Medical Ethics - as Required of MD's

In My Humble Opinion
21

Yeah, sounds like you’re kind of screwed. 30 mg temazepam isn’t a particularly high dose, but lots of docs are unreasonably scared of benzos. Ironically, your case would be much stronger if she were abruptly discontinuing something which could cause life-threatening withdrawal if stopped abruptly.

However, this isn’t medical abandonment. First off, she* isn’t *refusing to treat you, she’s just refusing to treat you in the particular way you would like to be treated, and the treatment plan she is offering is well within the bounds of standard medical practice.

And if she were refusing to treat you, the obligation to refer you elsewhere is pretty light, and certainly doesn’t require her to find a doctor who will give you the particular treatment you want.

The one time I actually had to fire a patient, I consulted my lawyer and was told that saying “there are lots of great doctors in the phone book, and here’s the address of the free clinic” was sufficient. Which is good, because no way in hell was I going to send that person to anyone I actually knew. It might be different in the case of someone practicing a rare subspecialty and/or in an area with very few doctors.

22

I can empathize with UsedtoBe (and Panache) to some extent. Chronic pain is hard to cope with and makes you cranky and you want it solved NOW. While the doctor may be treating Usedtobe with correct medical protocols what I don’t see happening is good “bedside manner”. I know it’s a difficult situation, but when you can’t give the patient as much pain relief as he wants, the worst thing you can do is to blow off his concerns. Can the doctor find some way to discuss the issue to at least sound compassionate and explain better why she’s doing the taper and what she plans for future treatment?

23

For all we know, usetobe’s doctor could be titrating him off of his meds because she no longer thinks he needs them. The OP still has not told us what pain the painkillers were prescribed to treat.

24

Or she wants to eliminate rebound pain and start him off with a clean slate to evaluate his true pain levels. Remember, this is a person who claims to have been unable to sleep without medical intervention since puberty. Considering that sleep aids, particularly prescription sleep aids, are less about mimicking real sleep and more about putting you into the equivalent of a temporary coma, we’re talking about alleged decades of not getting any kind of rejuvenating, healing sleep. This isn’t doing anything for his alleged chronic pain.

I’d really like to see the original email that the doctor states she won’t address.

25

I was diagnosed in 2005 with osteoarthritis - bone-on-bone pain.
Stated with vicodin, then dilaudid. This bozo decided that morphine was better than dialaudid.
It wasn’t.
She very happily wrote 45mg morphine ER 3x daily for years.
And 2 benzos for sleep - temazepam and clonazepam.

Then DEA and UCD whent on which hunt for opioids and/or benzos.

She is a low-level doctor - rather than defend her actions, she decided that dumping me was safer.

Here is the part you missed: she refused, without notice or warning to renew the sleeper on 1/27.
Because I had been having the script mailed, the refill arrived 2-3 days early.

By 2/16 (when all hell broke loose), I still had sleepers.
Because it was no longer on the CURRENT meds (script not renewed = no longer current) I was not given any sleeper for 5 days of hell with a foley up my dick.

At this point, ,I get one or 2 good days and then spend 2-3 in bed barely keeping cat fed and watered.
I think I want induced coma - come out healthy or dead, but not this damned in-between.

I got the new printer working, and will send a bunch of links to my email, where I can pull them up from any machine.

She may not be required to treat me to my satisfaction, but if she is going to do a 180 degree turnabout, notice and mitigation is required.

Her “find me a pain specialist” consisted of printing off a list the UCD had (some of the phone numbers were obsolete) and telling me to “find one”.

I talked to the Internal Medicine Group, but will make no changes until speak with lawyer.

This PCP takes off days and weeks w/o notice - I suspect she has maybe 5 patients and sees no reason to be in the office “just in case”.
The exam room has a mirror which allows the patient to see who is opening the door - not only is her lab coat starched at 4:00 p.m., she puffs up her hair and onetime adjusted her stethoscope.

