Someone explain to me

[OuttaLuckMove]

I do a procedure, say an L5-S1 intralaminar epidural, and patient says they got 80% relief, but they are here for their legacy monthly refill of ms contin 15mg BID and morphine IR 15 QID for their 8/10 pain. Don't worry... It's under 90 OME so that means that it is okay. They are getting their alprazolam from their psychiatrist, I'm not the one writing it, so it's obviously okay. It makes no sense. There are only a few cases where the medication management doesn't essentially seem like I'm treating opioid use disorder. What am I actually doing? Every day I feel like I'm crazy for wondering why most of my patients have OME that magically comes out to 90. It seems like the magical regimen for curing most pain just somehow comes out to be oxycodone 10 every 4 hours.

50% of my panel are med refills in their 30s-60s, 48% are med refills who I do procedures on (that are indicated), 2% are my own follow up patients I've established with and kept off opioids with adequate follow-up and usually procedures. This is something I was shielded from in fellowship at an academic hospital. It is driving me crazy with the pressures from owners to keep patients happy. Now I'm stuck in a remote part of the state with my spouse, a non-compete, a sign-on bonus to pay back if I left, and tail coverage to pay for if I left.

Hope this helps any future fellows. I'm not sure how I would have changed how I looked at jobs prior to this as this is not what was presented to me during the interview stage. Now I'm looking at upending our lives again for a move to work somewhere that hopefully I won't come home feeling miserable about what I'm contributing to the community every day.

---

Members don't see this ad.

 

[lobelsteve]

Do more frequent UDS and you will stop more opiates in patients with aberrant behaviors. Then transition to bupe. They stay and are off traditional opioids. Set a drop dead date for 6 mo out that no one on bzd will get opioids. Another aberrant behavior averted.

Say this a lot: “that’s not how I treat pain.”

 

[OuttaLuckMove]

Do more frequent UDS and you will stop more opiates in patients with aberrant behaviors. Then transition to bupe. They stay and are off traditional opioids. Set a drop dead date for 6 mo out that no one on bzd will get opioids. Another aberrant behavior averted.

Say this a lot: “that’s not how I treat pain.”

That's a good suggestion and I will probably start implementing that tomorrow. Thanks. I just cannot shake the feeling that most of the time any opioid (partial or full agonist) is just not the right treatment, and I am actively harming them. A 30 something year old mom of five who has scoliosis shouldn't be on 90 OME, but in the end my patient reviews that are submitted immediately after the visit are the most important thing to the physician owners.

 

[Agast]

Have you tried tapering or rotating those patients and met resistance?

 

[Ferrismonk]

It's a hard situation, but unfortunately a very common one.

What you're describing is what most pain clinics (in my experience at least) were like 10-15 years ago. With the exception that now the patients are limited to 90MMED to comply with 2016 CDC recommendations. I guarantee that there is nothing magical about pain control 90MMED, and your patients would be just as miserable, or more miserable, on higher doses.

What you need to do is completely dependent on what your contract says and what your relationship with the owners is. Have you talked to the owners to voice your concerns? That would be my first step.

Ultimately what you do, each procedure and each medication refill, is on you and your medical license. That puts you in a tough spot. Luckily, it doesn't sound like they're making you do anything illegal and it's all above board, albeit not desirable.

I agree with Steve, if you simply tighten your compliance measures, you'll be amazed how many of your patient's aren't actually doing what they appear at your monthly visits. Increase UDS frequency and make them more randomized. Call people in mid-month for UDS or pill counts. Be very strict on refill dates, no "extra" days of pills out there. Make sure you're testing for THC and EtOH. Tell them they need to wean off benzos or you'll wean off opioids after a certain time frame. Of course, you'll need to show your evidence why you're doing this to the owners prior.

 

[OuttaLuckMove]

It's a hard situation, but unfortunately a very common one.

What you're describing is what most pain clinics (in my experience at least) were like 10-15 years ago. With the exception that now the patients are limited to 90MMED to comply with 2016 CDC recommendations. I guarantee that there is nothing magical about pain control 90MMED, and your patients would be just as miserable, or more miserable, on higher doses.

What you need to do is completely dependent on what your contract says and what your relationship with the owners is. Have you talked to the owners to voice your concerns? That would be my first step.

Ultimately what you do, each procedure and each medication refill, is on you and your medical license. That puts you in a tough spot. Luckily, it doesn't sound like they're making you do anything illegal and it's all above board, albeit not desirable.

