Your most frustrating illness to treat?

[FrustratedFamDoc]

Give me the uncontrolled Bipolar, schizophrenic ilegal substance abuser asking for (demanding) 2 mg Alprazolam QID b/c "it's the only thing that's ever worked and I've been tried on EVERYTHING" before giving me the unmotivated diabetic any day of the week please!

Is it just me or is diabetes the most frustrating condition to treat? At least 25% of my population is totally unmotivated to make real changes to potentially cure themselves of this ailment, and at each visit when they're 3-5 lbs heavier, it always nothing but salad and water that they've had.... no idea how I gained that weight doc! Moreover, with the unaffordable care act standards and PCMH and the new pay for performance standards, their unmotivated butts are really going to knock us. I'm in a small town and endocrine is already booked up 3 mos in the future.... if you've got good insurance. Sure I could just drop them as patients but it's always more complicated than that. Many of these fall in to the realm of no money/no insurance... but they're good people.

How have you guys managed to fade the frustration of the endless 9+ A1c and already on 3 oral agents in the unmotivated but broke and no insurance population?

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[JustPlainBill]

That I can live with -- I just give them the JPB Blue Light Special speech -- "This can make you go blind, we treat you like you've already had 1 heart attack, it makes you more susceptible to a stroke, if you don't get it controlled, we will likely have to start you on dialysis and begin removing significant portions of your pedal anatomy before too long --- oh, and by the way, for men, it can directly affect your ability to achieve and maintain an erection satisfactory of penetration" ---

The one's I want to scream at are the "cough, cold, nasal congestion x 2 days" -- usually want a ZPack, steroid shot, Medrol dose pack, inhaler and narcotic cough syrup ----

 

[styphon]

I have no problem treating non compliant diabetics.

The most frustrating to me are worried well hypochondriacs who spend all day looking at webMD.

 

[JustPlainBill]

I have no problem treating non compliant diabetics.

The most frustrating to me are worried well hypochondriacs who spend all day looking at webMD.

Like the kind who want a complete serologic workup for a hordoleum as they are convinced it's a sign of a grim systemic illness....No, I am not kidding -- up to and including Lyme disease, hantavirus, and Crutzfeld/Jacob disease ---....

 

[FrustratedFamDoc]

Perhaps I just look at it different. To me the hypochondriac is really just begging you to read between the lines. 'so I've got a pretty rough anxiety problem, but I'm going to come see you every week until you finally ask me about it... Usually with several very frustrating non-specific somatic complaints....but it'll always involve fatigue... Just to keep you even more frustrated.'

to me, one of the easiest thins to say is, 'look man, you've been here every other week for the last 3 months with something different each time. You're nerves are really killing you these days, aren't they?' if they bust out the list on me, that's even more confirmation.

What is y'all's solution to the no money/no insurance unmotivated guy/gal with an A1c of 10 who is already on 3 $4 meds but can't afford insulin? I Guess I just haven't figured it out yet.

 

[deleted87716]

What is y'all's solution to the no money/no insurance unmotivated guy/gal with an A1c of 10 who is already on 3 $4 meds but can't afford insulin? I Guess I just haven't figured it out yet.

NPH and regular insulin is cheap. If you want the fancy branded stuff, there's always the pharma indigent plans. No excuses.

As for the lack of motivation, I'll work with anyone up to a point. After that, they don't need my help to take crappy care of themselves.

 

[deleted87716]

Like the kind who want a complete serologic workup for a hordoleum as they are convinced it's a sign of a grim systemic illness....No, I am not kidding -- up to and including Lyme disease, hantavirus, and Crutzfeld/Jacob disease ---....

Meh. Ophtho referral.

 

[JustPlainBill]

Perhaps I just look at it different. To me the hypochondriac is really just begging you to read between the lines. 'so I've got a pretty rough anxiety problem, but I'm going to come see you every week until you finally ask me about it... Usually with several very frustrating non-specific somatic complaints....but it'll always involve fatigue... Just to keep you even more frustrated.'

to me, one of the easiest thins to say is, 'look man, you've been here every other week for the last 3 months with something different each time. You're nerves are really killing you these days, aren't they?' if they bust out the list on me, that's even more confirmation.