O - one time, the nurse was having a tough time getting a BP reading, left when MD arrived, and came back in as soon as the MD left.
My BP was 10 points HIGHER after the chat.
Nurse was appalled. “It was not a pleasant conversation” was all I said - the nurse bolted.

26

I gave me sister the userid and password for my UCD portal.Would you like to see all 8 years?

Too bad.

27

I assumed it was something similar to what they wrote in reply to that email–people don’t generally do an about-face in these situations, especially when they’re heated like the OP.

Unless your doctor is Conrad Murray, things like “When I say I need a pill, it really means I NEED a pill” won’t generally yield a response. And I find it hard to believe that they’d go from talking about their symptoms to sentences like that with minimal turn around time.

28

I have never threatened anyone in any way. I am, prompt, corteous, and you see from the quote above how I disagree with her.
My prior PCP was a locally (SF CA) famous oncologist - and I left that practice only because of financial reversal.

Even the UCD hospital cites the morphine as the reason for my hospitalization.

She is rapidly running out of friends.

My kidney function was rock solid from 2008 - 2017. I am now near death due to kidney failure, caused by her morphine.

Kinda hard to say “you deserved it”, ain’t it?

29

Here are the hospital’s tests.

Creatinine is the name of the primary toxin removed (or not) by kidneys. Ref. is < 1.27
2/16 - 4.25 (admit)
2/21 - 2.04 (discharge)
3/9 - 3.33 (apt re sleeper and ability to pee - it took over a week to get a damned prostate pill!

That morphine has deprived me of the little life I had left.
This shit is NOT GOING AWAY!
03/09/2017 CBC WITH AUTO DIFFERENTIAL - Already viewed Burl Robert Don, MD
03/09/2017 BASIC METABOLIC PANEL - Already viewed Amy Mae Yip, DO
02/21/2017 HEPATIC FUNCTION PANEL - Already viewed John Frederick MacMillan, MD
02/21/2017 MAGNESIUM (MG) - Already viewed John Frederick MacMillan, MD
02/21/2017 BASIC METABOLIC PANEL - Already viewed John Frederick MacMillan, MD
02/21/2017 CBC WITH AUTO DIFFERENTIAL - Already viewed John Frederick MacMillan, MD
02/20/2017 MAGNESIUM (MG) - Already viewed John Frederick MacMillan, MD
02/20/2017 BASIC METABOLIC PANEL - Not yet viewed John Frederick MacMillan, MD
02/20/2017 CBC WITH AUTO DIFFERENTIAL - Not yet viewed John Frederick MacMillan, MD
02/19/2017 OSMOLALITY SPOT URINE - Already viewed Hershan S Johl, MD
02/19/2017 MAGNESIUM (MG) - Already viewed John Frederick MacMillan, MD
02/19/2017 BASIC METABOLIC PANEL - Already viewed John Frederick MacMillan, MD
02/19/2017 CBC WITH AUTO DIFFERENTIAL - Already viewed John Frederick MacMillan, MD
02/18/2017 CREATININE SPOT URINE - Not yet viewed Hershan S Johl, MD
02/18/2017 SODIUM SPOT URINE - Not yet viewed Hershan S Johl, MD
02/18/2017 MAGNESIUM (MG) - Not yet viewed John Frederick MacMillan, MD
02/18/2017 BASIC METABOLIC PANEL - Not yet viewed John Frederick MacMillan, MD
02/18/2017 CBC WITH AUTO DIFFERENTIAL - Not yet viewed John Frederick MacMillan, MD
02/17/2017 CULTURE SURVEILLANCE, MRSA - Already viewed John Frederick MacMillan, MD
02/17/2017 ABDOMEN 1 VIEW - Already viewed Hershan S Johl, MD
02/17/2017 PROTHROMBIN TIME (PT) - Already viewed John Frederick MacMillan, MD
02/17/2017 PHOSPHORUS (PO4) - Not yet viewed John Frederick MacMillan, MD
02/17/2017 MAGNESIUM (MG) - Already viewed John Frederick MacMillan, MD
02/17/2017 BASIC METABOLIC PANEL - Not yet viewed John Frederick MacMillan, MD
02/17/2017 CBC WITH AUTO DIFFERENTIAL - Not yet viewed John Frederick MacMillan, MD
02/16/2017 URINALYSIS-COMPLETE - Already viewed Kendra Leigh Grether-Jones, MD
02/16/2017 MR L-SPINE - Already viewed Kendra Leigh Grether-Jones, MD
02/16/2017 ELECTROCARDIOGRAM WITH RHYTHM STRIP - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 US KIDNEY (RENAL), COMPLETE - Already viewed Kendra Leigh Grether-Jones, MD
02/16/2017 TROPONIN I - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 BASIC METABOLIC PANEL - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 CBC WITH AUTO DIFFERENTIAL - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 CHEST 2 VIEWS - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 CT HEAD - Already viewed Sarah Elizabeth Medeiros, MD
02/16/2017 ELECTROCARDIOGRAM WITH RHYTHM STRIP - Not yet viewed Kendra Leigh Grether-Jones, MD