I agree with Steve, if you simply tighten your compliance measures, you'll be amazed how many of your patient's aren't actually doing what they appear at your monthly visits. Increase UDS frequency and make them more randomized. Call people in mid-month for UDS or pill counts. Be very strict on refill dates, no "extra" days of pills out there. Make sure you're testing for THC and EtOH. Tell them they need to wean off benzos or you'll wean off opioids after a certain time frame. Of course, you'll need to show your evidence why you're doing this to the owners prior.

Have you tried tapering or rotating those patients and met resistance?

Yes, I was told to not taper patients because there is no point if they are doing fine on their current regimen. With new patients, lately I've been told to just continue their current regimens because there's no harm in it if they are stable.

Yes we had a meeting that basically went nowhere. I was told that I should be using my best judgment for prescribing and if there are no red flags should continue their regimens. I was questioned by the clinic manager why I would write "consider tapering" in my notes for legacy patients if they had been doing well. Ultimately the meeting was being recorded and they were being very politically correct.

My first few months were peachy where I was doing okay and tapering patients as possible when it was an amicable plan with the patient. I made a one chance policy where if a UDS was negative or had some aberrancy, that was the one chance they had with me. Every other doc in the clinic gives patients up to 8-10 chances before cutting the patient off. Most patients were fine with being switched to suboxone. Then I got one negative google review and had the hammer come down on me by the owners as if it was the excuse they needed to put me on notice after a large pain management clinic closed due to the owner "retiring". How could I treat patients this way? In what world is it okay for me to call patients "junkies"? Of course I didn't actually do or say what the patient claims, but per the owners I should have just continued their regimen for something completely not indicated. The next google review, a friend of the first patient, said basically the same thing. Despite accepting the patient and them agreeing to a taper, they are now following with one of the owners who justified maintaining their high OME.

 

[Ferrismonk]

As a counter, guidelines say you should periodically try to wean to the "lowest effective dose".

You should understand though that they hired you specifically to write meds and keep the churn going. They won't be happy if you stop unless you're bringing in major procedures.

 

[RoloTomassi]

You need to just move to a non-opioid practice before you burn out. Hopefully you know what questions to ask and how to suss it out this time around. Remote part of the state is almost always a red flag for heavy meds

 

[OuttaLuckMove]

As a counter, guidelines say you should periodically try to wean to the "lowest effective dose".

You should understand though that they hired you specifically to write meds and keep the churn going. They won't be happy if you stop unless you're bringing in major procedures.

This wasn't advertised to me during the job hunt. In fact it was the opposite, with one of the owners telling me they want to get away from med management. Now I'm stuck.

For what it's worth I brought in 250k in payments in the first 3 months I worked here with nearly 35% of my patients having medicaid. Routinely did about 30 fluoro procedures a week that I brought in which I know is not a lot for most people, but was for me as a new attending.

 

[OuttaLuckMove]

You need to just move to a non-opioid practice before you burn out. Hopefully you know what questions to ask and how to suss it out this time around. Remote part of the state is almost always a red flag for heavy meds

And my biggest mistake of all was buying a house here. Hope some people learn from me

 

[Centurion38]

You need to take YOUR medicine and get a new job and move. This job is going to destroy you personally and professionally. It could even be dangerous for you and your family, if you elect to taper the wrong patient and take away their medication (read: mortgage payment/IV drug money/child support money/cigarette and alcohol stipend).

No joke.

Sadly, this is about average for most private practice jobs- esp. if Anesthesia based. Good luck

 

[OuttaLuckMove]

You need to take YOUR medicine and get a new job and move. This job is going to destroy you personally and professionally. It could even be dangerous for you and your family, if you elect to taper the wrong patient and take away their medication (read: mortgage payment/IV drug money/child support money/cigarette and alcohol stipend).

No joke.

Sadly, this is about average for most private practice jobs- esp. if Anesthesia based. Good luck

I spent today applying to other jobs. It sucks to be honest because other than the whole logistics of moving/selling our home/tail coverage, etc., I work hard and hustle. I'm in clinic an hour before other docs, I leave clinic at least an hour or two after other docs. I call patients personally to follow up on how they do after I transition them to suboxone, or after it's been a week s/p epidural. I've worked hard on referrals and worked hard on getting local orthopods to trust me in the short time I've been here... Mostly because they know I won't run down a checklist of procedures for their patient and that the patient won't come back to them on percs. I don't know that any hospital employed position will have the same potential for rewarding hard work as opposed to just doing what's on my schedule.

