changes. Would require them to see their pcp and be complaint with their BP meds. The benefit of keeping them functional is almost certainly going to yield overall better health than taking away the stimulant. Hell, taking away the stimulant might cause their smoking to go up if they consciously or unconsciously replace it with nicotine.

Would also aggressively be treating their smoking addiction (varenicline, bupropion, NRT) if not already done.

As for 2, I've occasionally been successful leaning on services to do things inpt they normally would do outpatient, but never anything dental, so if anyone has a magic solution to that I sure would also like to know.

 

[allantois]

1) I have encountered this. Tough luck. Never works out well. I would avoid having these visits altogether

2) Sounds like a problem for someone higher up

3) I probably would continue? Idk I don't see geriatrics much

4) Switch to something else

 

[comp1]

1, 2 and 4 can be solved by working for the VA (yes, the VA will provide/cover emergent dental care for otherwise ineligible inpatient veterans). As far as 3, it's just a documentation issue. I mean it's a very important documentation issue because the patient/family may indeed try to sue you if something goes wrong, but it's still a documentation issue. That's one where I would have a patient sign something if they want to continue.

 

[Egg122]

For number 1- patient needs to figure out a way to pay for their own visits or be discharged with referral to community health center or a clinic that provides discount services they can afford. Take yourself out of the middle.

 

[whopper]

1-This never ended well. I ended up terminating all patients in this situation when I sincerely made efforts to fix this situation. Patients allowed their dysfunctional family member paying the bill to come in so legally it wasn't violating HIPAA then told me they only allowed them in cause they were paying the bill. In all of these cases the person was financially dependent on the other person who was controlled them in some dysfunctional manner.

One of those patients ended up being involuntarily committed. A sad case. Severe depression but she also had several severe physical disorders and her husband was paying for everything. She needed him to pay for it or else she wasn't getting treatment whatsoever. It finally got to the point where I had to send her to the hospital against her will. Even then she wouldn't get released despite being there for weeks cause (and I talked to the treating doctor about it) the long-term of her situation was she had no way out other than suicide or putting her foot down and then dying from lack of treatent. The hospital doc wouldn't let her go. An independent court doctor also discussed the case with me and wouldn't let her go either.

2-In all of these cases despite that a dentist was needed the patient never got one. In a psych case we had to keep her in the psych unit until we could transfer the patient to a long-term facility that had a dentist. She didn't get dental care for weeks that was needed much sooner.

3-Agree with everyone's comments.

4-With Latuda I stockpiled samples of it and everyone on it I had them see me December and prescribed a 90-day supply. It weathered that storm cause generic Lurasidone didn't hit the shelves till about March but didn't become cheap until late April. Problem is this will happen with Vyvanse and you can't stockpile samples of it cause it's a schedule 2.

 

[VA Hopeful Dr]

Sometimes oral surgeons will have hospital privileges and can be cajoled into seeing inpatients

 

[mistafab]

2) I would rather consult OMFS, but like you said, these are rarely available. I've had luck where I currently work, and have had inpatient folks get teeth pulled (voluntary and involuntary).

 

[randomdoc1]

Yea, I stay out of cases with overly involved dysfunctional parents of a patient. It’s a never win situation. Nothing goes anywhere….I just….can’t.

 

[FlowRate]

2) Patient needs a dental consult because of a severe dental problem. Most hospitals don't have dentists, but patient is involuntarily committed in the psych unit and too dangerous to discharge. IM pretty much tells you to eff off cause it's dental and not something they treat when you ask them to consult.

What types of problems are we talking about?

Depending on setting and staff proclivities, sometimes emergency med have some basic urgent/emergent dental skills since they are the physicians who most frequently end up seeing dental emergencies. I'd imagine rural FM may, as well. You'd think some ENT and facial plastics would also possibly have basic knowledge. Someone else already mentioned the obvious with OMFS.

 

[whopper]

I stay out of cases with overly involved dysfunctional parents of a patient. It’s a never win situation. Nothing goes anywhere….I just….can’t.

My most extreme case was a physician who kept on calling my office demanding to know what was going on with his son and his son, a lawyer, refused to sign a HIPAA release. I had to have a lawyer send him a cease and desist to stop him from asking me to violate HIPAA.

 

[annoyedpsychiatrist]

1) Patient doesn't want family member in the meeting, but family member is paying for the visits and won't pay for visits unless that family member is included in the meetings.