What is y'all's solution to the no money/no insurance unmotivated guy/gal with an A1c of 10 who is already on 3 $4 meds but can't afford insulin? I Guess I just haven't figured it out yet.

Social worker to try to get funding and/or county health plans....

 

[JustPlainBill]

Meh. Ophtho referral.

Exactly what I did -- but it was an interesting discussion with a "I've done my research on the internet" significant other -- I have amazing self-control sometimes --- but no workup done....

 

[JustPlainBill]

Sweet, smilin', slippery baby Jesus --- I love the "I just know that this is ---" pick your poison ---- or "I promise you there's nothing wrong with my heart ---"....can you tell what I've had a run of over the last 2 days?!!!!

 

[drcrispmd]

Perhaps I just look at it different. To me the hypochondriac is really just begging you to read between the lines. 'so I've got a pretty rough anxiety problem, but I'm going to come see you every week until you finally ask me about it... Usually with several very frustrating non-specific somatic complaints....but it'll always involve fatigue... Just to keep you even more frustrated.'

to me, one of the easiest thins to say is, 'look man, you've been here every other week for the last 3 months with something different each time. You're nerves are really killing you these days, aren't they?' if they bust out the list on me, that's even more confirmation.

What is y'all's solution to the no money/no insurance unmotivated guy/gal with an A1c of 10 who is already on 3 $4 meds but can't afford insulin? I Guess I just haven't figured it out yet.

Most drug companies have patient assistance programs. I use levemir's a lot. The applications are on their website. I have several for different drugs saved on my computer in their own folder. The patient just fills it out and brings it and their income proof back. You fill out the rx portion and fax it in. I have a lot of patients with no insurance. I have not had one turned down yet. The others I use a lot are januvia/janumet and/or invokana/invokamet.

 

[cabinbuilder]

Sweet, smilin', slippery baby Jesus --- I love the "I just know that this is ---" pick your poison ---- or "I promise you there's nothing wrong with my heart ---"....can you tell what I've had a run of over the last 2 days?!!!!

I totally despise the geriatric grandmother who comes in for dizziness.

 

[deleted87716]

I totally despite the geriatric grandmother who comes in for dizziness.

http://www.aafp.org/afp/2010/0815/p361.html

 

[VA Hopeful Dr]

http://www.aafp.org/afp/2010/0815/p361.html

Eh, I didn't mind dizziness in practice but in an urgent care setting it can be frustrating since you don't have follow up (or at least, you shouldn't).

 

[JustPlainBill]

Eh, I didn't mind dizziness in practice but in an urgent care setting it can be frustrating since you don't have follow up (or at least, you shouldn't).

How many times have I heard,"Well, you're my PCP" when I'm working in an urgent care clinic -- only to respond,"No, I'm not and this is an URGENT care" -- "well, I always come here for my BP/thyroid/inhaler refills" -- and it's at that point I usually pull the filter off and let them hear the stream of consciousness aka Physician's Inner Monologue that's going on while I'm doing my exam -- usually, on the first abnormal finding or Big/Bad/Evil (tm) r/o that I do, they stop me and ask WTF I'm talking about -- it's at that point that I begin to discuss further workups for the Big/Bad/Evil (tm) that I've just attempted to r/o on physical exam -- usually that gets them to realize they don't want some doc they just met and may never see again to do their continuity care and they agree to go to their PCP ---

What's interesting is when the medical director for an urgent care tells you to go ahead and give BP/thyroid/inhaler refills -- in spite of the fact that the patient has promised,promised,promised to find a PCP in a suburb of 60 thousand who has insurance to manage their BP/thyroid/inhaler needs-- but keeps coming back for clonidine refills "cause I've tried everything else and it doesn't work for me" -- why refill? well, the medical director is concerned that if the patient leaves and has an event related to uncontrolled BP, the clinic is on the hook.....