30

Yes, if you get real busy, you can ID the players

I begged the PCP for CBC, BMP, and P04 - she never ordered them.

31

I don’t think anyone is saying you deserved it, but rather that we don’t have all the data to judge your complaint.

I do wish you the best, unfortunately, it is surprisingly difficult, even in this day and age, to resolve chronic pain and chronic sleep issues.

32

Here is her response to my desperate request for blood work - the day I called the ambulance.

J street clinic is no more- all services are now at midtown -
Please schedule an appointment for evaluation here - we can talk about the sleep issue then

----- Message -----
From: usedtobe
Sent: 2/15/2017 9:45 PM PST
To: PCP
Subject: Non-urgent Medical Advice Question

This is “Heads Up”

for last 2 days, incredibly weak and “light headed”.

In addition to requiring 60 mg morphine to be able to stand upright.
Otherwise, I hobble bent about 90 degrees at the waist.
Somewhere around vertebrae #4 something is creating a 11 on a scale of 1-10 on pain.

I can not possibly drive in this condition.

I think I’m overdue for CBC, BMP, P04 and parathyroid something something.

I am now very glad I bought a $5 pair of crutches at the thrift store. a walker with seat would be more useful

Please order CBC w/diff, BMP, P04 and whatever else you can think of.

Oh yes - an X-ray or better of the lower spine would seem to be indicated.
If I can get out, I’ll probably use J Street lab - I think they can do X-ray.

I’ll check MyChart (I do hope I will outlive all the “I-this” and “My-that”.

Have a nice day…
d

By the time she did her “come in and I’ll tell you again that I have no intention of treating you”, I was unconcious and at the hospital.

33

Attitude has a lot to do with it.

People who reject other options off-hand & demand pills (which is what a lot of this reads like to me) are going to subject themselves to a stricter scrutiny than those who make a good faith effort to try the alternatives and report back that they don’t work.

It sucks for those with issues, but it’s how you need to play the game.

Ok, a couple of things:

  1. Your “desperate request” had the headline “Non-urgent Medical Advice Question”. I’m not sure what I’m supposed to take away from your last line, but it looks to me like you’re at least somewhat upset that your doctor treated a self-described “non-urgent” email as “non-urgent”.

  2. She didn’t say anything about having no intention of treating you & gave you good advice on how to proceed.

You keep equating “treatment” with “pills”. That’s going to send up a red flag with any self-respecting medical provider.

As I said above, you come across like an addict. That attitude is not going to get you the pills, but is, instead, going to further cement the idea that you shouldn’t be anywhere near those pills.

I don’t know why you couldn’t find a pain management specialist who would accept you as a patient, but I wouldn’t be surprised if this attitude had something to do with it.

In these messages you’ve posted, the doctor has said that she’ll discuss the sleep issue with you further. Have you done that? What was the outcome of the discussion?

As you’ve seen, your “pills or nothing” attitude won’t get you very far. That’s just how it is–it sucks, but you can’t change it. What you can change is how you’re perceived. An openness to suggestions that aren’t pills would be a great start for that.