Thanks everyone for letting me basically just vent here. I know I need to leave the job. I'm just mad at myself for thinking I knew better than everyone else. The rental market here is absolutely horrific and most docs buy when they get here so it is a little different from the norm, but still I thought that I would be the exception to the rule for doing well in the first job.

 

[Agast]

Yes, I was told to not taper patients because there is no point if they are doing fine on their current regimen. With new patients, lately I've been told to just continue their current regimens because there's no harm in it if they are stable.

Yes we had a meeting that basically went nowhere. I was told that I should be using my best judgment for prescribing and if there are no red flags should continue their regimens. I was questioned by the clinic manager why I would write "consider tapering" in my notes for legacy patients if they had been doing well. Ultimately the meeting was being recorded and they were being very politically correct.

Oh boy that’s really weird and….why were they recording you? I’d find a new job just for that

 

[OuttaLuckMove]

Oh boy that’s really weird and….why were they recording you? I’d find a new job just for that

I'm assuming that they were recording me. The group was starting to talk about some artificial intelligence software and the best way to inform patients about recording the visit, when the primary owner said something like "Well, good thing we live in a one party consent state" or something like that. It just seemed weird.

 

[Centurion38]

HOPD jobs can be extremely rewarding both personally and professionally. Many offer a lot more personal control over your schedule than your typical PP job working for a physician "owner."

Ask @lobelsteve or @Ducttape

The reason you didn't see this crap in fellowship was that your academic HOPD docs (a frequent target of Hans Herman Hoppe acolytes here) were able to SCREEN their patients to filter out this refuse. They weren't cooling their heels in meetings being given marching orders by an "office manager."

Ayn Rand fanboys and haters on this forum may not like the wRVU system but it is a fair way, IMO, for paying physicians for their work and not ultimately what is collected, or not collected due to the inattention/malfeasance of whatever GED certificate does your billing, or whatever is stolen from you by the physician "owner" who diverts all the patients with decent reimbursement/DME revenue/in house UDS receipts etc....and dumps the rest on you.

If you are this morally conflicted already, then go to Academics, HOPD (do your research) or open a solo PP where you make the rules. The last option will involve a lot of upfront cost, risk and capital but ultimately could be rewarding in the right AO. All you have to do is work 5am-9pm and read the Fountainhead twice daily.

Or just leave Pain altogether. If you are Anesthesia trained, there's never been a better time to do so.

I spent today applying to other jobs. It sucks to be honest because other than the whole logistics of moving/selling our home/tail coverage, etc., I work hard and hustle. I'm in clinic an hour before other docs, I leave clinic at least an hour or two after other docs. I call patients personally to follow up on how they do after I transition them to suboxone, or after it's been a week s/p epidural. I've worked hard on referrals and worked hard on getting local orthopods to trust me in the short time I've been here... Mostly because they know I won't run down a checklist of procedures for their patient and that the patient won't come back to them on percs. I don't know that any hospital employed position will have the same potential for rewarding hard work as opposed to just doing what's on my schedule.

Thanks everyone for letting me basically just vent here. I know I need to leave the job. I'm just mad at myself for thinking I knew better than everyone else. The rental market here is absolutely horrific and most docs buy when they get here so it is a little different from the norm, but still I thought that I would be the exception to the rule for doing well in the first job

 

[Norepi]

OP, I am sorry you are going through this. For whatever it's worth, I newly finished fellowship and didn't even make it 1 year before I decided this juice wasn't necessarily worth the squeeze. I got a taste of "real" private practice pain in a large metro area and after a decent amount of research, I concluded that unless I take a hospital employed position where I don't feel pressured to run pill addicts through an injection hamster wheel, I wasn't going to be happy. Never in my life did I think I'd have to put up with some of the treatment by some of the patients in the name of padding Google reviews, pleasing unrealistic PCPs. Patients straight up threatening to "take their business elsewhere" and me having to entertain that. Eventually I asked myself what am I doing for these people and recently transitioned to gas working no in house call, no weekends or nights for more pay and a consistent schedule. Maybe I'll come back, I don't regret doing the fellowship but me being naive about the realities of how the sausage is made outside of large centers led to me departing with a sour taste in my mouth. Happy to chat further.