So I do what good I can, realize that it's not worth getting excited over, educate where I can and move on.....

Remember, at least in one large southern state, the song most physician's sing is ---

"Hold the pickles,
hold the lettuce,
special orders don't upset us,
all we ask is that you let us serve it your way...
Have it your way,
have it your way,
have it your way
at ....."

The Burger King Theme song ----

 

[cabinbuilder]

How many times have I heard,"Well, you're my PCP" when I'm working in an urgent care clinic -- only to respond,"No, I'm not and this is an URGENT care" -- "well, I always come here for my BP/thyroid/inhaler refills" -- and it's at that point I usually pull the filter off and let them hear the stream of consciousness aka Physician's Inner Monologue that's going on while I'm doing my exam -- usually, on the first abnormal finding or Big/Bad/Evil (tm) r/o that I do, they stop me and ask WTF I'm talking about -- it's at that point that I begin to discuss further workups for the Big/Bad/Evil (tm) that I've just attempted to r/o on physical exam -- usually that gets them to realize they don't want some doc they just met and may never see again to do their continuity care and they agree to go to their PCP ---

What's interesting is when the medical director for an urgent care tells you to go ahead and give BP/thyroid/inhaler refills -- in spite of the fact that the patient has promised,promised,promised to find a PCP in a suburb of 60 thousand who has insurance to manage their BP/thyroid/inhaler needs-- but keeps coming back for clonidine refills "cause I've tried everything else and it doesn't work for me" -- why refill? well, the medical director is concerned that if the patient leaves and has an event related to uncontrolled BP, the clinic is on the hook.....

So I do what good I can, realize that it's not worth getting excited over, educate where I can and move on.....

Remember, at least in one large southern state, the song most physician's sing is ---

"Hold the pickles,
hold the lettuce,
special orders don't upset us,
all we ask is that you let us serve it your way...
Have it your way,
have it your way,
have it your way
at ....."

The Burger King Theme song ----

\

Sounds like you need to get out of this city thing you are in and move on to better things where the patients actually appreciate you being open and the administration no longer is relevant to you. AKA: locums.

 

[deleted87716]

Yeah, my theme song for noncompliant patients goes more like this...

 

[JustPlainBill]

Yeah, my theme song for noncompliant patients goes more like this...

So -- BD -- would you mind enlightening me on your criteria for "discharging" a patient from your practice for non-adherence (kinder, gentler phrase we were required to use in residency -- at least the residents were -- attendings, following the dictum "Do as I say, Not as I Do" were allowed to talk trash about their patients but we got scolded -- yes, I still strongly dislike that place)....and one that doesn't cause you grief with your local medical board....

 

[deleted87716]

So -- BD -- would you mind enlightening me on your criteria for "discharging" a patient from your practice for non-adherence (kinder, gentler phrase we were required to use in residency -- at least the residents were -- attendings, following the dictum "Do as I say, Not as I Do" were allowed to talk trash about their patients but we got scolded -- yes, I still strongly dislike that place)....and one that doesn't cause you grief with your local medical board....

Chronic, recurrent non-adherence to treatment and/or follow-up of a serious medical condition, putting their life and/or health at risk (e.g., uncontrolled diabetes, hypertension, CAD, etc.)

I'm not talking about people who can't afford their meds or anything like that. I can work with those folks. I'm talking about the ones who just don't give a crap.

 

[brats800]

Chronic pain. I don't want to come at these visits cynical and assuming the patient is a seeker / abuser but pain patients are so high-maintenance and I've had failed drug screens too many times to trust these patients.

 

[VA Hopeful Dr]

Chronic pain. I don't want to come at these visits cynical and assuming the patient is a seeker / abuser but pain patients are so high-maintenance and I've had failed drug screens too many times to trust these patients.