34

Chronic pain and sleep disorders are miserable things and management has been all over the place. The rates of suicide and unintentional death is high in the population. Chronic renal disease increases the risk of opioid use and the need for monitoring closely. Feeling desperate, possibly coming off as demanding and having an attitude, being depressed, are all somewhat understandable. The circumstance sucks.

There are current evidence-based guidelines available to help guide the use of opioids in the context of chronic pain. I am no expert on this stuff, far far far from it, but a cursory review of those guidelines would seem to place you as someone at very high risk. Comorbid renal disease, concurrent benzo use, sleep disorder, possible depression … and while your doc is not reading this board, now expressing something that reads to me as minimally bordering on suicidal ideation. These in combination are not red flags for risk, they are freakin’ sirens screaming with flashing lights!

Prescribing the same plan you’ve had seems not to likely be the best course and by your description your PCP is out of her depth in dealing with the high risk circumstance you represent.

You really do need to somehow find a way to get into a pain specialist, or at least a PCP with a strong interest and expertise in the problem who you can develop a trusting relationship with. And fairly soon. Otherwise you may soon be usedtobe who used to be. I don’t know you but I’d still like to see that not happen!

Trying to force your PCP to prescribe more benzo and opioid concurrently will not serve your long term interests, that much is certain.

35

In usedtobe’s defense, I will say that my doctor’s office also uses MyChart, and I would tend to doubt he actually wanted to use the term ‘non-urgent.’ With that software, as implemented in my locale, you don’t type your own subject; you pick from the list, which includes certain very specific options (“Test follow-up question” e.g.) and a general Question for Doctor that is automatically system-labelled as non-urgent. (The system instructs you that if the question is urgent, you should call 911; anything not obviously requiring immediate emergency services is by default “non-urgent.”)

I also must say that if an older adult describes him- or herself as incredibly weak and lightheaded, “make an appointment sometime” isn’t exactly the first advice that comes to mind. Whatever has caused the breakdown of communication between you and your doctor, you need a new doctor. It sounds like there may be fault, or at least misunderstanding, on both sides; the line between drug-seeking addict and person in chronic agonizing pain can be very fuzzy, and you don’t necessarily present yourself in the best light. Do you have somebody who can go with you to medical appointments?

36

I didn’t consider the possibility that the subject line was selected, at least in part, by the program.

The program used by my primary allows me to fill in the subject, so I wasn’t thinking beyond that.

That being said, my primary does treat those emails as “non-urgent”, with the same caveat you posted above. I get replies generally within 2 business days; as I know going in that it’s a low priority, I can’t fault my doctor for not responding sooner. I’m inclined to feel the same about the doctor in this instance.

As someone who’s been incredibly active on the boards as of late because I’m waiting for the call that my 90 year old aunt succumbed to pneumonia in the ICU, I agree wholeheartedly on this.

But, at the same time, the main message isn’t so much the symptoms but rather the OP’s request for test orders–at least how I read it. With that, the comments made about coming in for an evaluation make sense. I don’t know of any doctor who would cut straight to calling the lab instead of asking to see the patient first. It’s possible that, by the end, those points got overlooked. Even though they’re mentioned first, they do (as I mentioned) strike me as an afterthought.

I think the best way to describe this situation as I see it is “backseat doctoring”. There’s no “what do you think I should do”, just a lot of “here’s what you need to do”. That’s not going to play well–especially when the relationship as of late is more-or-less all about narcotics.

All that said, the doctor’s bedside manner is definitely lacking with regard to this case, and she absolutely should’ve done a bit more follow up on the light-headed thing.

An advocate (not a lawyer) is probably some of the best advice given in this thread. I also rank my advice of an attitude change up there as well, but I know that when pain like that is concerned, it can be easier said than done–hence the advocate.