2) Patient needs a dental consult because of a severe dental problem. Most hospitals don't have dentists, but patient is involuntarily committed in the psych unit and too dangerous to discharge. IM pretty much tells you to eff off cause it's dental and not something they treat when you ask them to consult.

3) Patient has severe ADHD. Patient is also in their 70s, not in the best of health making stimulants have some risk (Hypertension, patient is a smoker). Non-stimulants were tried without benefit. Only med that helps is a stimulant. Do you cut the stimulant off?

4) Medication is on a tradename med, and it works great. Several generics were tried and failed. Medication goes generic so now insurance won't pay for the tradename medication cause it went generic. Problem is the medication JUST WENT GENERIC and the generics aren't expected to hit the shelves for several months. (This happened with Latuda in January and will happen with Vyvanse around August).

1. This is something the family member and patient need to work out. They need to come to a mutual decision together and do their best to meet in the middle. I would encourage active conversation between the two parties. I would also be quite logical and explain that the patient has the right to refuse family during sessions but explain that the family is funding medical expenses that allow for treatment and concessions have to be made by one or both parties. Or the family member could write out their concerns in a letter for you to go over during each session without them being physically present

2. Usually hard to get this on inpatient setting. Im guessing will end up having to be done outpatient.

3. Probably nearly 70% of my patient population is geriatric. Just yesterday i had a 98 year old, 97 year old and 93 year old. A lot of the latest evidence shows the stimulant risk of exacerbating CV is moreso in initiation of a stimulant rather than maintenance/continuation. Also many people feel the risk may be overstated. Often times ill refer to cardiology and have them do a workup for "cardiac clearance" which often includes assessment from a cardiologist, ekg, echo, etc. Ive done this more than a few times. I thoroughly document risk and benefits and heavily document that the goal is improved quality of life and function which the medication has done for the patient and that potential risks were explained to the patient, and patient fully acknowledges these risks and agrees with the treatment plan. I have some people in their 60s on stimulants and a few in their early 70s. I dont make it a habit, but sometimes people do poorly off it. Theres also the idea that stimulants decrease fall risk in the elderly by improving cognition. If someone had hx of multiple STEMIs though then obviously I would be extremely hesitant with doing a stimulant.

4. Is there a patient support program through the manufacturer where he can get it for free? Like vyvanse has takeda help at hand, pretty easy to meet income requirement and get it for free.

 

[whopper]

1. This is something the family member and patient need to work out. They need to come to a mutual decision together and do their best to meet in the middle. I would encourage active conversation between the two parties. I would also be quite logical and explain that the patient has the right to refuse family during sessions but explain that the family is funding medical expenses that allow for treatment and concessions have to be made by one or both parties. Or the family member could write out their concerns in a letter for you to go over during each session without them being physically present

In the cases where this was a problem-the "controlling" family member themselves were highly pathological and were not reasonable enough for this to happen. In the more extreme case I mentioned above, the patient told me if I tried to do this the husband would've refused to pay for the treatment, she wouldn't be able to see the provider, she needed him for car rides (this was before Uber was a thing), and that this had happened with prior providers. Seriously-this guy was controlling his wife using her lack of finances and her health problems against her.

4. Is there a patient support program through the manufacturer where he can get it for free? Like vyvanse has takeda help at hand, pretty easy to meet income requirement and get it for free.

When meds go generic pretty much all copay cards and patient assistance pretty much ends. The insurance company argues the med goes generic so they won't pay for the tradename med. The problem being is that when a med goes generic that only means a competing company can also make it. It can take several months before such a company has the competing generics available. So the only version of the med available for months is the tradename med. In the meantime the patients are coitus'd -especially if that's the only med that worked well on the patient.

 

[HemeOncHopeful19]

When meds go generic pretty much all copay cards and patient assistance pretty much ends. The insurance company argues the med goes generic so they won't pay for the tradename med. The problem being is that when a med goes generic that only means a competing company can also make it. It can take several months before such a company has the competing generics available. So the only version of the med available for months is the tradename med. In the meantime the patients are coitus'd -especially if that's the only med that worked well on the patient.

Uh, is this a universal issue with pretty much 100% of insurance or will some at least cover until the generic is available? Asking for a friend…

 

[TexasPhysician]

Will #4 happen? Vyvanse almost went generic before. It took a legal event to extend the patent. Another company had already put the generic together. I don’t see why they couldn’t hit shelves asap.