That's easy - stop writing for chronic narcotics. All my new patients sign a contract that explains that I don't do chronic controlled substances.

I can make exceptions if I wish - like the 85 year old who takes a single norco at bedtime to help her arthritis. Otherwise, offer other treatments or refer.

 

[smq123]

Chronic pain. I don't want to come at these visits cynical and assuming the patient is a seeker / abuser but pain patients are so high-maintenance and I've had failed drug screens too many times to trust these patients.

We have signs up in all the clinic rooms that explains that none of us write for chronic pain meds. My MA just points to the sign now whenever patients come in asking for Norco refills.

 

[cabinbuilder]

That's easy - stop writing for chronic narcotics. All my new patients sign a contract that explains that I don't do chronic controlled substances.

I can make exceptions if I wish - like the 85 year old who takes a single norco at bedtime to help her arthritis. Otherwise, offer other treatments or refer.

This I would do. Had deadbeat come through urgent care this week, "in total agony" because his finger tuft fracture from 10 DAYS AGO "was keeping him up at night" and wanted narcotics while his girlfriend was tweaking in the lobby. Right. He left with some 800mg IBU. Amazing, the next day I have a guy with such a bad ankle sprain that I sent for MRI cuz his foot was almost black who refused a Rx for pain meds. Sigh........ all in a day.

 

[deleted87716]

Two words: "Lodine" (sounds like "codeine"), and "Dolobid" (say it fast...sounds like "Dilaudid.")

 

[Bacchus]

Meh. Ophtho referral.

When I do this, referrals that I don't think need to happen, I'm sure to put "Patient requested" as the first part of my reason for sending, haha.

 

[drcrispmd]

Two words: "Lodine" (sounds like "codeine"), and "Dolobid" (say it fast...sounds like "Dilaudid.")

I have used the dolobid several times. Have not tried the lodine one but will.

All patients in my office sign a paper with new patient paperwork that says they understand that we do not routinely prescribe chronic narcotics or benzos. No one has ever remembered signing it. I revised our controlled substance contract when I started working there. We have had several cut off or referred elsewhere after their drug test or other violations.

 

[mabinante]

Two words: "Lodine" (sounds like "codeine"), and "Dolobid" (say it fast...sounds like "Dilaudid.")

This is amazing. I'm going to use this.

 

[Board Vitals]

Give me the uncontrolled Bipolar, schizophrenic ilegal substance abuser asking for (demanding) 2 mg Alprazolam QID b/c "it's the only thing that's ever worked and I've been tried on EVERYTHING" before giving me the unmotivated diabetic any day of the week please!

Is it just me or is diabetes the most frustrating condition to treat? At least 25% of my population is totally unmotivated to make real changes to potentially cure themselves of this ailment, and at each visit when they're 3-5 lbs heavier, it always nothing but salad and water that they've had.... no idea how I gained that weight doc! Moreover, with the unaffordable care act standards and PCMH and the new pay for performance standards, their unmotivated butts are really going to knock us. I'm in a small town and endocrine is already booked up 3 mos in the future.... if you've got good insurance. Sure I could just drop them as patients but it's always more complicated than that. Many of these fall in to the realm of no money/no insurance... but they're good people.

How have you guys managed to fade the frustration of the endless 9+ A1c and already on 3 oral agents in the unmotivated but broke and no insurance population?

Hello,
I think being a primary care physician is very very frustrating in this society because it is our jobs to educate patients and explain why we cannot prescribe a Z-pack after 2 days of nasal congestion or why we cannot hand out Percocet, diet pills etc without the proper protocol treatments. Diabetes is frustrating and I have learned to show pictures of amputations a end-stage diseases that are caused by diabetes. Unfortunately we are not allotted enough time in the office to counsel our patients so I think training the office staff to teach and counsel whenever possible is very very important. We are teachers first and I think it is important to always remember that before becoming frustrated. We are dealing with patients who did not go to medical school. ~M.D. Editor/Author BoardVitals