37

FWIW, I have terrible, chronic insomnia which is managed by a new anticonvulsant, an very old ADHD med, and a very new antipsychotic, all prescribed off-label, plus some OTC melatonin. It took a lot of trial and error to get there, and I do have Ambien and a benzo as PRNs, but I take them very rarely. It I took them every night, they’d probably stop working.

The old ADHD med I take in an extremely small dose, so even while it has potential for abuse, I don’t get every much of it at once. The other two meds I take daily are meant to be taken daily. They get prescribed off-label for other things, including migraine management and depression.

I’m just noting that as a counterpoint to what Cub Mistress says-- but again, it was a long road to get here, and I finally saw a psychiatrist who specialized in sleep disorders to get the mix.

Anyway, to address to OP’s complaint. I understand that the underlying issue is probably sleeping with pain, but the way the situation is being described, it really sounds like the narcotic is being used as a sleep med.

Your doctor may be under the impression that you have some kind of organic insomnia and wants to treat it without knocking you out, but with addressing your actual sleep cycles. Has there ever been talk of referring you for a sleep study?

Before you tell me that I’m wrong, understand, I’m not trying to tell you what your problem is, just how you are coming across. If it’s not clear to me that the sleep problem is a pain problem, maybe it isn’t clear to the doctor either.

And if the sleep problem IS an organic sleep problem, then try being open to treatments that don’t involve narcotics, benzos, and other “knock-out” medicines.

38

Folks -

Thanks for the thoughts.

I also looked up the number of “units” a non-specialist can prescribe on her own - we did not come close (93 out of a possible 120).

As for using a pain killer when trying to sleep - we ARE kidding, right? Forget lifelong insomnia - how much sleep do you get while clenching your teeth in pain?
On those nights, I don’t even bother with pill/pills - if I can’t control the pain, the sleeper will be wasted

I hold little hostility (but it is increasing rapidly) for her. I am a Medicare patient. I will never again get top-drawer talent.
All I ask is that I be allowed to sleep and live with minimal pain.
A low-level MD who can and will write script is about right for what Medicare pays.

The problem was the noise from DEA, which caused UCD to search for all opioids. Apparently, they also went double and came up with a list of Benzos.
My name was on both lists.

I have been on benzos since 10/00 - this is not a new crisis requiring fixing while my kidneys still have me in bed 3 out of 4-5 days.

I have printed off the last 15 months of scripts - PCP’s name is all over it. This list on Walgreen’s site.

I also have her salary grade range (IV-VII) and pay scales for each grade. Yes, simply EVERYTHING is online.
I would have expected a senior MD to say “Yes, I DO prescribe those, and I can defend those 'scripts against all charges”.

A Medicare-grade MD? “Throw the patient under the bus”.

The mid-point salary grades IV-VII:
$128,300 - 193,400.
Michael Jackson was paying his MD $500,000.
I was hoping to be coherent enough today to start the lawyer search. Looks like another few days, at least.

39

Yes, the only email headings MyChart allows are “Non-Urgent”. A note says, if urgent, call 911.

Since I do not have after hours numbers (and dear PCP is 60/40 to be in on any random day), that email is the only way to contact them off-hours. I am in bed more than 50% of time, so timing a call is tricky.

40

How many people need to tell you to drop this before you do it?

Drop it.

You do not want these emails and posts entered into evidence–if they are, I assure you that you won’t win any lawsuit.

With how you’re acting, it would be very hard for any MD to justify continuing to give you medication of that nature. I’m not saying you’re an addict, but you are coming across like one. The way you talk about this situation with us and in the communications you’ve shown with the doctor(s) is neither calm nor rational.

Demanding pills won’t get a self-respecting doctor to change their mind–instead, it will convince them (and any court you opt to involve) that they made the right decision. Whatever valid legal action you have available to you is greatly overshadowed by this.

Stop talking about looking for a lawyer and either change your attitude or find someone with a better one (again, not a lawyer) to help you out. Anything else will just significantly decrease your chance of ever being prescribed these medications again by any provider.

I don’t know how else to say it. You’re hurting, rather than helping, yourself here.