 

[PsyDr]

In Freuds Construction of Analysis, he describes how your job is to be an imperfect mediator between the absurdities of reality and the demands of the psyche.

Which is a fancy way of saying, “sometimes you have to acknowledge that things are $tupid and F’ed up”

 

[nexus73]

In Freuds Construction of Analysis, he describes how your job is to be an imperfect mediator between the absurdities of reality and the demands of the psyche.

Which is a fancy way of saying, “sometimes you have to acknowledge that things are $tupid and F’ed up”

I prefer your phrasing

 

[whopper]

Vyvanse almost went generic before. It took a legal event to extend the patent. Another company had already put the generic together. I don’t see why they couldn’t hit shelves asap.

Think about this if you're a CEO of a pharm company. Say a medication could go generic in 3 months. You have to build a factory or modify an existing one. Then you have 1 million pills ready to ship out the day it's allowable as a generic. Then "some legal event happens" that extends the patent, and as you mentioned this already happened with Vyvanse. Your 1 million pills have a limited shelf life, and you got a factory you built that only makes this 1 med you spent millions on and you still can't sell your pills. WTF?!?!?

So the smarter thing to do is to wait for the medication to go generic (in a legal sense, not in a "it's available" sense) then get working on making the pills.

Hence the drag time it takes. In the meantime patients who need the med are coitus'd.

In Freuds Construction of Analysis, he describes how your job is to be an imperfect mediator between the absurdities of reality and the demands of the psyche.

I've been spending a lot of time not talking about medicine but the bureaucracy of medicine especially in the last year. Questions like..
1) Why do I have to come in now if telemedicine is fine?
2) Why won't my insurance pay for Vyvanse if it goes generic?
3) Why did my insurance stop paying for Latuda even though the generic won't hit the shelves for months?
4) I can't find Adderall. Why wont the pharmacist help me?

 

[smalltownpsych]

I have worked with a lot of the number one types and my philosophy tends to be to lend my support toward helping the patient develop autonomy. Independence is not something that you are given, it is something you take. I look at it in developmental terms and often begin encouraging healthy defiant behavior. Our systems reward compliance but that is not healthy for someone who has not developed sufficient maturity to have autonomy of self to choose to comply. In other words, to choose, you have to be able to say no.

 

[whopper]

We've had quite a few upset patients, more so in the last year, cause of issues like the above.

I tell patients if they don't understand how their insurance works it's not my fault and kindly refer them to their HR. Their own HR are supposed to be the people who are supposed to deal with this. HR is the part of an organization that gets the medical insurance and acts as a bridge between the health insurance that they picked for their employee and the employee who happens to be your patient.

I hate saying it but you got to break patients in. Especially young patients who magically think that because they have insurance EVERYTHING IS PAID FOR, EVERYTHING.

I also refer them to doctors who don't accept insurance if they want to take that option.

Oh yeah they love that.

What usually happens is when patients go tell me to go eff myself and say they're getting a new doctor, within weeks they're begging me to take them back, (and I'm being nice. I've been put in the role of breaking in the reality that they got to know how their insurance works. That's not my job).

 

[randomdoc1]

We've had quite a few upset patients, more so in the last year, cause of issues like the above.

I tell patients if they don't understand how their insurance works it's not my fault and kindly refer them to their HR. Their own HR are supposed to be the people who are supposed to deal with this. HR is the part of an organization that gets the medical insurance and acts as a bridge between the health insurance that they picked for their employee and the employee who happens to be your patient.

I hate saying it but you got to break patients in. Especially young patients who magically think that because they have insurance EVERYTHING IS PAID FOR, EVERYTHING.

I also refer them to doctors who don't accept insurance if they want to take that option.

Oh yeah they love that.

What usually happens is when patients go tell me to go eff myself and say they're getting a new doctor, within weeks they're begging me to take them back, (and I'm being nice. I've been put in the role of breaking in the reality that they got to know how their insurance works. That's not my job).

So much this. Patients seem to not give at sh** if we get paid and like to think somehow it just works out. Many times I just want to tell them please tell me where to find this magical money. Not just for my living expenses and loans. But to pay the employees, rent, software, utilities etc. they tend to have more personality pathology. I hold our reasonable boundaries and rules firmly. Take it or leave it. You get disruptive in our office, can’t be respectful enough to consider that we have expenses to meet, especially be disrespectful to our non clinical employees (yet kiss *** of the providers and try to staff split) you are fired from this clinic. This happens rarely. But I don’t care if your provider fully buys your version of the story and you villainize everyone else here. I saw what I saw. Help yourself to a 12 month wait at a hospital system for a 15 min med check from an NP who studied online. You get what you give, face the music.

 

[PsyDr]

Think about this if you're a CEO of a pharm company. Say a medication could go generic in 3 months. You have to build a factory or modify an existing one. Then you have 1 million pills ready to ship out the day it's allowable as a generic. Then "some legal event happens" that extends the patent, and as you mentioned this already happened with Vyvanse. Your 1 million pills have a limited shelf life, and you got a factory you built that only makes this 1 med you spent millions on and you still can't sell your pills. WTF?!?!?

So the smarter thing to do is to wait for the medication to go generic (in a legal sense, not in a "it's available" sense) then get working on making the pills.

Hence the drag time it takes. In the meantime patients who need the med are coitus'd.



I've been spending a lot of time not talking about medicine but the bureaucracy of medicine especially in the last year. Questions like..
1) Why do I have to come in now if telemedicine is fine?
2) Why won't my insurance pay for Vyvanse if it goes generic?
3) Why did my insurance stop paying for Latuda even though the generic won't hit the shelves for months?
4) I can't find Adderall. Why wont the pharmacist help me?

#4 is not caused by the issues of generics. It is caused by the SUPPORT Act of 2018, which made the DEA a closed system... from precursor production to distribution through DEA licensed providers. The DEA said that the 2021 production limits were sufficient, failing to take the increase of exports, and increase in diagnosis.

 

[finalpsychyear]

So much this. Patients seem to not give at sh** if we get paid and like to think somehow it just works out. Many times I just want to tell them please tell me where to find this magical money. Not just for my living expenses and loans. But to pay the employees, rent, software, utilities etc. they tend to have more personality pathology. I hold our reasonable boundaries and rules firmly. Take it or leave it. You get disruptive in our office, can’t be respectful enough to consider that we have expenses to meet, especially be disrespectful to our non clinical employees (yet kiss *** of the providers and try to staff split) you are fired from this clinic. This happens rarely. But I don’t care if your provider fully buys your version of the story and you villainize everyone else here. I saw what I saw. Help yourself to a 12 month wait at a hospital system for a 15 min med check from an NP who studied online. You get what you give, face the music.

Yeah. Hilarious how many new patients came once and found out they had a huge deductible and never showed up again. Used to just write it off than try to chase them to pay. Now everything is figured out well before they ever set foot and they are made aware and we have had minimal issues. maybe we are lucky but i would say 90 percent of my panel have small copays 25 or less.

 

[calvnandhobbs68]

So much this. Patients seem to not give at sh** if we get paid and like to think somehow it just works out. Many times I just want to tell them please tell me where to find this magical money. Not just for my living expenses and loans. But to pay the employees, rent, software, utilities etc. they tend to have more personality pathology. I hold our reasonable boundaries and rules firmly. Take it or leave it. You get disruptive in our office, can’t be respectful enough to consider that we have expenses to meet, especially be disrespectful to our non clinical employees (yet kiss *** of the providers and try to staff split) you are fired from this clinic. This happens rarely. But I don’t care if your provider fully buys your version of the story and you villainize everyone else here. I saw what I saw. Help yourself to a 12 month wait at a hospital system for a 15 min med check from an NP who studied online. You get what you give, face the music.

I also agree with your approach of having the doctor bring up payment with patients...I've found this to be much more successful with deliquent patients than having our billing people keep doing it so they just notify me when someone is starting to rack up a balance. I basically say just that, I'm literally not getting paid for the time I'm spending with you if you aren't paying your bills and I can't keep doing work for no pay, so we're going to have to go our separate ways if you can't figure this out.

I also throw the "small business" thing in there every now...along the lines of our small business isn't some huge hospital system that can absorb a ton of loss, the only way we stay in business is if we can collect fully for the services we provide.

I agree that I think a lot of people don't even think about this or realize this and think doctors just "make a lot of money" no matter what they do on their end.

 

[whopper]

#4 is not caused by the issues of generics. It is caused by the SUPPORT Act of 2018, which made the DEA a closed system... from precursor production to distribution through DEA licensed providers. The DEA said that the 2021 production limits were sufficient, failing to take the increase of exports, and increase in diagnosis.

You are correct but this is also caused by what I mentioned. You added more information that was true and important, and (possibly incorrectly interpreting your statement), more so with the stimulants? Cause what I'm talking about is the major problem of a tradename med going generic and now for months the patient can't get the generic cause it hasn't hit the shelves but the insurance companies won't pay for the tradename med because of the time it takes for these generics to actually start hitting distribution to pharmacies.

I also agree with your approach of having the doctor bring up payment with patients...I've found this to be much more successful with deliquent patients than having our billing people keep doing it so they just notify me when someone is starting to rack up a balance. I basically say just that, I'm literally not getting paid for the time I'm spending with you if you aren't paying your bills and I can't keep doing work for no pay, so we're going to have to go our separate ways if you can't figure this out.

And yet oddly there is a legal precedent and often times brought up in ethics that you aren't supposed to bring up money with patients. WTF? There are so many cases where had the patient navigated through the finances they could've EASILY charted to safer and cheaper waters had they known. E.g. on NPR they presented a case of a woman who was bitten by a raccoon, went to the ER for a rabies vaccine and the visit was about $50,000. Had she gone to the county vaccination clinic it would've cost a few hundred dollars and she was still in the safety time zone. No one in the ER brought up the price at all. No one. No one told her it's cheaper at the county clinic.

And this is completely ignoring the bottom line and sometimes the bottom line is what makes the patient face reality better and faster. E.g. thanks to my own medical knowledge I can foresee my shelf-life. It has helped to organize how much stress I'm willing to dish out and factor in how much that stress will affect my health. When patients are told for example that their current path will be unsustainable (e.g. they want a med they can't pay for), we're not supposed to tell them to factor in finances and the future? Or that their health will impact their retirement?

I always bring up "you want to try the cheaper med first that's still a good option?" Heck the idiot "ethics" say I'm not supposed to discuss price. WTF.

 

[mistafab]

You are correct but this is also caused by what I mentioned. You added more information that was true and important, and (possibly incorrectly interpreting your statement), more so with the stimulants? Cause what I'm talking about is the major problem of a tradename med going generic and now for months the patient can't get the generic cause it hasn't hit the shelves but the insurance companies won't pay for the tradename med because of the time it takes for these generics to actually start hitting distribution to pharmacies.



And yet oddly there is a legal precedent and often times brought up in ethics that you aren't supposed to bring up money with patients. WTF? There are so many cases where had the patient navigated through the finances they could've EASILY charted to safer and cheaper waters had they known. E.g. on NPR they presented a case of a woman who was bitten by a raccoon, went to the ER for a rabies vaccine and the visit was about $50,000. Had she gone to the county vaccination clinic it would've cost a few hundred dollars and she was still in the safety time zone. No one in the ER brought up the price at all. No one. No one told her it's cheaper at the county clinic.

And this is completely ignoring the bottom line and sometimes the bottom line is what makes the patient face reality better and faster. E.g. thanks to my own medical knowledge I can foresee my shelf-life. It has helped to organize how much stress I'm willing to dish out and factor in how much that stress will affect my health. When patients are told for example that their current path will be unsustainable (e.g. they want a med they can't pay for), we're not supposed to tell them to factor in finances and the future? Or that their health will impact their retirement?

I always bring up "you want to try the cheaper med first that's still a good option?" Heck the idiot "ethics" say I'm not supposed to discuss price. WTF.

Some psych residency training programs have the residents collect payments for OP visits. At least some folks in medicine are taking this aspect of training seriously. GME had added something like 'cost consciousness' to required clinical competencies at some point.

I'm in the camp that purposefully avoiding discussion of cost is unethical - especially given our fiduciary responsibility implied in "do no harm."

 

[whopper]

especially given our fiduciary responsibility implied in "do no harm."

I think any reasonable person will understand that option A-a med that costs $20 vs option B a med that costs $1200, and the patient makes $30K a year, that if you only offer option B when A could've worked great is wrong.

And yet the "ethics" are what they are. Don't mention money. Seems though that this is changing in our field, albeit too slowly.

 

[allantois]

I used to go out of my way explaining to patients their insurance benefits, even calling pharmacies for them - this was never appreciated and I was always made the bad guy in the end. Now I just prescribe the cheap stuff or will only prescribe expensive stuff if they can afford to self-pay for it. There’s also pharmacies which will do PAs for you

 

[tr]

I hate saying it but you got to break patients in. Especially young patients who magically think that because they have insurance EVERYTHING IS PAID FOR, EVERYTHING.

I love it when they think it's our job to deal with their issues with their insurance company. One patient accused me of making her "the go-between" when I suggested she call her insurance company herself to get her coverage issue addressed.

 

[randomdoc1]

I love it when they think it's our job to deal with their issues with their insurance company. One patient accused me of making her "the go-between" when I suggested she call her insurance company herself to get her coverage issue addressed.

Technically, us billing insurance for them, is a courtesy. The onus is on the patient to sent their own claims even if we are in network. The provider actually does not have to. Talk about personality pathology. That person would have been discharged out of my office so fast. Because you know payment will be a chronic issue and she's gonna be eating up a lot of time. Which tends to generalize into being a terrible therapy candidate anyways.

 

[allantois]

Technically, us billing insurance for them, is a courtesy. The onus is on the patient to sent their own claims even if we are in network. The provider actually does not have to. Talk about personality pathology. That person would have been discharged out of my office so fast. Because you know payment will be a chronic issue and she's gonna be eating up a lot of time. Which tends to generalize into being a terrible therapy candidate anyways.

I will add wanting brand name meds into that as well. Ok yes, I will send you brand name Adderall. They will likely not be able to afford it and will not come back/

 

[whopper]

That person would have been discharged out of my office so fast. Because you know payment will be a chronic issue and she's gonna be eating up a lot of time. Which tends to generalize into being a terrible therapy candidate anyways.

I tell patients that ineffectively eat up a lot of time that they're going to have to come to my office way more often. E.g. one guy called my office daily over stuff that had nothing to do with treatment. I told him he was clogging my receptionist which could be dangerous because we might miss a call that was an emergency. So, I told him, if you feel you need to call my office daily, there's likely some issue going on, so our meetings better become daily until we figure out what's going on so he could call the office less.

Guy fired me. (THANK GOD!)

 

[Stagg737]

1, 2 and 4 can be solved by working for the VA (yes, the VA will provide/cover emergent dental care for otherwise ineligible inpatient veterans). As far as 3, it's just a documentation issue. I mean it's a very important documentation issue because the patient/family may indeed try to sue you if something goes wrong, but it's still a documentation issue. That's one where I would have a patient sign something if they want to continue.

Curious about the second situation where you're at. Where I did residency, the VA dental team would do an assessment and extraction for anyone, but would not provide any other dental services unless patient had 100% SC. Had a couple what I would have called emergent situations (symptomatic abscess stuff) where dental refused to treat and told us to just have IM/gen surgeons take care of it.

 

[comp1]

Yes, I meant just extractions for <100% SC. That's usually the treatment for an abscess along with antibiotics. If there was more than that it might indeed need a surgical consult. Outside the VA though, you usually can't even get the extraction.

 

[Candidate2017]

These are just basic issues encountered in all medicine:

1. Family enmeshment, a.k.a. child psych: Punt.
2. Lack of consultant/consultant is outpatient-only: request consult from most similar specialty (or IM), monitor for emergencies and need to send to ER; stabilize chief complaint and SW coordinates post-DC follow up.
3. Med risks and benefit: Every single patient encounter.
4. Insurance issues: Switch meds. Ideally, generics all the way, and bonus points for Molindone.

I've been spending a lot of time not talking about medicine but the bureaucracy of medicine especially in the last year. Questions like..
1) Why do I have to come in now if telemedicine is fine?
2) Why won't my insurance pay for Vyvanse if it goes generic?
3) Why did my insurance stop paying for Latuda even though the generic won't hit the shelves for months?
4) I can't find Adderall. Why wont the pharmacist help me?

1, 2, 3: Your insurance sucks.
4: I don't know. BTW did I tell you your insurance sucks?

 

[OldPsychDoc]

My only comment is that your title is wrong.
There's nothing "Weird" about these. This is everyday business-as-usual psychiatry in the wonderful world of American medicine.

 

[whopper]

Agree. One of those things where it happens quite a lot. Just never talked about in training unless outside the textbook.